OBJECTIVES Current guidelines recommend early repeat colonoscopy when bowel preparation quality is inadequate, defined as inability to detect polyps > 5 mm, but no data link specific bowel preparation categories or scores to this definition. Nevertheless, most physicians use a shortened screening/surveillance interval in patients with intermediate-quality preparation. We determined whether different levels of bowel preparation quality are associated with differences in adenoma detection rates (ADRs: proportion of colonoscopies with ≥1 adenoma) to help guide decisions regarding early repeat colonoscopy—with primary focus on intermediate-quality preparation. METHODS MEDLINE and Embase were searched for studies with adenoma or polyp detection rate stratified by bowel preparation quality. Preparation quality definitions were standardized on the basis of Aronchick definitions (excellent/good/fair/poor/insufficient), and primary analyses of ADR trichotomized bowel preparation quality: high quality (excellent/good), intermediate quality (fair), and low quality (poor/insufficient). Dichotomized analyses of adequate (excellent/good/fair) vs. inadequate (poor/insufficient) were also performed. RESULTS Eleven studies met the inclusion criteria. The primary analysis, ADR with intermediate- vs. high-quality preparation, showed an odds ratio (OR) of 0.94 (0.80–1.10) and absolute risk difference of −1% (−3%, 2%). ADRs were significantly higher with both intermediate-quality and high-quality preparation vs. low-quality preparation: OR = 1.39 (1.08–1.79) and 1.41 (1.21–1.64), with absolute risk increases of 5% for both. ADR and advanced ADR were significantly higher with adequate vs. inadequate preparation: OR = 1.30 (1.19–1.42) and 1.30 (1.02–1.67). Studies did not report other relevant outcomes such as total adenomas per colonoscopy. CONCLUSIONS ADR is not significantly different with intermediate-quality vs. high-quality bowel preparation. Our results confirm the need for early repeat colonoscopy with low-quality bowel preparation, but suggest that patients with intermediate/fair preparation quality may be followed up at standard guideline-recommended surveillance intervals without significantly affecting quality as measured by ADR.

Background & Aims Bowel preparation is defined as adequate if it is sufficient for identification of polyps >5mm. However, adequate preparation has not been quantified. We performed a prospective observational study to provide an objective definition of adequate preparation, based on the Boston Bowel Prep Scale (BBPS, 0–3 points for each of 3 colon segments). Methods We collected data from 438 men who underwent screening or surveillance colonoscopies and then repeat colonoscopy examinations within 60 days by a different blinded endoscopist (1161 colon segments total) at the West Haven Veterans Affairs Medical Center from January, 2014 to February, 2015. Missed polyps were defined as those detected on the second examination of patients with the best possible bowel preparation (colon segment BBPS score of 3) on the second examination. The primary outcome was proportion of colon segments with adenomas >5mm that were missed in the first examination. We postulated that the miss rate was non-inferior for segments with BBPS scores of 2 vs those with BBPS scores of 3 (non-inferiority margin, <5%). Our secondary hypotheses were that miss rates were higher in segments with BBPS scores of 1 vs those with scores of 3 or of 2. Results The adjusted proportion with missed adenomas >5mm was non-inferior for segments with BBPS scores of 2 (5.2%) vs those with BBPS scores of 3 (5.6%) (a difference of −0.4%; 95% confidence interval [CI], −2.9% to 2.2%). Of study subjects, 347 (79.2%) had BBPS scores ≥2 in all segments on initial examination. A higher proportion of segments with BBPS scores of 1 had missed adenomas >5mm (15.9%) than segments with BBPS scores of 3 (5.6%) (a difference of 10.3%; 95% CI, 2.7%–17.9%) or 2 (5.2%) (a difference of 10.7%; 95% CI, 3.2–18.1%). Screening and surveillance intervals based solely on the findings at the first examination would have been incorrect for 16.3% of patients with BBPS scores of 3 in all segments, for 15.3% with BBPS scores of 2 or 3 in all segments, and 43.5% of patients with a BBPS score of 1 in 1 or more segments. Conclusions Patients with BBPS scores of 2 or 3 for all colon segments have adequate bowel preparation for detection of adenomas >5 mm and should return for screening or surveillance colonoscopy at standard guideline-recommended intervals. Colon segments with a BBPS score of 1 have a significantly higher rate of missed adenomas >5mm than segments with scores of 2 or 3. This finding supports a recommendation for early repeat colonoscopic evaluation in patients with a BBPS score of 0 or 1 in any colon segment.

Background & Aims The effect of bowel preparation quality has been well-characterized for detection of adenomas but not for detection of sessile serrated adenomas/polyps(SSPs). We performed a prospective study to determine proportions of patients in whom SSPs were detected at different levels of bowel preparation quality, using common validated scoring systems. Methods Our study enrolled 749 male veterans 50–75 years old undergoing screening or surveillance colonoscopy. Proportions of patients in whom SSP were detected were calculated for each level of preparation quality based on the Aronchick scale (poor=low quality, fair=intermediate quality, and good or excellent=high quality) and the Boston bowel preparation scale (BBPS, scores of 0–3 for right, transverse, and left colon segments). We compared SSP detection among different levels of preparation quality using multivariate logistic regression, adjusting for age, indication, and endoscopist. Our primary hypothesis was that SSP detection would not be significantly lower with intermediate-quality than with high-quality preparations. Results SSPs were detected in a significantly smaller proportion of patients with intermediate-quality preparation than high-quality preparation, for the entire colon (4.6% vs 12.0%; odds ratio [OR]=0.37; 95% confidence interval [CI], 0.15–0.87) and right colon (1.5% vs 7.9%; OR= 0.19; 95% CI, 0.05–0.81). SSPs were detected in smaller proportions of patients with total colon BBPS scores <7 than in patients with BBPS scores of 7–9 (4.7% vs 12.6%; OR=0.36; 95% CI, 0.19–0.67). SSPs were detected in right colons of a smaller percentage of patients with BBPS scores of 2 than scores of 3 (4.7% vs 9.5%; OR=0.50; 95% CI, 0.26–0.94)). Conclusions Any bowel preparation quality below high quality is associated with a significant decrease in the detection of SSPs. Although intermediate-quality preparation and BBPS segment scores of 2 appear to be adequate for detection of adenomas, these levels of preparation quality may not be adequate for detection of SSPs.

Background and Aims Colonoscopy is less protective for right-sided colon cancers than distal colon cancers. Repeat right-sided examination has been suggested to increase adenoma detection and right-sided protective effect. Our prospective study assessed the yield of a second forward-view examination of the right colon done immediately after the initial examination. Methods All men, age 50 to 75 years, undergoing screening or surveillance colonoscopy at the West Haven Veterans Affairs Medical Center were invited to participate. A second forward-view examination was performed if the Boston Bowel Preparation Scale score was 8 to 9 (scale = 0 – 9) with right-colon-segment score 2 to 3 (scale = 0 – 3). The primary outcome was per-patient detection rate of adenomas (including sessile serrated polyps) on repeat right-colon examination, defined as number of patients with ≥1 adenoma on the second right-sided colon examination divided by total number of patients. An increase in the adenoma detection rate (ADR) was a secondary outcome. Results Repeat right-sided colon examination, performed in 280 patients, revealed additional adenomas in 43 patients (15.4%; 95% CI of difference, 11.3%–21.0%). Overall ADR increased by 3.2% (95% CI, 1.1%–5.3%) after the second right-sided colon examination; right-sided colon ADR increased by 6.7% (95% CI, 3.8%–9.7%). Ten (3.6%) patients had a change in their screening/surveillance interval with the addition of findings on the repeat right-sided colon examination. Conclusions A substantial 15.4% of patients had additional adenomas detected on repeat forward-view examination of the right side of the colon, whereas overall ADR increased significantly by 3.2%. Given the lack of additional training or equipment required, repeat forward-view examination of the right side of the colon is a simple, readily available method to achieve a modest improvement in ADR.

To estimate the risk of hepatitis B virus (HBV) infection among hospital workers, we measured the prevalence of HBV infection in employees in five hospitals in different parts of the country and examined the effect of occupational and non-occupational factors on HBV prevalence. Among 5,697 persons studied, serologic markers of HBV infection were found in 807 (14%). Prevalence of infection was strongly related to race (Asian > Black > White), sex (male > female) and increasing age.Risk related to health occupation, studied by examining the change in HBV prevalence with duration in occupational group, was most strongly correlated with frequency of contact with blood during work. Workers having frequent blood contact had the highest estimated infection rate (1.05 per 100 person-years) and those with moderate contact an intermediate infection rate, compared to a negligible infection rate in workers with no blood contact. Frequency of needle accidents had an independent, positive effect on HBV infection rates, while degree of patient contact had no effect. Infection risk was uniform among all hospitals for groups with frequent blood contact. Among different occupation groups, risk of HBV infection also correlated closely with degree of blood-needle contact during daily work. This study provides a general approach to assessing risk of HBV infection in hospital personnel, and indicates that risk may be most easily estimated by quantitating degree of blood-needle contact during daily work.