Transcript Top 10 POEMs 2011-2012

Top 10 GI POEMs 2012
Scott M. Strayer, MD, MPH
Professor and Interim Chairman
Department of Family and
Preventive Medicine
University of South Carolina
Objectives
1. Describe and use the principles of “Information
Mastery,” including relevance, validity and
usefulness of information.
2. Define patient oriented evidence that matters
(POEMs)
3. Know the top 10 POEMs for 2012 that apply to
primary care physicians performing GI care
and endoscopy.
4. Develop an approach for reviewing medical
literature that is based on identifying POEMs
as they are published
POEM
Patient-Oriented
Evidence
that Matters
matters to the clinician, because if valid, will require a
change in practice
Shaughnessy AF, Slawson DC, Bennett JH. Becoming an Information Master: A
Guidebook to the Medical Information Jungle. The Journal of Family Practice
1994;39(5):489-99.
Relevance: Type of Evidence
• POE: Patient-oriented evidence
– mortality, morbidity, quality of life
– Longer, better or both
• DOE: Disease-oriented evidence
– pathophysiology, pharmacology, etiology
Comparing DOEs and POEMs
Example
Antiarrhythmic
Therapy
DiseaseOriented
Evidence
Patient-Oriented
Evidence that
Matters
Drug X  PVCs Drug X increases
on ECG
mortality
Comment
POEM study
contradicts DOE
study
POEM agrees
Antihypertensive Antihypertensive Antihypertensive
therapy  BP
therapy  mortality with DOE
therapy
Prostate
Screening
PSA screening
detects prostate
cancer early
? whether PSA
screening 
mortality
DOE exists, but
the important
POEM is
unknown
Shaughnessy AF, Slawson DC. Getting the Most from Review Articles: A Guide
for Readers and Writers. American Family Physician 1997 (May 1);55:2155-60.
Determining Validity
• Levels of Evidence (LOE):
– 1a, b, c; 2a, b, c; etc., 5- expert opinion
– A, B, C, D
– SORT Criteria
– Therapy, diagnosis, prognosis, reviews,
etc.
Effect on Patient-Oriented
Outcomes
Symptoms
Functioning
Quality of Life
Lifespan
Effect on Disease Markers
Diabetes
Arthritis
Peptic Ulcer
SORT
B
SORT
A
SORT
C
Effect on Risk Factors for
Disease
Improvement in markers
(blood pressure,
cholesterol)
Uncontrolled Observations
&
Conjecture
Physiologic Research
Preliminary Clinical
Research
Case reports
Observational studies
Validity of Evidence
Highly Controlled Research
Randomized Controlled
Trials
Systematic Reviews
Finding the POEMS
• Reviewed all Essential Evidence Plus
(http://www.essentialevidenceplus.com/) daily
updates since Jan 2012 identifying studies that would
affect primary care endoscopy and GI care.
– EE+ reviews over 100 journals each month including
JAMA, BMJ, Lancet, NEJM, ER, Surgery, Psychiatry,
Dermatology, Urology and Family Medicine journals
– Also reviews Cochrane library
– Conducted separate PubMed “clinical queries”
– Reviewed the “Strassler list”
#1 Do colonoscopic polypectemies
lower mortality?
Over 20 years, performing approximately 9000
colonoscopies will prevent 13 deaths, or
approximately 1 for every 700 colonoscopies.
(LOE = 2b)
Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic
polypectomy and long-term prevention of colorectal-cancer deaths.
N Engl J Med 2012;366(8):687-696.
• The National Polyp Study identified 9112 patients
who underwent an index colonoscopy between
1980 and 1990, of whom 3778 underwent
polypectomy.
• At enrollment, the average age of those with
adenoma was 62 years and those without adenoma
was 57 years.
• Among those with a polyp, 89% had only a single
colonoscopy to clear all of the polyps, and 16.5%
had at least one first-degree relative with colorectal
cancer.
• The population differed from a typical screening
population because the vast majority had
symptoms (32%); an abnormal fecal occult blood
test, sigmoidoscopy, or barium enema result (53%);
or family history (5%).
• The current study included all patients who had
neoplastic polyps (adenoma) removed and patients
with nonadenomatous polyps. Over time,
approximately 81% had a subsequent screening
colonoscopy.
• .
• The authors used the National Death Index to
identify deaths due to colorectal cancer. They also
used data from the Surveillance Epidemiology and
End Results registry to determine the likelihood of
death due to colorectal cancer in the general
population.
• They then compared these rates, and after 20 years
there were 12 deaths in the group that had an
adenoma removed, compared with an expected
25.4 in the general population----53% reduction in
mortality based on standardized incidence-based
mortality.
#2 Flex sigs for colon cancer screening
Once-only flexible sigmoidoscopy near the age of 60
years was associated with a reduction in the incidence
of colorectal cancer, but not with a reduction in
mortality. (LOE = 1b)
Reference
Segnan N, Armaroli P, Bonelli L, et al, for the SCORE Working Group. Once-only
sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian
Randomized Controlled Trial--SCORE. J Natl Cancer Inst 2011;103(17):13101322.
•
•
•
•
A quarter of a million adults, between the ages of 55 and 64 years,
were invited to participate in this large, Italian study of screening
sigmoidoscopy in patients at average of risk for colorectal carcinoma
(CRC).
More than 34,000 patients who were likely to attend screenings were
then randomly assigned to receive a single flexible sigmoidoscopy or
to usual care.
Patients with large polyps, with inadequate bowel cleansing with at
least one polyp, and those with invasive CRC were referred for total
colonoscopy. Additionally, patients were referred for total
colonoscopy if they had 3 or more adenomas, villous adenomas, or
polyps with high-grade dysplasia.
The authors searched a research database linked to regional hospital
discharge records and pathology department records every 2 years
to determine the primary outcomes, CRC incidence and CRC-related
mortality, assessed via intention to treat.
• Finally, they also searched the national death registry to
assess the vital status at the end of the study.
• After approximately 10 years of follow-up, the researchers
could not trace fewer than 2% of the patients.
• Overall, 557 patients were diagnosed with CRC (251
intervention patients, 306 control patients).
• The overall CRC incidence rates in the intervention and
control groups were 144 and 176 per 100,000 person-years,
respectively.
• One would have to invite 3125 adults (95% CI, 2915-3289) to
be screened to identify one invasive CRC.
• There was no statistically significant difference in the all-cause
mortality rate for patients diagnosed with CRC between the 2
groups (50 per 100,000 person-years for control patients and
38 for the intervention group). However, the study was not
powerful enough to adequately evaluate this latter outcome.
#3 FOBT vs. colonoscopy for
screening
Fecal occult blood testing every 2 years is more
acceptable to patients than colonoscopy, and
results in a similar cancer yield but a much higher
yield of advanced adenomas. (LOE = 1b)
Quintero E, Castells A, Bujanda L, et al, for the COLONPREV Study
Investigators. Colonoscopy versus fecal immunochemical testing in
colorectal-cancer screening. N Engl J Med 2012;366(8):697-706.
• This report is from a Spanish clinical trial that
randomized 57,404 adults, aged 50 to 69 years, to
an invitation for either a single colonoscopy or
FOBT using an immunochemical test every 2 years.
• The final trial results of this "noninferiority" trial (ie, a
trial that determines whether the 2 interventions are
roughly the same) will not be available until 2021.
• Participants were excluded if they had hereditary or
familial polyposis, previous colorectal cancer
(CRC), or multiple first-degree relatives with CRC.
• Allocation was concealed, and analysis was by
intention to screen and "as screened."
• Participants were allowed to cross over from one
group to the other; this was more common for those
initially assigned to colonoscopy (1628 vs 106).
• Participation rates, a sign of acceptability, were
higher for FOBT than for colonoscopy (34.2% vs
24.6%; odds ratio = 0.62; 95% CI, 0.60 - 0.65).
• The yield of colorectal cancer was the same in both
groups (0.1%), but colonoscopy identified
significantly more advanced adenomas (1.9% vs
0.9%) and nonadvanced adenomas (4.2% vs
0.4%).
• The authors also looked at the results for those who
ultimately had colonoscopy or FOBT, whether or
not they were initially assigned to that group (the
"as screened" analysis).
• In this analysis, there was a trend toward a higher
percentage diagnosed with colorectal cancer in the
colonoscopy group (0.5% vs 0.3%; P = .09).
• The number needed to scope to find one colorectal
cancer was 191 in the colonoscopy group and only
18 in the FOBT group (positive FOBT results that
lead to colonoscopy), so the FOBT strategy was
less resource intensive.
• This is the initial 2-year analysis from a 10-year
study, so stay tuned for more results down the road.
#4 What is the true rate of
complications after colonoscopy?
In this study of patients undergoing colonoscopy,
1.3% had a major adverse event in the 30 days
following the procedure that required urgent
evaluation, and 32.5% had a minor adverse event.
Also, 68 of 1128 had rectal blood loss caused by the
procedure (6.0%), and 4 of those patients required
urgent evaluation. Physicians who refer patients for
colonoscopy should be aware that minor and major
adverse events are relatively common. (LOE = 2b)
Reference
de Jonge V, Nicolaas JS, van Baalen O, et al, for the SCoPE consortium. The
incidence of 30 day adverse events after colonoscopy among outpatients in the
Netherlands. Am J Gastroenterol 2012;107(6):878-884.
• Previous studies have reported very low rates of
adverse events following colonoscopy, with
procedure-related death rates of 0.007%,
perforation in 0.07% of patients, and bleeding in
0.16%.
• This study is the most careful look to date at the
rate of complications at 30 days after the
procedure.
• In this study, 1528 patients at 12 Dutch hospitals
gave permission to be contacted and 1144 actually
responded to a phone call made 30 days after the
procedure.
• The authors defined a major adverse event as
anything that made the patient visit an emergency
department or hospital, and a minor adverse event
as any health problem that did not require a
hospital visit.
• The events were classified as definitely related,
possibly related, or unrelated to colonoscopy.
• A total of 15 patients had definitely or possibly
related major adverse events (2%), including 4
episodes of rectal bleeding (.3%) and one
perforation (.09%).
• Minor adverse events that were definitely or
possibly related to colonoscopy occurred in 32.5%
of patients: primarily abdominal discomfort or
cramps (n = 195), rectal blood loss (n = 64) and
change in bowel habits (n = 62).
• Only a minority of patients were undergoing the
colonoscopy for screening, but if a patient had
bleeding as an indication, bleeding during the 30
days following the procedure was not counted as
an adverse event.
#5 NBI vs conventional colonoscopy
Narrow band imaging colonoscopy was not better than
high definition white light colonoscopy for the detection
of patients with colorectal polyps. There is weak
evidence that narrow band imaging colonoscopy could
be better than conventional white light colonoscopy for
detection of patients with colorectal polyps. (LOE 1a)
Nagorni A, Bjelakovic G, Petrovic B. Narrow band imaging versus conventional
white light colonoscopy for the detection of colorectal polyps. Cochrane Database
of Systematic Reviews 2012, Issue 1. Art. No.: CD008361. DOI:
10.1002/14651858.CD008361.pub2.
• This review analysed the role of narrow band
imaging colonoscopy compared to the white light
colonoscopy for detection of colorectal polyps.
• In total eight randomised trials with 3673
participants were analysed.
• There was no statistically significant difference
between WLC (standard definition and high
definition pooled) and NBI for the detection of
patients with colorectal polyps (6 trials, n = 2832,
RR 0.97, 95% CI 0.91 to 1.04), patients with
colorectal adenomas (8 trials, n = 3673, RR 0.94,
95% CI 0.87 to 1.02), or patients with colorectal
hyperplastic polyps (2 trials, n = 645, RR 0.87, 95%
CI 0.76 to 1.00).
• Number of patients with at least one colorectal
adenoma was not significantly different between
WLC and NBI group irrespective of adenoma size
(< 5 mm:RR 0.95, 95% CI 0.84 to 1.08, I2 = 56%; 6
to 9 mm: RR 1.06, 95% CI 0.81 to 1.39, I2 = 0%;
10 mm: RR 1.06, 95% CI 0.77 to 1.45, I2 = 0%).
• Number of patients with at least one colorectal
polyp, or colorectal adenoma was significantly
lower in the standard definition WLC group
compared to NBI group in fixed-effect metaanalysis (RR 0.87, 95% CI 0.78 to 0.97, I2 = 78%;
RR 0.87, 95% CI 0.77 to 0.99, I2 = 0%,
respectively), but not significantly different in
random-effects meta-analysis (RR 0.86, 95% CI
0.68 to 1.10, I2 = 78%).
• There was no statistically significant difference
between high definition WLC and NBI in the
number of patients with at least one colorectal
polyp or colorectal adenoma (RR 1.10, 95% CI 0.95
to 1.28; RR 0.87, 95% CI 0.77 to 0.99, I2 = 0%,
respectively).
#6 Simulator training for endoscopy or
“see one, do one, teach one?”
The results of this systematic review indicate that
virtual reality endoscopy training may provide some
advantage prior to patient-based training. There was
no conclusive evidence that simulation-based training
was superior to conventional patient-based training,
although data were limited. (LOE 1a)
Walsh CM, Sherlock ME, Ling SC, Carnahan H. Virtual reality simulation training
for health professions trainees in gastrointestinal endoscopy. Cochrane Database
of Systematic Reviews 2012, Issue 6. Art. No.: CD008237. DOI:
10.1002/14651858.CD008237.pub2.
• Thirteen trials, with 278 participants, met the
inclusion criteria.
• Four trials compared simulation-based training with
conventional patient-based endoscopy training
(apprenticeship model)
• Nine trials compared simulation-based training with
no training. Only three trials were at low risk of bias.
• The one trial (Park 2007) which reported a
composite score of competency as an outcome
measure showed a statistically significant increased
score in the virtual reality training group as
compared with the control group.
• Four (Ahlberg 2005; Di Giulio 2004; Sedlack 2004;
Yi 2008) out of five trials which reported the
outcome independent procedure completion
showed that trainees who received virtual reality
simulation-based training were able to complete
more procedures independently as compared with
their untrained peers.
• Three (Ahlberg 2005; Ferlitsch 2010; Yi 2008 ) of
the six trials which reported the outcome of
performance time showed that trainees who
received virtual reality simulation-based training
were able to complete procedures significantly
faster
i
• One trial (Tuggy 1998) showed that while trainees
were not faster after 5 hours of simulation-based
training, their performance time was significantly
quicker, as compared to controls, after 6-10 hours.
• Both trials (Ahlberg 2005; Sedlack 2004) which
reported the outcome of independent insertion
depth showed that trainees who received virtual
reality simulation-based training were able to insert
the endoscope significantly further independently
as compared with their untrained peers.
• The one trial (Tuggy 1998) which reported error
rate as an outcome showed that participants who
received virtual reality simulation-based training
had fewer directional errors as compared with their
untrained peers.
• Two (Cohen 2006; Di Giulio 2004) of the three trials
which reported an overall rating of performance or
competency showed statistically significantly more
positive ratings for virtual reality simulation trained
participants.
• Finally two (Sedlack 2004; Yi 2008) of the three
trials which reported visualization as an outcome
showed that trainees who received simulationbased training had greater visualization, and one
trial (Tuggy 1998) showed that while there was no
difference between groups after 5 hours of
simulation based training, after 6-10 hours of
training those trainees who virtual reality training
had significantly greater visualization.
• There was no conclusive evidence that simulationbased training, as compared with conventional
endoscopy training provided benefit. There was no
significant difference between groups as measured
by:
– Composite score of competency (Haycock 2010),
– performance time (Gerson 2003; Haycock 2010; Shirai
2008),
– complication or critical flaw occurrence (Gerson 2003;
Sedlack 2004a),
– independent insertion depth (Haycock 2010), and
– visualization (Sedlack 2004a).
• One (Sedlack 2004a) of the two studies which
reported patient discomfort as an outcome measure
found a significant training advantage for the virtual
reality group.
• Alternatively, one (Gerson 2003) of the two studies
that reported independent procedure completion
and an overall rating of performance or competency
found that trainees who received simulation-based
training were able to complete fewer procedures
independently and received statistically significantly
more negative overall ratings of performance as
compared to those receiving conventional patientbased endoscopy training.
#7 Best medication for C. Diff?
Metronidazole, vancomycin, and fidaxomicin are all
effective for the initial treatment of Clostridium difficile
infection and none is superior to the others. However,
as compared with vancomycin, fidaxomicin is less
likely to cause recurrence of infection. (LOE = 1a)
Drekonja DM, Butler M, MacDonald R, et al. Comparative effectiveness of
Clostridium difficile treatments. Ann Intern Med 2011;155(12):839-847.
• These investigators searched MEDLINE, the
Cochrane Library, and other databases, as well as
bibliographies from relevant studies, to find
randomized controlled trials addressing the
treatment of C. difficile infection.
• To address whether treatment efficacy was affected
by disease severity or strain, cohort studies were
also included.
• Two authors independently selected the 11 studies,
abstracted the data, and evaluated the quality and
strength of the evidence using methods developed
by the Agency for Healthcare Research and
Quality.
• No pooled analysis was done because of study
heterogeneity.
• Each of 3 studies that compared vancomycin with
metronidazole showed no significant difference in
rate of initial cure or recurrence of C. difficile
infection.
• In one study that compared vancomycin with
fidaxomicin, there was no difference detected in
initial cure, but fidaxomicin did decrease the rate of
recurrence (15% vs 25%; 95% CI, -17 to -3
percentage points).
• Of note, a per-protocol subgroup analysis of a
single study suggested that vancomycin was
superior to metronidazole for initial cure in patients
with severe disease (Zar et al; Daily POEM
9/25/07). However, since this difference did not
remain significant when strict intention-to-treat
analysis was performed, the authors of this review
rated the evidence as insufficient.
• Finally, a mortality difference between study drugs
was noted in only one of the included studies. In
this study, patients treated with metronidazole plus
rifampin were more likely to die than those treated
with metronidazole alone (32% vs 5%; P = .044).
#8 Best treatment approach for H.
Pylori
The best approaches to managing Helicobacter pylori
(HP) include a stool antigen test for diagnosis; a testand-treat strategy for uncomplicated dyspepsia in
young patients when HP infection is common; and the
use of omeprazole-amoxicillin-clarithromycin or
quadruple therapy, depending on clarithromycin
resistance, to eradicate HP. (LOE = 1a-)
Malfertheiner P, Megraud F, O'Morain CA, et al, for the European Helicobacter
Study Group. Management of Helicobacter pylori infection -- the Maastricht IV /
Florence consensus report. Gut 2012;61(5):646-664.
• The Maastricht guidelines are widely considered to
be the best summary of the evidence regarding the
diagnosis and treatment of HP infection
• Workgroups systematically reviewed the literature,
made recommendations graded by strength of
evidence, and voted on adoption of the final result.
• The major limitation is that they do not clearly
distinguish between patient-oriented and diseaseoriented outcomes, something we know is
important. For example, recommendations related
to diagnostic accuracy alone or to preparation for a
test received "A" recommendations.
• Nevertheless, there are some useful
recommendations that may differ from the current
practice of most physicians:
– (1) A urea breath test or stool antigen test are
recommended for diagnosis; if the patient is taking a
proton pump inhibitor, discontinue it for 2 weeks. Only
use IgG serology if the test has been validated and
found to be accurate.
– (2) HP eradication provides some benefit to patients
with functional dyspepsia (number needed to treat =
12), but not to patients with reflux disease.
– (3) A test-and-treat strategy for uncomplicated
dyspepsia is recommended when the prevalence of HP
infection is at least 20%
– (4) Test for HP infection in patients with a history of
ulcer, and consider it in a patient embarking on longterm NSAID or aspirin therapy.
– (5) If clarithromycin resistance is less than 15% to 20%,
use omeprazole-amoxicillin-clarithromycin for 7 to 14
days (about 5% better eradication with longer course).
– (6) If clarithromycin resistance is high, use bismuth
containing quadruple therapy or sequential therapy;
levofloxacin containing triple therapy is another option.
#9 ASA in hereditary nonpolyposis
colon cancer
Carriers of hereditary nonpolyposis colorectal cancer
appear to have a lower rate of colorectal cancer
(CRC) if treated with 600 mg aspirin for 2 years. (LOE
= 1b)
Burn J, Gerdes AM, Macrae F, et al, for the CAPP2 Investigators. Long-term
effect of aspirin on cancer risk in carriers of hereditary colorectal cancer: an
analysis from the CAPP2 randomised controlled trial. Lancet
2011;378(9809):2081-2087.
• The Colorectal Adenoma/carcinoma Prevention
Programme (CAPP) is a series of 2 studies
designed to evaluate aspirin or resistant starch (or
their placebos) for the prevention of CRC.
• In CAPP1 (1993-2002), the patients had familial
polyposis; CAPP2 evaluated carriers of Lynch
syndrome (hereditary nonpolyposis CRC).
• In this report of CAPP2, 861 patients took aspirin
(600 mg daily; n = 427) or placebo (n = 434) for
approximately 2 years.
• After an average 4.5 years of follow-up (the study
plans on a total of 10 years), 18 aspirin-treated
patients developed CRC compared with 30
placebo-treated patients.
• In the intention-to-treat analysis, the rate of CRC
was statistically nonsignificant, but 5 of the 48 total
patients who developed CRC had 2 primary
cancers, 4 of whom received only placebo.
• Taking this into account, aspirin's protective effects
became statistically significant. One would need to
treat approximately 38 patients with aspirin for 2
years to prevent one case of CRC within 4.5 years.
• The authors also broke down the time sequence
because of some preliminary reports suggesting a
"legacy effect" of aspirin; that is, the protection may
extend beyond the period of active treatment.
• During the first 2 years of follow-up, while all the
patients were taking either aspirin or placebo, 10
patients in each group developed CRC. During the
subsequent follow-up, 8 aspirin-treated patients
developed CRC compared with 20 in the placebo
group. The authors don't report data on any
adverse effects of aspirin.
• The strongest proof of aspirin’s antineoplastic effect
has been in colorectal tumours.
• In long-term follow-up of participants in five
randomised trials of cardiovascular prevention,
Rothwel and colleagues previously reported that
daily aspirin at any dose reduced risk of colorectal
cancer by 24% and of associated mortality by 35%
after a delay of 8–10 years. (7)
• First, these analyses do not include the largest
randomised trials in primary prevention: the
Women’s Health Study (WHS) of 39 876 women
treated with alternate-day 100 mg aspirin over 10
years and the Physicians’ Health Study (PHS) of 22
071 men treated with alternate-day 325 mg aspirin
over 5 years. After 10–12 years of follow-up, aspirin
was not associated with reduced risk of colorectal
cancer12,13
#10 Probiotics to prevent abxassociated diarrhea
Probiotic use is significantly associated with a reduced
risk of antibiotic-associated diarrhea (AAD). This
review found that both Lactobacillus-based
interventions and yeast-based (Saccharomyces)
interventions showed a significant reduction in the risk
of AAD in both children and adults 65 years or
younger. The evidence on the possible benefits or
harms of probiotic use in people older than 65 years is
inconclusive. (LOE = 1a-)
Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and
treatment of antibiotic-associated diarrhea. A systematic review and metaanalysis. JAMA 2012;307(18):1959-1969.
• These investigators searched multiple databases
including MEDLINE, EMBASE, DARE, the
Cochrane Library, and references of pertinent
studies and reviews for randomized controlled trials
(RCTs) of probiotic preparations for the prevention
and treatment of AAD.
• Trials included participants of all ages without any
language restrictions.
• Two reviewers independently assessed
publications for inclusion and methodologic quality
using standard validation criteria.
• Discrepancies were resolved through consensus
discussion.
• A total of 82 RCTs met inclusion criteria and the
overall methodologic quality was poor.
• The most common indication for antibiotic use was
H. pylori treatment.
• Most trials alone did not show a statistically
significant benefit to probiotic use, but a significant
association with a lower relative risk of developing
AAD with probiotic exposure did occur after formal
meta-analysis (relative risk (RR) =0.58; 95% CI,
0.50-0.68; number needed to treat [NNT] = 13;
10.3-19.1).
• After limiting the analysis to only high-quality trials,
the significant association was still sustained. Most
trials used blends of various probiotic genera,
primarily Lactobacillus.
• Both exclusive Lactobacillus-based and yeastbased (Saccharomyces) interventions showed a
significant reduction in the risk of AAD.
• Subgroup analyses of children, aged up to 17
years, and adults, aged 18 to 65 years, also
reported a significant association between probiotic
use and a reduced risk of AAD
• However, only 3 RCTs exclusively enrolled adults
older than 65 years and the pooled relative risk was
not significant for benefit or harm of probiotic use in
preventing or treating AAD. A formal analysis found
no evidence of publication bias and moderate
evidence of heterogeneity, most likely due to the
varied probiotic preparations.
One More Time….
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Do colonoscopies lower mortality?
Flex sigs for colon cancer screening
FOBT vs. colonoscopy for screening
What is the true rate of complications after
colonoscopy?
NBI vs conventional colonoscopy
Simulator training for endoscopy
Best medication for C. Diff?
Best treatment approach for H. Pylori
ASA in hereditary nonpolyposis colon cancer
Probiotics to prevent abx-associated diarrhea