Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand

ObjectiveAge and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI) malignancies are uncertain.DesignCross-sectional study.SettingData were extracted from the Gastrointestinal Endoscopy Centre of Siriraj Hospital, Thailand, during 2005–2011.ParticipantsConsecutive patients underwent a first-time upper endoscopy for dyspepsia. Patients with previous surgery, suspected UGI malignancy by imaging, or indefinite biopsy results on prior examination were excluded.Main outcome measuresAlarm features included dysphagia, unintentional weight loss, GI bleeding/anaemia, and persistent vomiting. The diagnostic performance of each alarm feature and different age cut-off values were evaluated.ResultsA total of 4664 patients (mean age: 52.0±14.4 years, 66% female) were included. Alarm symptoms were presented in 21.6%. The prevalence of active Helicobacter pylori infection was 26.3%. Fifty-eight (1.2%) patients had UGI malignancy. The prevalence of malignancy significantly increased with increasing age (0.6% in patients aged <50 years, and 1.8% in patients aged >60 years (p<0.001)). Cancer was found in two patients aged <50 years who did not have alarm features. Patients with alarm features had a higher prevalence of malignancy (OR 22.3, 95% CI 10.5 to 47.4; p<0.001) than those without. The pooled sensitivity, specificity, positive predictive value and negative predictive value of alarm features for UGI malignancy were 87.0%, 79.1%, 4.7% and 99.8%, respectively. Among all age groups, persistent vomiting had a positive likelihood ratio (PLR) >10, while dysphagia and GI bleeding/anaemia had a PLR >10 in patients <50 years old.ConclusionDespite the overall limited value of age and alarm features, persistent vomiting, dysphagia, and GI bleeding/anaemia are strong predictors for malignancy in patients aged <50 years. Without these symptoms, cancer prevalence is negligible; thus, they are worthy guidance for endoscopic evaluation in this age group.

Histopathological Analysis of Gastric Cancers in University of Ilorin Teaching Hospital: A 20-Year Review

Gastric cancer is a relatively common malignancy in Nigeria. Gastric cancer varies from region, being 4th to 20th in proportion to other malignancies. The symptom and signs are often non-specific with the early stages of the disease. This may be responsible for late presentation and poor prognosis. This is a 20-year retrospective analysis of 107 histopathologically confirmed gastric cancers in the department of pathology. This study aimed to analyze the Histopathological patterns of all the gastric cancer cases diagnosed in U.I.T.H Ilorin, over a twenty-year period. Gastric cancers were classified according to WHO 2010 and Lauren classification of gastric cancers. A total of 107 cases of gastric cancers diagnosed, that met the inclusion criteria, were analyzed with male: female ratio of 1.3:1 out of which epithelial malignancy accounted for 93.5% with tubular adenocarcinoma representing the commonest epithelial subtype. Epithelial malignancy is the commonest histological type in this area. Therefore, it is recommended that patients above 40 years with dyspepsia and other alarm features should undergo routine endoscopic screening.

Diagnostic utility of alarm features in predicting malignancy in patients with dyspeptic symptoms

Background Clinical features are of modest benefit in determining the etiology of dyspepsia. Dyspeptic patients with alarm features are suspected to have malignancy; but the proportions of patients and true cutoff values of various quantitative parameters in predicting malignancy are explored to a lesser extent. Methods This is a prospective observational study of consecutive patients undergoing esophagogastroduodenoscopy (EGD) for dyspeptic symptoms. Patients’ alarm features and clinical details were recorded in a predesigned questionnaire. The diagnostic accuracy of alarm features in predicting malignancy was studied. Results Nine hundred patients, 678 (75.3%) males, with a mean (standard deviation [SD]) age of 44.6 (13.54) years were enrolled. Commonest indication for EGD was epigastric pain in 614 (68.2%) patients. Dyspepsia was functional in 311 (34.6%) patients. EGD revealed benign lesions in 340 (37.8%) and malignancy in 50 (5.5%) patients. Among the malignant lesions, gastric malignancy was present in 28 (56%) and esophageal malignancy in 20 (40%) patients. Alarm features were present in 206 (22.9%), out of which malignant lesions were seen in 46 (22.3%) patients. Altogether, the alarm features had a sensitivity of 92% and specificity of 81.2% for predicting malignancy. The sensitivity and specificity for weight loss were 76% and 90.8%, while that of abdominal mass were 10% and 99.9% respectively. Based on receiver operating characteristic curve, the optimal age for screening of malignancy was 46.5 years in this population. Conclusions Patients of age group 40 to 49 years with dyspeptic alarm symptoms (predominant weight loss) need prompt endoscopy to screen for malignancy. The alarm features are inexpensive screening tools, found to be useful in India, and should be utilized in countries with similar healthcare conditions and disease epidemiology.

Diagnosing Constipation Spectrum Disorders in a Primary Care Setting

Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients’ expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of “primary constipation” include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.

Prolonged Diagnostic Intervals as Marker of Missed Diagnostic Opportunities in Bladder and Kidney Cancer Patients with Alarm Features: A Longitudinal Linked Data Study

Background: In England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed. Methods: We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence. Results: 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. Of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43–151) and visible haematuria with the shortest (median 50 days, IQR 30–79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis. Conclusion: More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers.

New Design of An Intelligent, Secure and Dependable Garage system.

This work introduces the design and development plan of a reliable, smart, secure, automation solution, applying modern design methodology, for solving real-life problems faced by many residents and related to the process of car parking inside a home garage, as well as, security and economy issues. The suggested solution is intended for achieving comfort, security and economy as a part of home automation. The solution consists of two main subsystems; security identification subsystem and the automated garage subsystem. The security identification subsystem is suggested to be placed inside the car on front tableau. The two subsystems are communicating with each other wirelessly, the whole automated garage system are activated from sleep mode and waiting for further actions, when a vehicle or a human is detected in the front of the gate by means of two sensors, or when identification signal is send from security identification subsystem. For maximum reliability and depending on customer needs, the security subsystem is designed to identify the residents, to have a permission to enter the garage by matching all of the following; face image, fingerprint, voice print, written password, specified oral password word, specially designed remote control board or radio frequency identification (RFID) card along with a alarm features. When the residents identified, the garage subsystem is activated in terms of controlling the garage gate open/close process and controlling electrical components including lighting, ventilation and surveillance camera. Each of the two subsystems, as well as overall system, was physically prototyped, tested in real situation successfully.

The diagnostic value of a change in bowel habit for colorectal cancer within different age groups

Background Change in bowel habit as a sole alarm symptom for colorectal cancer is disputed. Objective We investigated the diagnostic value of change in bowel habit for colorectal cancer, particularly as a single symptom and within different age groups. Methods This retrospective cohort study examined colorectal cancer fast track referrals and outcomes across four Swedish hospitals (April 2016–May 2017). Entry criteria constituted one or more of three alarm features: anaemia, visible rectal bleeding, or change in bowel habit for more than 4 weeks in patients over 40 years of age. Patients were grouped as having only change in bowel habit, change in bowel habit plus anaemia/bleeding or anaemia/bleeding only. Results Of 628 patients, 22% were diagnosed with colorectal cancer. There were no cases of colorectal cancer in the only change in bowel habit group under 55 years, while this was 6% for 55–64 years, 8% for 65–74 years and 14% for 75 years and older. Among subjects under 55 years, 2% with anaemia/bleeding had colorectal cancer, this increased to 34% for 55 years and older ( P < 0.0001). Change in bowel habit plus anaemia/bleeding gave a colorectal cancer prevalence of 16% in under 55 years and increased to 30% for 55 years and older ( P = 0.07). Conclusion Change in bowel habit as the only alarm feature has a low diagnostic yield for colorectal cancer in patients under 55 years.