Introduction There is increasing interest in documenting the performance of individual endoscopists for their own education and to safeguard quality standards.1 What has hitherto been lacking is an infrastructure to facilitate collection and analysis of data to allow practioners to easily compile a “report card” of their own practice or benchmark themselves against their peers. Methods The Endoscopic Retrograde Cholangiopancreatography Quality Network (ERCP N) is a web-based tool that started as a voluntary reporting system in the US.2 Anonymised key data points (indications, sedation/anaesthesia, therapies, successes and adverse events) on each case are uploaded through a web-based interface onto a central server. 73 American endoscopists have uploaded data on 11 015 ERCP procedures. Eight British endoscopists enrolled more recently and have reported so far on 1007 procedures. Individual report cards or benchmark reports against the average of all users can be user-generated online. Result The table shows some of the areas (mean values) where practice differed between countries. All numbers (except the total) are percentage, and all differences are statistically significant. These data do not purport to reflect average UK and US practice, as participants are self-selected and not necessarily representative. UK endoscopists in this study performed less complex procedures as judged by the accepted complexity grade3 with lower (but acceptable) technical success rates. There were no significant differences in average procedure and fluoroscopy times or the proportion of cases involving trainees (Abstract 016). Conclusion UK users have found it quick and easy to enter data and that it provides very useful information. Collection of this level of data about one9s own practice is likely to become mandatory in the near future. We hope that these very preliminary data will encourage other UK endoscopists to participate.

Introduction There is increasing interest in documenting the performance of individual endoscopists for their own education and to safeguard quality standards.1 What has hitherto been lacking is an infrastructure to facilitate collection and analysis of data to allow practioners to easily compile a “report card” of their own practice or benchmark themselves against their peers. Methods The Endoscopic Retrograde Cholangiopancreatography Quality Network (ERCP N) is a web-based tool that started as a voluntary reporting system in the US.2 Anonymised key data points (indications, sedation/anaesthesia, therapies, successes and adverse events) on each case are uploaded through a web-based interface onto a central server. 73 American endoscopists have uploaded data on 11 015 ERCP procedures. Eight British endoscopists enrolled more recently and have reported so far on 1007 procedures. Individual report cards or benchmark reports against the average of all users can be user-generated online. Result The table shows some of the areas (mean values) where practice differed between countries. All numbers (except the total) are percentage, and all differences are statistically significant. These data do not purport to reflect average UK and US practice, as participants are self-selected and not necessarily representative. UK endoscopists in this study performed less complex procedures as judged by the accepted complexity grade3 with lower (but acceptable) technical success rates. There were no significant differences in average procedure and fluoroscopy times or the proportion of cases involving trainees (Abstract 016). Abstract PWE-016 UK US Total ERCP procedures 1007 11 015 Complexity grade 1 63 42 Complexity grade 3 9 36 Anaesthesia used 3 62 Deep biliary cannulation 93 97 Stone <10 mm extraction 94 100 Stone >10 mm extraction 84 97 In-patient procedure 58 33 Conclusion UK users have found it quick and easy to enter data and that it provides very useful information. Collection of this level of data about one's own practice is likely to become mandatory in the near future. We hope that these very preliminary data will encourage other UK endoscopists to participate.

Background Management of benign intraductal papillary mucinous neoplasm (IPMN) of the pancreas is difficult because of the unpredictability of the lesion. Current practice often recommends aggressive surgery at the time of diagnosis. This can lead to significant postsurgical comorbidities and potential perioperative mortality. Many clinicians wonder whether expectant management, including no surgery and serial follow-up, is comparable. We sought to compare surgical versus nonsurgical management of benign IPMNs using decision analysis tools. Methods We used a Markov process to model progression of disease in both surgical and nonsurgical interventions (Figure 1). The base-case was a 65-year-old female with a 2 cm benign-appearing IPMN. We included literature-derived data concerning survival and transition probabilities. Transitions between benign and malignant cancer states and death were modeled in 1-year transitions, over a lifelong time horizon. Results Overall and interval survival for benign IPMNs did not differ significantly between the surgical and nonsurgical groups. Sensitivity analyses performed on each of the model9s parameters revealed it to be robust. Conclusions There is no observed survival benefit for patients undergoing surgery for small, benign-appearing IPMNs. Based on this model, conservative management with appropriate follow-up should be considered equal to surgical intervention for these lesions. Further analyses regarding potential cost and quality of life parameters are forthcoming.

Objectives To determine the prevalence of colorectal cancer among individuals with and without diabetes in a large nationally representative survey. To ascertain if there are increased odds of having colorectal cancer among individuals with diabetes mellitus after controlling for relevant confounders. Background Colorectal cancer is the third most common type of cancer and second most common cause of cancer-related death in the United States. An emerging risk factor for colorectal cancer is type 2 diabetes mellitus. Biochemical mechanisms postulated for this risk include hyperinsulinemia and elevated serum C-peptide levels, both of which affect colon mucosa adversely in vitro. Methods Data source: National Health Interview Survey (NHIS) 1997-2003, conducted by the National Center for Health Statistics. The NHIS is a comprehensive nationally representative survey weighted to represent the US adult population. Subjects selected by a complex sampling design involving stratification, clustering, and multistage sampling with a nonzero probability of selection for each person. There were 226,953 subjects represented in the combined 7 years of the NHIS, of which 13,399 reported a history of diabetes (5.9%). Dependent variable was colorectal cancer history, defined by an affirmative answer to "Have you ever been told by a health care professional that you have colon or rectal cancer? " The primary independent variable was a reported history of diabetes. Relevant covariates included age, race, gender, smoking history, alcohol use, and obesity. NHIS data from 1997-2003 were merged with SAS v. 9.1.3. Analyses performed with STATA v. 8.0, which accounted for the complex survey design of the NHIS and generated population estimates. Multiple logistic regression was used to determine whether diabetes was independently associated with colorectal cancer. Results Individuals with diabetes were more likely to have a history of colorectal cancer than individuals without diabetes (1.34% vs 0.47%, p < .001). After controlling for relevant confounders, the odds of having a history of colorectal cancer among individuals with diabetes was 1.4 times the odds of colorectal cancer among people without diabetes (CIs = 1.15 to 1.67). Conclusions The prevalence of colorectal cancer is nearly 3 times as high among individuals with diabetes as compared to subjects without diabetes. After controlling for relevant confounders, the odds of having colorectal cancer were significantly higher among people with diabetes. People age 50 and older, Caucasians, and former smokers were all more likely to have a history of colorectal cancer. If this association remains positive in prospective trials, people with diabetes may require more aggressive screening for colorectal cancer than the general population. Research should be directed at understanding the pathophysiologic reasons why diabetes is associated with colorectal cancer.

OBJECTIVE To assess the association between complementary and alternative medicine (CAM) use, preventive care practices, and use of conventional medical services among adults with diabetes. RESEARCH DESIGN AND METHODS We analyzed data on 2,474 adults with diabetes. We created an overall CAM-use category based on use of any of the following: diets, herbs, chiropractic care, yoga, relaxation, acupuncture, ayuverda, biofeedback, chelation, energy healing, Reiki therapy, hypnosis, massage, naturopathy, and homeopathy. We used multiple logistic regression to assess the effect of CAM use on preventive care practices (receipt of influenza and pneumonia vaccines) and use of conventional medical services (number of primary care and emergency department visits). STATA was used for statistical analysis to account for the complex survey design. RESULTS A total of 48% of adults with diabetes used some form of CAM. CAM use was independently associated with receipt of pneumonia vaccination (odds ratio 1.56 [95% CI 1.26-1.94]) but not significantly associated with receipt of influenza vaccination (1.17 [0.92-1.48]). CAM use was independently associated with visiting the emergency department (1.34 [1.06-1.70]), having six or more primary care visits (1.44 [1.14-1.83]), and having eight or more primary care visits (1.66 [1.22-2.25]). CONCLUSIONS In contrast to the findings of previous studies, CAM use appears to be associated with increased likelihood of receipt of preventive care services and increased emergency department and primary care visits. CAM use may not be a barrier to use of conventional medical services in adults with diabetes.

Purpose: To assess the risk of colon cancer among individuals with diabetes within a nationally representative population. Previous studies have yielded evidence that diabetes mellitus may be a risk factor for colon cancer. Both hyperinsulinemia and hyperglycemia have been noted in vitro to be promoters of colon cancer growth. Furthermore, insulin and insulin-like growth factor-1 (IGF-1) receptors have been found on colon cancer tissue. Also, high levels of circulating IGF-1 are associated with an elevated risk of colorectal adenomas and cancer. This study further considers the relationship between diabetes mellitus and colon cancer. Methods: Data collected by the 1997–2003 National Health Interview Survey (NHIS) was analyzed to assess the risk of colon cancer among individuals with diabetes. The NHIS is a comprehensive nationally representative survey weighted to represent the U.S. adult population. There were 226,953 subjects represented in the combined seven years of the NHIS, of which 161,235 had complete and comparable data which could be evaluated. Multiple logistic regression was performed probing the relationship between diabetes mellitus and colon cancer while controlling for age, race, gender, obesity, alcohol use, tobacco use, and physical activity. SAS statistical software was used to account for the complex survey design of the NHIS. Results: Among the 161,235 subjects in this study, 16,664 (10.3%) revealed a history of diabetes mellitus. Adjusted for potential confounders, individuals with diabetes were siginficantly more likely to have colon cancer than persons without diabetes (Odds ratio (OR) = 1.59, 95% Confidence interval (CI) = 1.3 to 1.9). Age > 50 years (OR = 14.48, 95% CI = 10.8 to 19.4), caucasians (OR = 1.91, 95% CI = 1.1 to 3.2) and smokers (OR = 1.55, 95% CI = 1.2 to 2.0) were also revealed to be significant risk factors. Conclusions: Caution should be taken with interpretation of this analysis, given the cross-sectional nature of this design. Commonly accepted risk factors for colon cancer including inflammatory bowel disease and family history were not clearly defined in the database. Furthermore, methods of treatment or duration of diabetes were not included in this analysis. Nevertheless, the results from this large cross-sectional survey analysis confirm and expand on previous research which indicates that diabetes mellitus is a significant risk factor for colon cancer.