Sorry

for my lack of updates on this recently guys. I promise to get right back onto it. The good thing is that I PASSED (whhooo!!!) my defense last week, so I can get back to updating this sight daily in the way that I want it.

You will start to see a little bit of a change with this blog. Not only will I post professional reviews, but also give Gastroenterologists the inside scoop on interesting things in the field.   Stay tuned, tomorrow will be lots of stuff. Can't wait to get back on this.   

Important to Notify Patients About Adverse Effects of Colonoscopy

A great study from the Netherlands detailing the negative effects of a Colonoscopy.

Summary: The main objective was to study was the adverse effects of a Colononscopy after the procedure. The authors found that about 1 percent of the accrued patients (n=1114) had experienced a major adverse event (hospitalization) and about 30 percent (!) of the patients had experience a minor adverse event (no hospitalization) 30 days after their colononscopy.  The study showed that those patients who experienced an adverse event were found to have a more negative view of Colononscopies and consequently less likely to return for another colonoscopy in the future.

Implications for Practice: The finding that 30 percent of patients were found to have a minor adverse effect from a Colonoscopy should raise an alarm for any Gastroenterologist.  This underscores the importance of notifying patients about the potential adverse effects of a Colonoscopy and following up with them after the procedure.  Still, Colononscopies are deemed rather safe and highly recommended.      

It is interesting that females and those under the age of 50 were shown to have significantly higher chance of experiencing an adverse event compared to males and those over the age of 50 respectfully.  It is difficult to elucidate the exact reason.  Another study did show that females were more likely to experience colonic perforation compared to men.  Follow up studies on this would be compelling.

Affordable Care Act is Finally "Safe"

Well, it's been 3 days since the decision, and it's honestly all I can think about. I can't tell you how many victory laps I have taken since the decision was announced. Like many of you, I was watching CNN and had a true "Dewey vs. Truman" moment.  CNN first in-correctly said that the law was turned down and then later correctly said that the law had been up-held.  Wow, what a swing of emotions in such a short period of time.  You are talking about the difference in countless lives and trillions of dollars between the two outcomes.  No, it's more than a "Dewey vs Truman" moment.  

But let's get to the law and it's implications - the important thing. There is simply no way to describe how beneficial this really is to the Gastroenterology community.  This article from USA Today sums up my feelings very well.  As I said in a recent post, there are many Gastroenterology patients who probably did not  receive the health care they needed due to a pre-existing condition, but for all children (and everyone else starting in 2014), they can no longer be discriminated against because of their pre-existing condition.  This is not only a win for patients, but also a win for Gastroenterologists everywhere.  Its a win-win across the board for everyone in the Gastroenterology community in more ways than just one.  Most importantly, private sector plans along with Medicare and Medicaid will now be required to cover colon cancer screening  tests with no cost to the patient. This is a great preventive step.  This is just one positive here.

However, there still is work to be done.  The American  Gastroenterology Society is busy detailing what they will be doing through their political action committee.  Most importantly, they will be trying to close a loop-hole which makes the patient pay out-of-pocket for the removal of polyps which are detected during colonoscopy.  A big thanks to the political action committee for all of the hard work they are doing over there.

But for now, let's just sit back and bathe in this win.  It's good to know that there is a small chance that this bill will get repealed.  We can talk about the ramifications later.  For now, let's just enjoy this moment.  Health Care for all at-last in the USA - what a win!

   

Great time to be a Gastroenterologist!

Well, as you all know, the Supreme Court came down very favorably yesterday for people with pre-existing conditions, the type of patients that Gastroenterologists typically care for.

Right now, I am just soaking this whole decision in right now, and I will have a very lengthy write-up later.  This has been a day-in-the-coming for many years now.  Just a great day for Gastroenterology. There should be a big write-up by tomorrow night.

In related, news, I look forward to updating this blog again more on a regular basis.  Thanks to all of you who read my blog, it's been fun!

Gastroenterologists need to be cautious of prescribing metoclopramide for non-diabetic patients

Reference: Parkman, H.P., et al., Clinical response and side effects of metoclopramide: associations with clinical, demographic, and pharmacogenetic parameters. J Clin Gastroenterol, 2012. 46(6): p. 494-503

A study out from Temple on the side effects of metoclopramide. 

Brief Summary: Gastroperesis is a disorder indicative of slow stomach emptying during digestion and is often associated with diabates.  A common drug prescribed for this condition is metoclopramide – an antiemetic drug effective against nausea and vommitting.  The main aim of this study was to determine the factors which are associated with response vs. no-response and side effects vs. no side effects with the use of metoclopramide.   100 patients from a hospital near Philadephia were accrued into the study, and clinical features were recorded including age, dosage, etiology (diabetes or no-diabetes) and genotype testing for a number of various genes though to implicate in the main find. 

Results: The patients who responsed were older and had a heavier body mass index.  Genetic polymorphisms in KCNH2 and DRA1D genes were associated with clinical response.   The patients who hads side effects to metoclopramide tended to be nondiabetic with normal gastric emptying.  Genetic polymorphsisms occurred in CYP2D6, KCNH2, and 5-HT4 receptor HTR4 genes.  Some of the side affects were very severe.      

Implications for Practice: Since some of the side effects were severe, gastroenterologists should be very wary of prescribing metoclopramide to nondiabetic patients.  For these non-diabetic patients, if genetic testing can be under-done, it may be very helpful in determing the effectiveness of metoclopramide.

Discussion: Really good paper here, and I had a really fun time reading it.  These types of studies are important in order to determine the effectiveness of various metabolic drugs.  I am glad to see that the authors included the genotype variables.   Furthermore, I really liked how the authors went in depth in the discussion section on the various genes which were under investigation and the potential biological mechanism at play.

Also, at the beginning of the discussion section, it was good to see that the authors included a brief section on the implications for practice in Gastroenterology. This is always important and something that many authors do not do.

Overall, just a very well investigated  and written paper with very interesting finds which every Gastroenterologist who prescribes metoclopramide should know really.

Commentary on Statistics and Study Design: My biggest suggestion has to with the absense of any multi-variate analysis, which should always be done in any type of risk factor study.  The authors only included a uni-variate (un-corrected) analysis, but it would also would have been helpful to conduct a multi-variate (corrected) analysis with logistic regression using either a forward or backward stepwise regression approach.  Doing this, the authors could have presented a set of clinical factors which were most associated with the outcome variable: having a positive response.  For instance, it may be that one of the clinical factors (body mass index) is not associated with the outcome variable (response vs. no-response) while controlling for one of the genes.  Due to the very large number of genes, it probably would not have been possible to include all of the genetic factors at once, but you could test just a sub-sample at a time.  You always want to conduct this type of multi-variate analysis, and report both the uni-variate and multi-variate results. 

Also, in the statistical analysis section, it seems as if three separate statistical techniques were used (Fisher’s Exact Test, ANOVA, and uni-varite logistic regression); however, it seems as if the entire paper could have been performed with just the logistic regression.  I don’t even see any of the results for the ANOVA analysis.  I’m not too sure here. It would have been helpful if the name of the statistical test used was under the tables.  This could be very helpful.   

Overall, a good investigation. Thanks to our buddies at Temple for doing this!        

Health Care Decision To Come Tommorrow

So, the big health care decision will be coming down tomorrow from the Supreme Court.   Time will be inching along until then. As expected, I will be following this decision very closely on this blog, and I look forward to the decision.  Expect a good and lengthy post on here about it some time tomorrow.  

Hopefully, the SCOTUS decides not to over-turn the part of the bill which outlaws insurance companies from denying people based on pre-existing conditions.  That is the important part which is most relevant to the Gastroenterology field.  Here is hoping!  

The Effectiveness of Fecal Immunochemical Tests May Decrease After Repeated Diagnostic Rounds For Colon Cancer

Another great experimental study out of the Netherlands on the effects of the Fecal Immunochemical Test (FIT) after repeated rounds of testing.

Summary: The main objective of the study was to determine the effects of repeated testing using the Fecal Immunochemical Tests (FIT).  Tests such as these can often have low evaluative test measures (high false negatives and positives) so it is important to do repeated testing - especially after an initial positive finding.  The study was conducted in two concurrent stages in order to determine the effectiveness .  Somewhat alarmingly, the Positive Predictive Value (PPV) was found to decrease from the first round to the second round of testing for the FIT test for those patients which had a negative result in the first round.  The PPV is an evaluative measure for a diagnostic test which divides the number of people who actually have the condition by all of those who tested positive for the condition: True Positives/(True Positives+False Positives)).  

Implications for Practice: The fact that the PPV decreased for the Fecal Immunochemical Test should come at somewhat of an alarm for Gastroenterologists. This result just helpsenforce the importance of getting a Colononscopy for patients if there is suspect of any bowel instabilities, as the the other diagnostic tests really can not measure up to a Colonoscopy.  Interestingly, the authors also found that there was no significant difference between a fecal immunochemical test (FIT) and a fecal occult blood test (FOBT: another diagnostic measure).  Thus, there is no reason to switch from a FIT based program to a FOBT based program.

Interestingly, the authors showed that there were several different sub-types of colon cancers which were diagnosed, and this suggests the potential that some sub-types may be more easily detected than others.  Another study did show that the sensitivity of the Fecal Immunochemical Test (FIT) is higher for cancers which are detected distal rather than proximal, and this may have something to do with it.