Training Primary Care Physicians in Flexible Sigmoidoscopy—Performance Evaluation of 17, 167 Procedures

The flexible fiber-optic sigmoidoscope is rapidly replacing the rigid sigmoidoscope in routine screening for colorectal cancer. This study was undertaken to evaluate the safety, usage pattern, and efficacy of fiber-optic sigmoidoscopy by evaluating the outcome of training and the results of procedures carried out by a group of primary care physicians. Of 1,153 participants in one-day flexible sigmoidoscopy workshops, 764 (66%) returned questionnaires evaluating their experiences following this training. Of these, 438 physicians had obtained a flexible sigmoidoscope, used it frequently, and had done a total of 17,167 examinations. The average time of scope usage was nine months. Although additional supervised training was suggested at the time of the workshop, 68% of physicians began doing flexible sigmoidoscopy without it. A total of 465 polyps and 153 cancers were detected by the study group for an overall detection rate of 2.7% for polyps and 0.9% for cancers. Four complications were reported. This study indicates that the technique of flexible sigmoidoscopy is readily learned, is diagnostically productive, and is reasonably safe in the hands of primary care physicians.     

An evaluation of flexible fibreoptic sigmoidoscopy.

Results of 350 flexible fibreoptic sigmoidoscopy examinations showed a diagnostic yield of 30% compared with 6.5% by rigid sigmoidoscopy of the same patients. The mean time for the examinations was eight minutes, a distance of over 50 cm being visualised in 65% of the patients. Preparation of the bowel with a single phosphate enema was adequate in 95% of the patients. As an outpatient investigation for clinicians fibreoptic sigmoidoscopy is a safe, quick, and useful addition to rigid sigmoidoscopy and should result in a decrease in the number of barium enema examinations required.     

Flexible sigmoidoscopy in outpatients with suspected colonic disease.

One hundred and fifteen patients attending a gastroenterology clinic were investigated by flexible sigmoidoscopy as outpatients. There were asked to fast before the examination and give a high-volume enema and sedated before the examination. A standard long colonoscope was used rather than the 60-cm sigmoidoscope, which limits the distance that can be examined and forces the operator to work very close to the patient. Preparation was considered good in 95 patients and 49 were examined as far as the hepatic flexure or beyond. Sixty-one patients were found to have lesions of the colon, 25 of them ulcerative colitis, 16 a poly, and nine carcinoma. Despite the fact that these patients were selected (some of them had already had ulcerative colitis diagnosed), flexible sigmoidoscopy proved to be a valuable initial outpatient investigation. The proximal colon was well visualised in 46 patients and a subsequent barium enema was considered unnecessary. There were no complications and the procedure seemed to be well tolerated.     

Sigmoidoscopy/proctoscopy service with open access to general practitioners.

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.     

Utilization of sigmoidoscopy by family physicians in Canada.

OBJECTIVE: To determine the extent to which sigmoidoscopy is used as an investigative tool by family physicians in Canada. DESIGN: Retrospective study of data from provincial and territorial health agencies for the fiscal year 1989. SETTING: Canada. PARTICIPANTS: All family physicians. MAIN OUTCOME MEASURES: Number of physicians in each province and territory who performed sigmoidoscopy (flexible and rigid), type of physician (generalist or specialist), number of procedures performed, fee schedule and number of physicians billing medicare in each province and territory. RESULTS: During the study period 3849 (15.1%) of all family physicians performed rigid sigmoidoscopy; the proportion varied from 3.4% (in Quebec) to 40.0% (in the Northwest Territories). A total of 43,914 rigid sigmoidoscopies were performed by family physicians, representing 23% of all such procedures. Flexible sigmoidoscopy was performed by 381 (1.5%) of all family physicians; the proportion varied from 0.4% (in Quebec) to 6.8% (in Prince Edward Island). A total of 5361 flexible sigmoidoscopies were performed, representing 6.0% of all such procedures. CONCLUSION: The proportion of Canadian family physicians who are using sigmoidoscopy, rigid or flexible, as a diagnostic tool is low.     

The use of endoscopic biopsy in evaluation of polypoid lesions of the colon

Use of flexible endoscopes affords biopsy sampling of polypoid lesions of the colon, especially within the rectum and sigmoid colon by flexible fiberoptic sigmoidoscopes. Histologic examination of colonic biopsies usually allows division of polyps into neoplastic and non-neoplastic categories. There are significant limitations to such biopsies, however, due to sampling error and inability to reach deep submucosal cores of polyps where malignant invasion may occur. When properly aware of its limitations, the endoscopist will find the endoscopic biopsy a valuable aid in planning the therapeutic approach to a polypoid lesion of the colon.     

Screening for colorectal cancer.

In the United Kingdom there are almost 31,000 new cases of colorectal cancer each year and nearly 20,000 deaths. It is the second most common cause of all deaths from cancer in the United Kingdom. The efficacy of screening with faecal occult blood tests to detect and treat tumours at an early stage, and thereby to reduce mortality, is currently being assessed in several randomised controlled trials. In general, faecal occult blood tests have a low sensitivity and only moderate levels of uptake among the population invited for screening. Until the studies in Denmark, Sweden, and Nottingham report their findings, there is no case for providing such screening routinely to an asymptomatic population. Detecting and removing premalignant adenomas by flexible sigmoidoscopy could be more effective than detecting early localised, asymptomatic cancers in reducing deaths from colorectal cancer. It is estimated that screening people at about the age of 60 by a single flexible sigmoidoscopy examination with appropriate colonoscopic surveillance could prevent 5500 cases of colorectal cancer and 3500 deaths in the United Kingdom each year. A randomised controlled trial to confirm these observations should be seen as a priority.     

Standard colonic lavage alters the natural state of mucosal-associated microbiota in the human colon

Background & Aims

Past studies of the human intestinal microbiota are potentially confounded by the common practice of using bowel-cleansing preparations. We examined if colonic lavage changes the natural state of enteric mucosal-adherent microbes in healthy human subjects.

Methods

Twelve healthy individuals were divided into three groups; experimental group, control group one, and control group two. Subjects in the experimental group underwent an un-prepped flexible sigmoidoscopy with biopsies. Within two weeks, subjects were given a standard polyethylene glycol-based bowel cleansing preparation followed by a second flexible sigmoidoscopy. Subjects in control group one underwent two un-prepped flexible sigmoidoscopies within one week. Subjects in the second control group underwent an un-prepped flexible sigmoidoscopy followed by a second flexible sigmoidoscopy after a 24-hour clear liquid diet within one week. The mucosa-associated microbial communities from the two procedures in each subject were compared using 16S rRNA gene based terminal restriction fragment length polymorphism (T-RFLP), and library cloning and sequencing.

Results

Clone library sequencing analysis showed that there were changes in the composition of the mucosa-associated microbiota in subjects after colonic lavage. These changes were not observed in our control groups. Standard bowel preparation altered the diversity of mucosa-associated microbiota. Taxonomic classification did not reveal significant changes at the phylum level, but there were differences observed at the genus level.

Conclusion

Standard bowel cleansing preparation altered the mucosal-adherent microbiota in all of our subjects, although the degree of change was variable. These findings underscore the importance of considering the confounding effects of bowel preparation when designing experiments exploring the gut microbiota.     

Clinical Experience with Flexible Sigmoidoscopy in Asymptomatic and Symptomatic Patients

The purpose of this study was to evaluate the diagnostic yield of flexible sigmoidoscopy when performed as a routine procedure in asymptomatic patients over the age of 40 being referred for a complete physical examination. The preliminary results of this ongoing program are presented together with the diagnostic yield in 408 patients with symptoms and signs suggestive of colorectal disease who were of similar age (56.6 vs. 56.5 years) and sex distribution (79 percent male) to the asymptomatic population, and who underwent flexible sigmoidoscopy as an indicated part of their evaluation. In the 122 asymptomatic patients, the mean distance examined by the procedure was 50.8 cm with the instrument being advanced beyond the optimal rigid sigmoidoscopy distance of 20 cm in 100 percent of patients. Adenomatous and hyperplastic polyps were identified in 16 patients, 13.1 percent, in the asymptomatic group, a similar percentage to the symptomatic population, 15.4 percent. Adenomatous polyps were diagnosed in 7.4 percent of the asymptomatic subjects and 9.1 percent of the symptomatic group. Colonic cancer was diagnosed in 0.8 percent of asymptomatic patients vs. 3.2 percent of the symptomatic group (p < 0.05). Seventy-seven percent of the neoplastic polyps detected in the asymptomatic patients and 60 percent in the symptomatic group were beyond 20 cm from the anus. Diverticulosis was diagnosed in a similar percentage of patients, 13.1 percent in the asymptomatic and 10.0 percent in the symptomatic group. No complications were encountered and the procedure was well tolerated without analgesia. It is concluded that: (1) in an asymptomatic population over the age of 40, flexible sigmoidoscopy, as a routine examination, results in a diagnostic yield not possible with rigid proctosigmoidoscopy and which approaches that observed in a symptomatic population of similar age; (2) for the internist trained in this procedure, flexible sigmoidoscopy has a future role in the detection of colorectal lesions and as an interval screening examination for premalignant lesions and colorectal cancer in asymptomatic and symptomatic patients.     

Factors associated with inadequate colorectal cancer screening with flexible sigmoidoscopy

Background and study aim: Inadequate colorectal cancer screening wastes limited endoscopic resources. We examined patients factors associated with inadequate flexible sigmoidoscopy (FSG) screening at baseline screening and repeat screening 3–5 years later in 10 geographically-dispersed screening centers participating in the ongoing Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Methods: A total of 64,554 participants (aged 55–74) completed baseline questionnaires and underwent FSG at baseline. Of these, 39,385 participants returned for repeat screening. We used logistic regression models to assess factors that are associated with inadequate FSG (defined as a study in which the depth of insertion of FSG was <50 cm or visual inspection was limited to <90% of the mucosal surface but without detection of a polyp or mass). Results: Of 7084 (11%) participants with inadequate FSG at baseline, 6496 (91.7%) had <50 cm depth of insertion (75.3% due to patient discomfort) and 500 (7.1%) participants had adequate depth of insertion but suboptimal bowel preparation. Compared to 55–59 year age group, advancing age in 5-year increments (odds ratios (OR) from 1.08 to 1.51) and female sex (OR = 2.40; 95% confidence interval (CI): 2.27–2.54) were associated with inadequate FSG. Obesity (BMI >30 kg/m²) was associated with reduced odds (OR = 0.67; 95% CI: 0.62–0.72). Inadequate FSG screening at baseline was associated with inadequate FSG at repeat screening (OR = 6.24; 95% CI: 5.78–6.75). Conclusions: Sedation should be considered for patients with inadequate FSG or an alternative colorectal cancer screening method should be recommended.     

A new approach for evaluating flexible working hours

Recent studies on flexible working hours show at least some of these working time arrangements seem to be associated with impairing effects of health and well-being. According to available evidence, variability of working hours seems to play an important role. The question, however, is how this variability can be assessed and used to explain or predict impairments. Based on earlier methods used to assess shift-work effects, a time series analysis approach was applied to the matter of flexible working hours. Data on the working hours of 4 week's length of 137 respondents derived from a survey on flexible work hours involving 15 companies of different production and service sectors in Germany were converted to time series and analyzed by spectral analysis. A cluster analysis of the resulting power spectra yielded 5 clusters of flexible work hours. Analyzing these clusters for differences in reported impairments showed that workers who showed suppression of circadian and weekly rhythms experienced severest impairments, especially in circadian controlled functions like sleep and digestion. The results thus indicate that analyzing the periodicity of flexible working hours seems to be a promising approach for predicting impairments which should be investigated further in the future.     

Schizophillum commune Causing Sinusitis with Nasal Polyposis in the Sub-Himalayan Region: First Case Report and Review

Schizophillum commune is an environmental fungus rarely causing human infections of diverse nature. Sinusitis occurs in immunocompromised persons and seldom in healthy subjects. Though easily isolated, the lack of awareness of its virulence is a bottleneck in the diagnosis of this infection. We report the first case of S. commune sinusitis with nasal polyps in an immunocompetent male from the sub-Himalayan region. The computerized tomography scan findings established the clinical diagnosis, and causative agent was confirmed as S. commune. A white, woolly mold with septate, hyaline hyphae and characteristic spicules but unclamped connections suggested a monokaryotic isolate. Patient was treated successfully with fiberoptic endoscopic sinus surgery, and no antifungal therapy was instituted. There was no recurrence at review after 1 year.     

Flipper bone distribution reveals flexible trailing edge in underwater flying marine tetrapods

Hydrofoil-shaped limbs (flipper-hydrofoils) have evolved independently several times in secondarily marine tetrapods and generally fall into two functional categories: (1) those that produce the majority of thrust during locomotion (propulsive flipper-hydrofoils); (2) those used primarily to steer and resist destabilizing movements such as yaw, pitch, and roll (controller flipper-hydrofoils). The morphological differences between these two types have been poorly understood. Theoretical and experimental studies on engineered hydrofoils suggest that flapping hydrofoils with a flexible trailing edge are more efficient at producing thrust whereas hydrofoils used in steering and stabilization benefit from a more rigid one. To investigate whether the trailing edge is generally more flexible in propulsive flipper-hydrofoils, we compared the bone distribution along the chord in both flipper types. The propulsive flipper-hydrofoil group consists of the forelimbs of Chelonioidea, Spheniscidae, and Otariidae. The controller flipper-hydrofoil group consists of the forelimbs of Cetacea. We quantified bone distribution from radiographs of species representing more than 50% of all extant genera for each clade. Our results show that the proportion of bone in both groups is similar along the leading edge (0–40% of the chord) but is significantly less along the trailing edge for propulsive flipper-hydrofoils (40–80% of the chord). Both flipper-hydrofoil types have little to no bony tissue along the very edge of the trailing edge (80–100% of the chord). This suggests a relatively flexible trailing edge for propulsive flipper-hydrofoils compared to controller flipper-hydrofoils in line with findings from prior studies. This study presents a morphological correlate for inferring flipper-hydrofoil function in extinct taxa and highlights the importance of a flexible trailing edge in the evolution of propulsive flipper-hydrofoils in marine tetrapods.     

Statistical studies of flexible nonhomogeneous polypeptide chains

Unfolded proteins attract increasing attention nowadays because of the accumulation of experimental evidence that they play an important role in different biological processes. Therefore, studies of various statistical properties of flexible protein-like polypeptide chains are becoming increasingly important as well. This paper presents distributions (histograms) of distances between atoms of titratable residues for flexible polypeptide chains with various residue compositions and with the hard-spheres potential taken into consideration. The factors influencing the parameters of the obtained histograms have been identified and analyzed. It was found that the sensitivity of the distributions with respect to the internal structure of intermediate residues increases with the number of residues between the considered charged residues. It was shown that branching at C(beta) atoms of the side chains of the intermediate residues is among the most considerable factors influencing the shape of the distance distribution and the average distance between atoms in flexible chains. Despite the model simplicity, the results of the calculations can be applied for systems with other types of interactions presented, and this was demonstrated for the charge-charge interactions. In particular, it was shown that those interactions have a significant effect on distances between the unlike charges, while such an effect for the like charges is much less pronounced. The comparison of predictions made on the basis of the presented calculations to some experimental data is also given, and possible applications of the theoretical concept described in the paper are discussed.     

Endoscopic fine needle aspiration biopsy

A catheter assembly that can be passed through the biopsy channel of a standard fiberoptic gastroduodenoscope was devised to permit fine needle aspiration biopsy of gastrointestinal neoplasms under direct vision of the endoscope. This technique for endoscopic aspiration biopsy was performed in ten consecutive patients with esophageal and gastric carcinomas, along with the conventional endoscopic brushing and biopsy. Endoscopic aspiration biopsy gave a positive diagnosis in all ten cases while the other two techniques gave inconclusive results in one patient with an ulcerative growth. We feel that endoscopic aspiration biopsy can be used to obtain representative samples from gastrointestinal neoplasms, and it may add to the diagnostic accuracy of endoscopic biopsy and brushing cytology.     

Normal mode based flexible fitting of high-resolution structure into low-resolution experimental data from cryo-EM

A new method for the flexible fitting of high-resolution structures into low-resolution maps of macromolecular complexes from electron microscopy has been recently described in applications to simulated electron density maps. This method uses a linear combination of low-frequency normal modes in an iterative manner to deform the structure optimally to conform to the low-resolution electron density map. Gradient-following techniques in the coordinate space of collective normal modes are used to optimize the overall correlation coefficient between computed and measured electron densities. With this approach, multi-scale flexible fitting can be performed using all-atoms or Calpha atoms. In this paper, illustrative studies of normal mode based flexible fitting to experimental cryo-EM maps are presented for three different systems. Large, functionally relevant conformational changes for elongation factor G bound to the ribosome, Escherichia coli RNA polymerase and cowpea chlorotic mottle virus are elucidated as the result of the application of NMFF from high-resolution structures to cryo-electron microscopy maps.     

An imported human case of hookworm infection with worms in the rectum]

An imported case of rectal hookworm infection was diagnosed by stool examination and recovery of adult worms from the rectal mucosa by sigmoidoscopy. The chief complaints of a patient were diarrhea, abdominal pain and weight loss for about 1 month after returning from his travel abroad to the Southeast Asia. Leukocytosis(16,750/microliters) and peripheral eosinophilia(33.7%) were noticed without anemia. Typical hookworm eggs were detected by stool examination, and 3 worms were collected by sigmoidoscopy from rectal mucosa of this patient. Those worms were confirmed as adult worms of Ancylostoma duodenale(male:1, female:2) based on their morphological characteristics. The symptoms were relieved after treatment with anthelmintics. This case was considered as one of the imported parasitic infections in Korea, and a rare case of hookworm infection on human rectal mucosa.     

Implications of flexible work systems for work studies

The relationship between changing work systems and work study methods is discussed by focusing on a recent trend toward more flexible work systems in different countries. These systems are commonly characterized by (a) uncoupling of working hours from business hours, (b) combining different atypical work forms and (c) individualized work patterns. Increased flexibility in working patterns is demanded because business hours may be covered by different workers and because special arrangements become necessary for unpopular shifts or linking separate jobs. Changes in work systems seem more successful when they are associated with (a) multiskilled work, (b) independent task implementation, (c) networked communication, (d) balanced or adjusted workload, and (e) accommodation of workers' preferences. Special attention is drawn to safety and health concerns and work-life effects. Many intervention studies done for work improvement are paying attention to multifaceted work aspects, locally available options, and participation by people. All these elements are important because prepackaged solutions do not exist. The following three views seem especially useful for action-oriented work studies: 1) Look at multiple aspects of the work, including work content and atypical work forms; 2) Know worker preferences and available options; and 3) Take into account work elements that may not be well defined, but important from local points of view. It is envisioned that these studies can provide support for a well-informed participatory process of work system changes in each local context.