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    Abstract: BACKGROUND: Colorectal cancer is the most common cancer in Germany. Screening colonoscopies have been offered as a primary screening tool in Germany since the end of 2002. OBJECTIVE: To estimate the numbers of clinically manifest colorectal cancers prevented by detection and removal of advanced adenomas in the initial 6 years of the program. DESIGN: Markov model with single-year transitions. SETTING: German screening colonoscopy program. PATIENTS: Participants in the screening colonoscopy program from 2003 to 2008. INTERVENTIONS: Screening colonoscopy with the removal of advanced colorectal neoplasms. MAIN OUTCOME MEASUREMENTS: The expected numbers of incident colorectal cancers prevented by detection and removal of advanced adenomas. RESULTS: An estimated total number of 73,024 cases of colorectal cancer might have developed from the removed advanced adenomas and become clinically manifest between 55 and 84 years of age in the absence of screening colonoscopy. This number exceeds the number of colorectal cancers diagnosed in 2002 by 27%. Among prevented cancers, 8%, 43%, and 49% would have occurred at ages 55 to 64, 65 to 74, and 75 to 84 years (median age 74 years), respectively; 60% and 40% would have occurred among men and women, respectively; and 22%, 32%, 25%, and 20% would have occurred within 1 to 5, 6 to 10, 11 to 15, and 16 to 30 years, respectively, after colonoscopy (median 10 years). LIMITATIONS: Diagnoses of advanced adenomas are based on records from a large number of endoscopists and pathology laboratories. CONCLUSIONS: Despite relatively low screening participation, the German screening colonoscopy program is expected to make a major contribution to the prevention of colorectal cancer, even though most of the impact will only be seen in the longer run.
    Type of Publication: Journal article published
    PubMed ID: 20883856
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    Keywords: POPULATION ; RISK-FACTORS ; score ; COLORECTAL-CANCER ; COMPLICATIONS ; RANDOMIZED CONTROLLED-TRIAL ; POLYPECTOMY ; sigmoidoscopy ; THERAPEUTIC COLONOSCOPY ; PERFORATION
    Abstract: BACKGROUND: The incidence of adverse events (AEs) is a crucial factor when colonoscopy is considered for mass screening, but few studies have addressed delayed and non-GI AEs. OBJECTIVES: To investigate the risk of AEs requiring hospitalization after screening and nonscreening colonoscopies compared with control subjects who did not undergo colonoscopy. DESIGN: Retrospective matched cohort. SETTING: Statutory health insurance fund in Germany. PATIENTS: A total of 33,086 individuals who underwent colonoscopy as an outpatient (8658 screening, 24,428 nonscreening) and 33,086 matched controls who did not undergo colonoscopy. INTERVENTIONS: Outpatient screening and nonscreening colonoscopies. MAIN OUTCOMES MEASUREMENTS: Risk of AEs (perforation, bleeding, myocardial infarction, stroke, splenic injury, and others) requiring hospitalization within 30 days after colonoscopy/index date and risk differences between the group that underwent colonoscopy and the group that did not. RESULTS: The incidence of perforation was 0.8 (95% confidence interval [CI], 0.3-1.7) and 0.7 (95% CI, 0.4-1.1) per 1000 screening and nonscreening colonoscopies, respectively. Hospitalizations because of bleeding occurred in 0.5 (95% CI, 0.1-1.2) and 1.1 (95% CI, 0.8-1.7) per 1000 screening and nonscreening colonoscopies, respectively. The incidence of myocardial infarction, stroke, and other non-GI AEs was similar in colonoscopy and control groups. No splenic injury was observed. Those with AEs generally had a higher mean age and comorbidity rate than the overall study population. LIMITATIONS: The analysis relies on health insurance claims data. CONCLUSIONS: This study provides further evidence of the safety of colonoscopy in routine practice with regard to delayed and non-GI AEs. Hospitalizations because of the investigated AEs were uncommon or rare for both screening and nonscreening colonoscopies.
    Type of Publication: Journal article published
    PubMed ID: 23410698
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    Keywords: neoplasms ; COLORECTAL-CANCER ; PREVALENCE ; FALSE DISCOVERY RATE ; OCCULT BLOOD-TEST ; ADENOMA DETECTION RATE ; QUALITY INDICATORS ; MODELING FRAMEWORK ; DETECTION RATES ; WINBUGS
    Abstract: Background: The adenoma detection rate (ADR) is an important surrogate measure of performance quality for screening colonoscopies. Objective: To demonstrate how physicians with unusual performance concerning the adenoma detection rate may be identified in screening colonoscopy databases. Design: Bayesian random-effects modeling and Winsorization of potential outliers were applied to develop a robust model for the majority of providers. Divergence was assessed with adjustment for multiple testing. The steps in the analysis were visualized by using funnel plots. Additionally, minimum requirements for the number of colonoscopies with 1 or more detected adenomas were derived. Setting: Data from 422 physicians offering screening colonoscopy and participating in a quality assurance program in Bavaria, Germany, were used. Patients: A total of 69,738 asymptomatic individuals 55 to 79 years of age. Intervention: Screening colonoscopy. Main Outcome Measurements: Physician-specific ADRs. Results: The overall ADR in the sample was 26%. From an initial model, 62 physicians (15%) were identified as potential outliers. A model with normally distributed random effects was then chosen as the robust null model. Of the potential outliers, 10 (16%) were confirmed as physicians with unusual performance at a false discovery rate of 5%. For all of them, the observed ADR was lower than expected, and together they accounted for 1.4% of all included colonoscopies. Limitations: Analysis of routine data. Conclusion: The applied statistical approach appears suitable to identify unusual performance in screening colonoscopy databases. Its application may help to evaluate and improve the quality of colonoscopy in population-based colorectal cancer screening programs.
    Type of Publication: Journal article published
    PubMed ID: 25523387
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    Keywords: CANCER ; DEATH ; MORTALITY ; POPULATION ; REDUCTION ; RISK-FACTORS ; DESIGN ; colorectal cancer ; COLORECTAL-CANCER ; COST-EFFECTIVENESS ; SURVEILLANCE ; SCREENING SIGMOIDOSCOPY ; ENDOSCOPY ; SERVICES TASK-FORCE ; AMERICAN-COLLEGE ; DECISION-ANALYSIS
    Abstract: BACKGROUND: Use of colonoscopy is thought to reduce colorectal cancer (CRC) mortality, but its impact at the population level is unclear. OBJECTIVE: To estimate the effect of current colonoscopy use on CRC mortality and its further potential in reducing CRC mortality. DESIGN: Population-level analysis was performed by using the concepts of prevented and attributable fractions, by using data from the National Health Interview Survey, the Surveillance, Epidemiology and End Results Program, and estimates of the effectiveness of colonoscopy at reducing CRC mortality. SETTING: The 2005 U.S. population aged 50 years and older. EXPOSURE: Colonoscopy within 10 years or less. MAIN OUTCOME MEASUREMENTS: Percentages and absolute numbers of CRC deaths prevented and potentially preventable by colonoscopy. LIMITATIONS: Uncertainty in effectiveness estimates. RESULTS: Overall, the proportions of CRC deaths in 2005 prevented by colonoscopy (ie, the prevented fractions) range from 13% (95% CI, 11%-15%) to 19% (95% CI, 12%-24%) across the estimates of colonoscopy effectiveness. Corresponding numbers of CRC deaths prevented range from 7314 (95% CI, 6010-8467) to 11,711 (95% CI, 7077-14,898). The proportions of CRC deaths attributable to nonuse of colonoscopy (ie, the attributable fractions) range from 28% (95% CI, 22%-33%) to 44% (95% CI, 24%-60%), depending on the assumed effectiveness. Corresponding numbers of CRC deaths attributed to nonuse of colonoscopy range from 13,796 (95% CI, 11,076-16,255) to 22,088 (95% CI, 12,189-29,947). CONCLUSIONS: Although we estimate that colonoscopy has prevented substantial numbers of CRC deaths, many more deaths could have been prevented with more widespread use. These findings highlight the potential benefits from public health interventions to increase the use of screening colonoscopy.
    Type of Publication: Journal article published
    PubMed ID: 21353840
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    Keywords: INHIBITOR ; Germany ; MICROSCOPY ; THERAPY ; PROTEIN ; PROTEINS ; COMPONENTS ; PATIENT ; MECHANISM ; mechanisms ; IDENTIFICATION ; mass spectrometry ; MASS-SPECTROMETRY ; LENGTH ; Jun ; DEGRADATION ; CALCIUM ; PROTEASOME ; chronic pancreatitis ; MANAGEMENT ; GEL-ELECTROPHORESIS ; INHIBITORS ; MASSES ; albumin ; PRODUCTS ; LIGHT ; PH ; WEIGHT ; SODIUM ; development ; methods ; pancreatic ; MASS ; PLACEMENT ; CRITERIA ; CRYSTAL ; JUICE ; LITHOSTATHINE ; STENTS ; STONE PROTEIN ; SULFATE ; technique
    Abstract: Background: Endoscopic management of chronic pancreatitis (CP), especially pancreatic stent placement, has made tremendous advances. However, good clinical results are hampered by rapid occlusion. The objective of this study was to understand mechanisms and materials that cause stent occlusion. Methods: The clogging material of 50 lyophilized pancreatic endoprostheses (length 8.5 cm, range 5-14 cm, diameter 7-11F) from patients with CP was completely removed and weighed. Protein solubilization was achieved at pH 8.0 by using sodium dodecyl sulfate (SDS) and 2-mercaptoethanol in the presence of proteasome inhibitors. Proteins were separated by using a SDS-polyacrylamide gel electrophoresis. Protein identification was performed by the Western blot technique, as well as by mass spectrometry. Insoluble components were examined by polarized light microscopy and after staining (periodic acid-Schiff [PAS]). Results: Clogging material was found in 49 prostheses, mainly at the duodenal flap (80%). More than a third of the prostheses contained visible calcium carbonate calculi. Light microscopy and PAS staining showed plant debris (80%), crystals (73.5%), and mucopolysaccharides (100%). The dry weight of clogging material (18 +/- 13 mg, range 3-72 mg) correlated significantly with the stent diameter (p = 0.029) but not with any other stent- or patient-related criteria. Albumin, its degradation products, and lithostathine were identified as the main proteinaceous components. Conclusions: Almost all pancreatic stents had clogging material, predominantly located at the duodenal flap, which contained plant material, mucopolysaccharides, and crystals, as well as visible calcium carbonate calculi. Albumin and lithostathine may play an important role in the development of stent occlusion
    Type of Publication: Journal article published
    PubMed ID: 15933688
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    Keywords: COLORECTAL-CANCER ; COLON-CANCER ; UNITED-STATES ; FLEXIBLE SIGMOIDOSCOPY ; SERVICES TASK-FORCE ; SCREENING COLONOSCOPY ; HEALTH INTERVIEW SURVEY ; CANCER TEST USE ; FACTOR SURVEILLANCE SYSTEM ; MEDICARE BENEFICIARIES
    Abstract: BACKGROUND: Lower GI endoscopy, such as colonoscopy or sigmoidoscopy, is thought to have a substantial impact on colorectal cancer incidence and mortality through detection and removal of precancerous lesions and early cancers. We aimed to review prevalence estimates of history of colonoscopy or sigmoidoscopy in the general population and to analyze recent trends. METHODS: A systematic review of the medical literature, including MEDLINE (1966 to August 2008) and EMBASE (1980 to August 2008), was undertaken, supplemented by searches of the European Health Interview & Health Examination Surveys database and bibliographies. Detailed age-specific and sex-specific prevalence estimates from the United States were obtained from the Behavioral Risk Factor Surveillance System surveys 2002, 2004, and 2006. RESULTS: The search yielded 55 studies that met our inclusion criteria. The majority of the reports (43) originated from the United States. Other countries of origin included Australia (2), Austria (2), Canada (5), France (1), Germany (1), and Greece (1). Estimates from the United States were generally increasing over time up to 56% (2006) for lifetime use of colonoscopy or sigmoidoscopy in people aged 50 years and older. Analysis of national survey data showed higher prevalences among men aged 55 years and older than for women of the same age. Prevalences were highest for people aged 70 to 79 years. CONCLUSION: Data from outside the United States were extremely limited. Prevalence estimates from the United States indicate that a considerable and increasing proportion of the population at risk has had at least 1 colonoscopy or sigmoidoscopy in their lives, although differences between age and sex groups persist. Prevalences of previous colonoscopy or sigmoidoscopy need to be taken into account in the interpretation of time trends in, and variation across, populations of colorectal cancer incidence and mortality.
    Type of Publication: Journal article published
    PubMed ID: 19846082
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