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1 Preparing for Colonoscopy Rosalinda S. Hulse Jordan Hospital Plymouth, MA, USA 1. Introduction Colorectal cancer is the third leading cause of cancer-related mortality in the United States and the fourth most common cancer in men and women. Colonoscopy is the best screening test done to detect and prevent colorectal cancers. Abnormal growths such as a polyp, a tumor, or a suspicious-looking lesion in the colon or rectum can be biopsied or removed preventing the initiation of the carcinogenic process and potential metastases into other areas of the body, thereby, allowing patients to obtain a more effective treatment (s) with fewer side effects. Patients whose cancers are found early and treated in a timely manner are more likely to survive than those whose cancers are not found until symptoms appear (Atreja, A., Nepal, S. & Lashner, B., 2010; American Cancer Society [ACS], n.d, 2005). Figure 1 shows a picture of a polyp. Figure 1.a shows a picture of a cancerous tumor of the colon. Fig. 1. Polyp in sigmoid colon Fig. 1.a Cancerous tumor in the colon The hardest part of the colonoscopy procedure is the preparation. It usually starts one-to- two weeks prior to the test depending on the recommendation of the physician. Careful planning and strict adherence to these instructions is crucial to the success of the test. Many individuals who have undergone this procedure will attest to the difficulty in complying www.intechopen.com 4 Colonoscopy with these instructions and the harshness of taking the oral prep. As a result, many are hesitant to go through with it risking the possibility of missing diagnoses of cancerous or non-cancerous lesions, tumors or polyps in the colon or rectum. The key to a successful colonoscopy is good bowel prep, which also depends on the right choice of bowel cleansing agent. The colon needs to be totally clean for good visualization to avoid missing any abnormal or suspicious-looking areas. A small polyp or lesion can hide behind a small piece of stool. Poor or inadequate bowel prep may lead to a prolonged and costly procedure and a potentially inaccurate exam. It may also increase the chance of being aborted; to be repeated at another time which may be at an interval sooner than what is called for or suggested in the standard guidelines. A repeated colonoscopy also increases the risks and complications, such as perforation and bleeding of the colon, and infection (Lawrence, E. & Pickhardt, P., 2010; Hendry, P., Jenkins, J. & Diament, R., 2007; Froehlich, F., et al, 2005). Preparing for colonoscopy may sound complicated, uncomfortable and time- consuming, but it doesn't have to be. Following the instructions carefully and being prepared ahead of time will help the individual tolerate the procedure with minimal discomfort. This chapter will discuss the step-by-step process in preparing for this procedure for the adult population, explaining the different types of oral preps (including the adjuncts) to take as well as diet modification that will achieve the best results, taking into consideration any medical condition the individual might have. Special conditions that might be adversely affected by the prep, such as diabetes and any heart condition that require taking blood thinners will also be discussed. Tips to alleviate the discomfort while taking the prep will be outlined as well. The goal is to explain the process in a simple, non-intimidating fashion to encourage more individuals to avail of this life-saving screening procedure minimizing any fear and anxiety they may have. A well-informed individual is better able to follow directions carefully to ensure good results. Figure 2 shows an adequately clean transverse colon. Fig. 2. Transverse Colon www.intechopen.com Preparing for Colonoscopy 5 2. Bowel cleansing preps Some key questions need to be answered prior to selecting an appropriate bowel cleansing agent for the individual: 1. Does the individual have any condition (s) that is contraindicated to taking a bowel prep (i.e. bowel obstruction, perforation, and severe ileus)? If the answer is "yes," then another alternative diagnostic exam need to be considered. 2. Is the individual at risk for fluid and/or electrolyte imbalances? If the answer is "yes," then avoid the sodium phosphate group. Choose the polyethylene glycol. 3. Can the individual tolerate full volume solutions? If not at risk for fluid and electrolyte imbalance and cannot tolerate large doses, choose low-volume polyethylene glycol or sodium phosphate. Sodium picosulfate and magnesium citrate can also be another alternative to sodium phosphate. This is the choice in most European countries and is currently not available in the United States (Atreja, A., Nepal, S. & Lashner, B., 2010). Otherwise, a 4-L polyethylene glycol solution is the choice especially if the individual has a history of poor bowel prep or is worried about cost or insurance coverage. Compliance to completing a bowel prep is also dependent on a number of factors, namely, poor palatability of the prep, concomitant medications, comorbitites affecting renal and hepatic functions, time of test i.e. early morning or late in the afternoon, sex, and cost (Atreja, A., Nepal, S. & Lashner, B., 2010 & ASGE, 2009). Colonoscopies performed in the afternoon have shown higher rates of poor bowel prep and lower rates of adenoma detection (Varughese, S., Kumar,A.,George, A., & Castro, F., 2010; Sanaka,M., Shah,N., Mullen,K. et al,2006; Ness,R., Manam, R., Hoen,H. et al, 2001). One study found males to have poorer preps than females and the authors recommended these individuals schedule their colonoscopies in the afternoon to take advantage of the split-dosage regimen. The authors also found that colonoscopies performed within 6-8 hours of the end of the bowel prep resulted in a better cleansing than those performed more than 8 hours after ingestion of the last prep dose (Marmo, R., Rotondano, G., Riccio, G. et al. 2010). The criteria for good bowel prep include: • Require a short period of ingestion and the ability to empty out the colon in a rapid fashion without grossly or microscopically altering the lining of the colon • Will not cause undue shifts in fluid and electrolyte balances • Are safe to administer in light of existing comorbidities • Easy to complete regimen • Reimbursed by health insurance company or is inexpensive Unfortunately, none of the preparations currently available on the market meet all these criteria. As a result, several adjunctive methods have been added along with the main prep and are now available on the market to make it easier and tolerable for the individual to take (Lawrence, M. & Pickhardt, P., 2010). Historically, bowel cleansing agents evolved from preparations prior to surgical and radiologic exams. These included enemas, ingestion of cathartics as well as dietary restriction of low residue diet for 2-3 days prior to the procedure (Wexner, S., et al. 2006). These were harsh regimens which were time consuming, uncomfortable and inconvenient for the patient; hence, compliance was difficult. In addition, the early preparations contained mannitol, which, when fermented by bacteria in the colon resulted in combustible methane and hydrogen, which created a high risk for gas explosion when cautery was used. This was also true for sorbitol preparations (ASGE, 2009). This led to the development of an www.intechopen.com 6 Colonoscopy osmotically balanced solution with minimal water absorption or secretion into the colon by Davis and his colleagues in the 1980s (Davis, 1980). The solution was polyethylene glycol, "a high-molecular weight, nonabsorbable polymer in a dilute electrolyte solution that has an osmotic effect on the colon (Atreja, A., Nepal, S. & Lashner, B., 2010)." There are several commercially prepared bowel cleansers, and the compounds used in these preps generally fall into three major groups according to their mechanism of action: isosmotic (the polyethylene glycol group), hyperosmotic (the sodium phosphate group), and bowel stimulants (Atreja, A., Nepal, S. & Lashner, B., 2010; ASGE, 2009; Barkun, A. et.al, 2006; Wexner, S., Beck, D., Baron, T., et al., 2006). Other preparations have since been introduced to improve palatability and compliance, e.g. low volume prep such as PEG and Bisacodyl (Halflytely) and PEG and ascorbic acid (MoviPrep). The most commonly used bowel preparations in the United States are the oral sodium phosphate (NaP) solutions and the polyethylene glycol (PEG) solutions (Atreja, A., Nepal, S. & Lashner, B., 2010 & ASGE, 2009; Barkun, A., Chiba, N., Enns, R., et al., 2006). A summary is shown on Table 1. Approved Approved Bowel Prep by Product Active Ingredient Bowel Prep By Amount FDA for FDA for Adults Pediatrics Isosmotic FV* Colyte ( Flavored Polyethylene Yes No 4000 ml (4L) & Nonflavored) Glycol (PEG) GoLYTELY Polyethylene (Flavored & No 4000 ml (4L) Glycol (PEG) Yes Nonflavored) Sulfate-free TriLyte Polyethylene Yes >6 months 4000 ml (4L) (Flavored) Glycol NuLYTELY Sulfate-free (Flavored & Polyethylene Yes >6 months 4000 ml (4L) Nonflavored) Glycol Isosmotic LV** PEG & Ascorbic Yes No 2000 ml (2L) MoviPrep Acid 4 Bisacodyl Delayed-Release Halflytely PEG & Bisacodyl Yes No tablets plus 2000 ml (2L) PEG PEG-3350 without Glycolax No No 255 grams electrolytes PEG-3350 without Miralax No No 255 grams electrolytes Hyperosmotic Sodium phosphate Osmoprep Yes + No 32 tablets (oral) www.intechopen.com Preparing for Colonoscopy 7 Sodium phosphate Visicol Yes + No 40 tablets (oral) Sodium phosphate Fleet Enema Yes + >12 years 135 ml (enema) Magnesium Magnesium citrate Yes >6 years 300 ml Citrate (oral) Available as Fleet Phospho- Sodium phosphate prescription No 75 ml Soda EZ-Prep (oral) only+ Magnesium citrate LoSoPrepKit plus Bisacodyl oral Yes No One package & suppository Sodium No. Available Two sachets Picolax picosulfate & only in Europe Yes dissolved in 300 magnesium citrate & UK ml solution Sodium No. Available Two sachets CitraFleet picosulfate & only in Europe No dissolved in 300 magnesium citrate & UK ml solution Stimulant laxatives Sodium No. Available Two sachets Picolax # picosulfate & only in Europe Yes dissolved in 300 magnesium citrate & UK ml solution Sodium No. Available Two sachets CitraFleet# picosulfate & only in Europe No dissolved in 300 magnesium citrate & UK ml solution Senna Senna No No 100 tablets *Full Volume +Black Box warning included # Classified as osmotic and stimulant laxative **Low Volume +FDA recommends against over-the-counter use Table 1. Commonly Used Bowel Preparation Agents 2.1 Isosmotic or the polyethylene glycol group Polyethylene glycol solutions are nonabsorbable fluids that act as purgatives to evacuate the colon of stool. These are high volume gut lavage solutions that are osmotically balanced and do not induce a significant electrolyte and fluid shifts, hence, are more effective, better tolerated, and safer for individuals who have advanced liver or kidney disease, poorly compensated congestive heart failure, or have documented electrolyte imbalances. These also do not cause significant physiologic changes in the individual's vital signs, weight, and blood counts. However, some rare adverse events have been reported in association with polyethylene glycol ingestion. These include Mallory-Weiss tear, esophageal perforation, colitis, cardiac dysrhythmias, hyponatremia, aspiration, pancreatitis, and a syndrome of inappropriate antidiuretic hormone secretion (Lichtenstein, G., Cohen, L. & Uribarri, J., 2007). Commercially prepared polyethylene glycol solutions come in full volume: flavored and unflavored GoLYTELy, flavored and unflavored Colyte, NuLytely (sulfate-free), Trilyte flavored (sulfate-free); and low volume: Halflytely and MoviPrep (ASGE, 2009). www.intechopen.com 8 Colonoscopy The standard large volume polyethylene glycol (PEG) solutions, Colyte and GoLYTELY have been studied extensively and were found to have the most evidence for safety and effectiveness. The sodium sulfate in PEG allow for a reduction in sodium absorption in the small intestine. These solutions are also inexpensive and most health insurance companies reimburse the cost. The conventional adult dose is 4L, given as 240ml of the solution every 10 minutes 12-15 hours prior to the procedure until the 4L is consumed and rectal output is clear and watery. If given through a nasogastric tube, 20 to 30ml is instilled every minute. However, because of the large volume required to cleanse the colon and its poor palatability (salty taste and smell of sulfates), about 15% of individuals do not complete the prep (Atreja, A., Nepal, S. & Lashner, B., 2010 & Wexner, S., Beck, D., Baron, T., et al., 2006). The main complaint was nausea, bloating, abdominal cramping, and vomiting. To remedy this, splitting the dose allowed for better compliance and tolerability by the patients; half the dose was ingested the night before the procedure and the other half taken 4-5 hours prior to the procedure (Marmo, R., Rotondano, G., Riccio, G. et al, 2010). This method resulted in a better cleansing of the colon. With the traditional method of single dosing, the long interval between the end of the prep and the start of the procedure allowed secretions from the small intestine to flow into the large intestine, obscuring the view of the cecum and ascending colon. A study conducted by Varughese and associates found that for colonoscopies scheduled in the afternoon, ingestion of the one gallon or 4 L solution of polyethylene glycol resulted in superior cleansing of the colon and was better tolerated by the study participants. There were fewer side effects, too. This method evacuated the contents of the large intestine in a timely manner and did not allow time for the contents of the small intestine to flow to the large intestine thereby obscuring the view (Varughese, S., Kumar,A.,George, A., & Castro, F., 2010). Stimulant laxatives or ascorbic acid were also added to low-volume PEG solutions (e.g. MoviPrep) to improve compliance and palatability (Atreja, A., Nepal, S. & Lashner, B., 2010). Other suggestions to make ingestion of PEG solutions more tolerable are: • Adding flavor enhancers, such as Crystal Light, Gatorade, lemon juice or lemon slices. • Chilling the solution or adding ice cubes and drinking through a straw. • Taking metoclopramide (Reglan) 5-10mg tablets prior, to prevent nausea. • Adding one bottle of magnesium citrate (about 300 ml) or two to four tablets of bisacodyl 5mg/tab to decrease the volume ingested. • Stopping ingestion of the prep once the stool is clear and watery on the day of the test. • Administration of the prep via a nasogastic tube for individuals with altered mental status or with swallowing disability. • Ingestion of sulfate-free or flavored PEG solutions, such as NuLytely and TriLyte (flavors come in cherry, pineapple, orange, lemon-lime, and citrus-berry). • Ingestion of a low-volume solution (2 liters) plus a stimulant laxative, e.g. HalfLytely with two bisacodyl tablets and magnesium citrate; MoviPrep which is PEG plus ascorbic acid. A sulfate-free PEG solution was developed by Fordtran et al in the 1990s to improve palatability and smell of PEG solutions. The improved taste is the result of a decreased amount of potassium, increased amount of chloride and no sodium sulfate. Examples of these products are NuLYTELY and TriLyte and come in different fruit flavors. Dosing is the same as the 4L PEG solution. It is comparable in terms of safety, tolerance, and effectiveness to the conventional PEG solutions (Wexner, S., Beck, D., Baron, T., et al. 2006). Low-volume www.intechopen.com Preparing for Colonoscopy 9 Fig. 3. Several commercially prepared polyrethylene glycol solutions: Top left, GoLytely; top right, HalfLytely. Bottom left, Colyte and bottom right, MoviPrep. PEG preparations (e.g. PEG + ascorbic acid, PEG + electrolytes) were developed to improve patient tolerance by reducing the amount of solution required, and thus, reducing volume- related symptoms such as nausea, bloating, and abdominal cramping. Studies have shown equal efficacy with full volume PEG solutions but with improved compliance and tolerance by patients (Ell, C., Fischbach, W., Bronisch, H. et al. 2008; Bitoun, A., Ponchon, T., Barthet, M. et al., 2006; DiPalma, J., Wolff, B., Meagher, A. & Cleveland, M., 2003). 2.2 Hyperosmotic or the sodium phosphate solutions Sodium phosphate is widely used worldwide and is an effective bowel cleansing agent. It is better tolerated than PEG preps due to its smaller volume (1.5 -2 liters compared with www.intechopen.com 10 Colonoscopy polyethylene glycol's 4 liters) and better flavor. Its hyperosmotic property draws water into the colon stimulating peristalsis and eventually affecting a bowel movement. Unfortunately, this is the main disadvantage of NaP solutions, because it causes major fluid and electrolyte shifts in the body, such as hyperphosphatemia, hypocalcemia, hypokalemia, hyponatremia and/or hypernatremia, hypovolemia and increased plasma osmolality. This may lead to an acute phosphate nephropathy in patients with renal failure (ASGE, 2009; Balaban, D., 2008; Khurana, A., McLean,L, Atkinson, S. et al., 2008; Curran, M. & Plosker, G., 2004). Sodium phosphate solutions are therefore, not recommended in individuals with congestive heart disease, bowel obstruction, hepatic and renal disease, ascites, and megacolon. The following may also be at risk of injury to the kidneys if prescribed NaP: individuals over the age of 55, patients who are already dehydrated, patients with acute colitis, individuals taking diuretics, ACE (angiotensin converting enzyme) inhibitor drugs, ARB (angiotensin receptor blockers), and non-steroidal anti-inflammatory drugs (NSAIDS) (Ker, T., 2006; Hookey, L., Depew, W. & Vanner, S., 2002). A study done by Yakut and his associates found that in a selected group of elderly patients without comorbidities such as heart, kidney and liver failure, and diabetes, the administration of NaP preparation for colonoscopy was safe and well tolerated, with a low frequency of side effects (Yakut, M., Kubilay, C., Gülseren, S. et al., 2010). Dong Choon and associates conducted a retrospective study between August of 2005 and May of 2008 in patients with normal kidney function, undergoing colonoscopy at a health center in Korea using NaP solution as the bowel cleansing agent and found that it was safe and effective and no untoward renal injury was noted (Dong Choon, S., Sung Noh, H., Jeong Hwan, K. et al. 2010). Abaskharoun and colleagues also corroborated this findings with their own retrospective study in a Canadian health center (Abaskharoun, R., Depew, W. & Vanner, S., 2007). A prospective study by Casais et al. found that hyperphosphatemia in low-risk individuals was related to low weight and can be minimized with adequate hydration. It was their recommendation to prescribe an appropriate NaP dose according to the individual's weight (Casais, M., Guillermo, R-D., Perez, S, et al., 2009). In December 2008, the Federal Drug Administration (FDA) has recommended NaP preparations be removed as an over-the-counter bowel prep to avoid inappropriate use or overdosing, and a black box warning be included in the labels of prescription products warning consumers of the risk of acute phosphate nephropathy. C.B. Fleet Company voluntarily recalled its oral NaP products, Fleets Phospho-Soda and Fleet EZ-PREP. Sodium phosphate comes in tablet form or aqueous solution. The tablet form, Visicol and OsmoPrep, are the only two sodium phosphate prep available in the United States. The aqueous solution is no longer available (US FDA, 2008; Ainley, E., Winwood, P. & Begley, J., 2005). Figure 4 shows examples of sodium phosphate products available in the market. The differences in efficacy and safety of PEG and NaP solutions in cleansing the bowel prior to colonoscopy have been studied extensively, and, in general, the histology of the normal colon has been shown to be preserved with PEG solutions. Sodium phosphate solutions can alter the macroscopic as well as the microscopic appearance of the mucosa of the colon mimicking inflammatory bowel diseases. Thus, these preps are to be avoided in individuals with or suspected with colitis or inflammatory bowel diseases (Bucher, P., Gervaz, P., Egger, J., et al., 2006; Rejchrt, S., Bures, J., Siroky, M. et al. 2004). Magnesium Citrate is a saline laxative and also a hyperosmotic, and like sodium phosphate, acts by drawing water into the colon. Since it contains magnesium, and elimination is www.intechopen.com Preparing for Colonoscopy 11 Fig. 4. Sodium phosphate products available in the US: OsmoPrep and Visicol. The aqueous formula is available only as a prescription. through the kidneys, administer with extreme caution in individuals with renal insufficiency or failure (Atreja, A., Nepal, S. & Lashner, B., 2010). Magnesium citrate is often used as an adjunct to bowel prep. In addition to the PEG solution, adding magnesium citrate to the prep reduces the amount of PEG solution required to 2L. Taken the night before the procedure (one 300 ml bottle of magnesium citrate) plus two bisacodyl tablets and 2L of PEG solution, has shown to be just as effective as taking the full dose of PEG solution. Used alone, magnesium citrate is not an effective bowel cleansing agent prior to colonoscopy procedures. Magnesium citrate is often used as an adjunct to bowel prep (Atreja, A., Nepal, S. & Lashner, B., 2010; Wexner, S., Beck, D., Baron, T., et al., 2006). Fig. 5. Magnesium Citrate bottle 2.3 Stimulant preparations Stimulant laxatives such as bisacodyl (Dulcolax) have been added to low volume PEG solutions and have achieved comparable results to those given the standard dose of PEG solutions (Atreja, A., Nepal, S. & Lashner, B., 2010). It is poorly absorbed in the small intestine and its active ingredients stimulate colon motility, with an onset of action between 6-10 hours (ASGE, 2009). www.intechopen.com 12 Colonoscopy Fig. 6. Dulcolax tablets Sodium picosulfate is another cathartic with osmotic action on the bowel similar to NaP. It is a saline laxative used in combination with magnesium citrate. An observational study done in Canada by Love and his colleagues found that administration of sodium picosulfate and magnesium citrate yielded a high percentage positive rate for efficacy (Yakut, M., Kubilay, Ç., Gülseren, S. et al., 2010). This preparation is mostly used in Europe and Canada and is not available in the United States (ASGE, 2009). Fig. 7. Sodium picosulfate products. Not available in the US Senna, an anthracene derivative also helps stimulate colon peristalsis by increasing smooth muscle wall activity. A low dose senna (four 8.6 mg tablets of Sennakot) added to a low- volume solution of polyethylene glycol have been found to be just as effective as taking the full-volume PEG solution. It is usually taken within 2 to 6 hours of starting the PEG solution. A study found that there was better visualization of the right colon when senna was added to the magnesium citrate prep and was also better tolerated by the subjects (Vradelis, S., Kalaitzakis, E., Sharifi, Y. et al 2009). www.intechopen.com Preparing for Colonoscopy 13 Fig. 8. Senna products 2.4 Adjunct bowel preparation agents Enemas are useful in cleansing the distal colon in preparation for a sigmoidoscopy, but not recommended as prep for a full colonoscopy. They are used as adjuncts when patients come poorly prepped. The common types are: tap water enemas, soap suds enemas, sodium biphosphate (Fleet), and oil-based enemas such as, cottonseed oil plus docusate (Colace) and diatrizoate sodium (Hypaque). The last one is an iodinated water-soluble contrast agent used in radiographic exams that has a cathartic property. It slows absorption of water from the bowel so that the stool is softer. One study found that combining diatrizoate sodium with a low-volume saline laxative prep (preferably magnesium citrate) was just as effective as, if not better, than the other regularly prescribed preps. It consistently outperformed the standard high-volume PEG solutions in terms of effectiveness as a bowel cleanser and patient compliance and tolerance (Lawrence, E. & Pickhardt, P., 2010). One disadvantage to using this prep was that some individuals developed severe allergic reactions such as anaphylaxis and angioedema. Others have experienced muscle cramps and intermittent leakage of stool in their undergarments for up to 24 hours after the test (Atreja, A., Nepal, S. & Lashner, B., 2010; Lawrence, E. & Pickhardt, P., 2010 & Sohn, N. & Weinstein, M., 2008; Wexner, S., Beck, D., Baron, T., et al., 2006). Dietary modifications alone are inadequate prep for colonoscopy, but are a beneficial adjunct, by decreasing the formation of solid residue. Drinking clear liquids is recommended in ALL bowel preps and helps maintain adequate hydration (Atreja, A., Nepal, S. & Lashner, B., 2010; ASGE, 2009; Dykes, C. & Cash, B., 2007; National Guideline Clearinghouse, 2006). Carbohydrate-electrolyte solutions such as Gatorade and E-Lyte have been added to both PEG and NaP solutions to improve palatability and to avoid severe fluid and electrolyte shifts (Wexner, S., Beck, D., Baron, T., et al., 2006). Antiemetic agents such as metoclopramide (Reglan 5-10mg) are commonly used to prevent nausea and vomiting associated with taking bowel preparations. Antifoaming agents, such as Simethicone (three 80 mg tablets), an anti-gas, anti-flatulent agent, has been added to the prep to reduce the bubbles and improve visibility during colonoscopy (Tongprasert, S., Sobhonslidsuk, A. & Rattansiri, S., 2009). Nasogastric or orogastric tube installation is usually reserved for inpatients that are unable to drink the polyethylene glycol solutions, for patients who are unresponsive or those on mechanical ventilators. www.intechopen.com 14 Colonoscopy Rectal Pulsed Irrigation administered immediately prior to the colonoscopy preceded by intake of magnesium citrate the night before is also another alternative, though this is time consuming, expensive and requires expert nursing skill to be efficiently performed (Wexner, S., Beck, D., Baron, T., et al., 2006). Clebopride is another adjunct that has gained some interest among endoscopists. It is a D-2 dopamine antagonist with antiemetic and prokinetic properties which can improve the efficacy of bowel cleansing. A study was done to evaluate the efficacy, safety, tolerability, and acceptance of Clebopride as an adjunct to PEG solution as prep for colonoscopy. The authors found that Clebopride was better accepted by patients and was better tolerated as well. It diminished the symptom of nausea, abdominal distention, and borborygmus (Abdullah, M., Aziz Rani, A., Fauzi, A. et al., 2010). 3. Special considerations Diabetes Mellitus. Diabetic patients need to follow certain pre- and post- colonoscopy instructions to prevent hyper- or hypoglycemia episodes. The individual needs to discuss his/her medications with the physician at least two weeks prior to the test. Individuals taking insulin may need to have their regular dosages adjusted the day before and the day of the procedure. See tables 2 and 3 for general guidelines. Cardiac conditions. Individuals taking blood thinners will need to consult their physician as to when to stop taking these medications prior to colonoscopy. A blood test to check the PT/INR will need to be drawn in the morning the day before the exam. He or she should not stop taking his or her other cardiac medications without consulting his or her physician. Blood pressure medications are generally allowed to be taken even on the day of the procedure. The elderly. The elderly often have poorer bowel preps which may be attributed to a decrease or alteration in intestinal motility secondary to the aging process or other comorbidities. Constipation contributes to the poor quality of the colonoscopy which may be associated with the elderly's sedentary lifestyle, inadequate intake of fiber, depression, and dementia (Yakut, M., Kubilay, Ç., Gülseren, S. et al., 2010). They are also at risk for fluid and electrolyte imbalance, especially phosphate intoxication, due to concomitant medication use, comorbidities, poor kidney function or other gastrointestinal disorders. Adequate hydration without compromising cardiac function is of utmost importance with this population. Pregnancy. The need for colonoscopy during pregnancy is rare, hence the safety and efficacy of the bowel preps have not been studied. If it is deemed that the potential benefit of colonoscopy outweigh the small, but possible risks, then the pregnant woman may be cleansed with PEG solutions. NaP preps may be used with caution in select patients (ASGE, 2009; National Guideline Clearing House, 2006). The pediatric population will be discussed in another chapter. 4. Colonoscopy bowel preparations: general patient instruction guidelines Two weeks prior to your procedure: • You need to speak with or see the physician who will be performing your colonoscopy to go over your medical and surgical history, medications you take on a regular basis, allergies, any other pertinent information relevant to your procedure or concerns you may have. For women, please let the physician know if you are pregnant or maybe www.intechopen.com Preparing for Colonoscopy 15 pregnant. If you have kidney or liver disease and are on fluid restriction, your prep and diet may need to be adjusted. • Your physician will advise you what medications you need to discontinue and when to discontinue these prior to the test. These include all types of blood thinners or antiplatelet medications, anti-inflammatory drugs, multivitamin with iron and any other medication containing iron preparation, and bulk-forming agents. • If you have diabetes, it is advisable to schedule an appointment early in the day so that you can eat after and take your medications as close to your usual time as possible. You will be asked to bring your blood glucose meter and test strips and any treatment you use when you experience low blood sugar levels on the day of the exam. • For asthma sufferers, you need to bring your inhaler (s) the day of the exam. • For individuals using a CPAP or BiPAP machines, you will be asked to bring these on the day of the exam as well. • You will be asked to arrange for a ride to your colonoscopy as you will not be allowed to drive a car, take the bus or taxi home after the procedure. You will be given sedation medications for the procedure and the effects usually linger for a few hours after the test is completed. You will spend about 1-2 hours in the endoscopy suite, which includes the pre-procedure prep, the colonoscopy itself, and post- procedure recovery time. You will go home after to rest and allow the rest of the sedatives to wear off. If you arrive without an escort, your test will be cancelled or rescheduled. Seven days prior to your procedure: • Stop taking the following medications: • Iron, vitamin E and medications containing either component • Garlic, Ginko Biloba, ginger • Blood thinners (anticoagulant) such as warfarin (Coumadin), Fondaparinux (Arixta), enoxaparin (Lovenox) • Antiplatelets such as prasugrel (Effient), clopidogrel (Plavix), cilostazol (Pletal), anagrelide (Agrylin), pentoxifyline (Trental), dipyridamole (Persantine), dipyridamole with aspirin (Aggrenox), aspirin and any other products containing aspirin (Anacin, Alka Seltzer, Bufferin). Note: You must have your PT/INR checked in the morning the day before your test if you are on Coumadin or Warfarin, Plavix or Jantovan. Five to three days prior to your test: • Confirm your ride. • If you need to cancel or reschedule your appointment, this is the time to do so. Call the office where you booked your appointment. • Review the diet you need to follow as well as medication schedule if you are a diabetic. Most heart medications such as ones for high blood pressure are generally allowed to be taken even on the day of the exam. Diuretic medications are usually asked to be taken after the procedure is completed. • Purchase your prescription bowel prep, but DO NOT MIX or PREPARE the solution until the day before the exam, if not taking the pill form. • Stop taking bulk-forming agents such as Metamucil or Citrucel. www.intechopen.com 16 Colonoscopy Two days before the procedure: • Stop taking ALL anti-inflammatory drugs such as ibuprofen and ibuprofen products (Advil, Motrin, Nuprin), Voltaren, naproxen (Aleve, Anaprox, Midol Extended Relief, Naprelan, Naprosyn), Indocin, Relafen, Voltaren. Acetaminophen (Tylenol) is okay to take for any headache or discomfort you might be experiencing. • Stop eating seeds, nuts, corn, popcorn, whole grains. • Drink a minimum of eight glasses of water throughout the day. • Do not eat any solid food after midnight. Day before the procedure: • Beginning at breakfast, DO NOT EAT ANY SOLID FOOD. Instead, start a clear liquid diet which means drinking liquids that you can see through, e.g. apple juice, white grape juice, ginger ale, lemon-lime soda, Gatorade, Kool-Aid, Jello, coffee (without the creamer), tea, Seltzer, broth, bouillon or consommé. Do not drink liquid that is red, blue, or purple (cherry, purple grape, or berry flavors). Also avoid milk, milk products, non-dairy creamers, or alcohol. • For diabetics, the following are suggested clear food choices: • Apple juice (4 oz.) 15 Gm carbohydrate • Plain Jello without fruit (regular sweetened, ½ C.) 15 Gm carbohydrate • Grape juice (white, 4 oz.) 20 Gm carbohydrate • Any sports drink such as Gatorade (8 oz.) 15 GM carbohydrate • Italian Ice 3 0 Gm carbohydrate • Ice pops, orange or yellow popsicles 15 Gm carbohydrate • Coffee or tea with 1 tsp. sugar (one packet) 4 Gm carbohydrate • Fat-free beef or chicken broth, bouillon or consomme´ no carbohydrate • Clear diet soda, such as ginger ale no carbohydrate • Seltzer (flavored or nonflavored) no carbohydrate • Flavored water no carbohydrate • Tea with slice of lemon *Note: Aim for 45 grams of carbohydrate during mealtimes and 15-30 grams for snacks. Read the label of commercially prepared drink items for carbohydrate measurement per serving. Refer to Table 2 for diabetic medication guidelines. • In addition to water, drink a variety of liquid throughout the day (recommended every hour while awake). Your body needs a combination of water, sugar, and electrolytes. It will keep you from being dehydrated, weak, and hungry and you will be better able to tolerate the bowel prep. A new product on the market, called Colonoscopy Prep Assistant, helps individuals keep track of their hydration status. It is a web application that tracks the number of glasses of fluid the patient has taken, the time interval between drinks, and notifies the patient when it's time to take the next glass of fluid. This application is available for free in the Android market and iTunes and can also be downloaded at www.wellapps.com. • For individuals taking polyethylene glycol (PEG) prep, do the following: • In the morning, mix the PEG solution as directed and refrigerate. • Around 1:30 PM, take one tablet of metoclopramide (Reglan), if prescribed, to prevent or relieve the nausea that accompanies ingestion of the PEG solution. www.intechopen.com Preparing for Colonoscopy 17 Medications Morning Lunch Dinner/Supper Bedtime Actos, Actoplus Met, Avandamet, Avandia, Take your usual Take your usual Take your usual Metformin, dose dose dose Janumet, and Januvia Amaryl, Avandaryl, Duetact, Glipizide, Glucovance, Do not take Do not take Glyburide, Metaglip, Prandin, and Starlix Humalog, Regular If prescribed a If prescribed a or Novolog fixed dose, take fixed dose, take Insulin ½ the regular ½ the regular amount OR amount OR cover your carbs cover your carbs with usual carb with usual carb ratio ratio Lantus or NPH Take your usual Take your Insulin dose usual dose Novolog Mix Take half the 70/30, Novolin Take half the usual usual dose at 70/30, Premixed dose at dinner time breakfast insulin75/25 Table 2. General guidelines for diabetic medications the day before colonoscopy Fig. 9. Varieties of clear liquid: broth, Jello, apple juice or white grape juice, Gatorade, and ginger ale www.intechopen.com 18 Colonoscopy • If prescribed the 4-L GoLytely, take one glass (8 oz) every 15-20 minutes half-an- hour after taking the metoclopramide tablet, until half gallon is gone. Remember to drink clear liquids or water in between until you go to bed. Be sure to stay close to the bathroom. The rest of the half gallon will be taken the next day, about 3-4 hours prior to the scheduled procedure. If you have a morning appointment, you may need to get up in the middle of the night to complete your prep. If your test is in the afternoon, you may start taking the rest of the prep at 6 AM, one glassful every 15-20 minutes until the half gallon is consumed. • If nausea continues, take a second tablet of metoclopramide around 5 or 6 PM. Let your physician know if you are having difficulty completing the prep or uncomfortable side effects such as nausea, vomiting continues. • Another approach would be to take 3L the night before and 1L the day of the procedure. • For low-volume PEG preparations plus bisacodyl tablets, the clear liquid diet the day before is also followed. • Around noon time, take four (5mg) bisacodyl delayed-release tablets. • Start taking the PEG solution after a bowel movement occurs following taking the bisacodyl tablets. Keep drinking a glassful of the prep every 10-15 minutes until the 2 liters is consumed. You may take a break in-between dose if bloating, nausea, or vomiting ensues. Resume after the symptom (s) subsides. • For low-volume PEG prep (MoviPrep) with magnesium citrate, do the following: • Upon waking up the day before the exam, prepare the solution by mixing pouches 1 & 2 into the disposable container provided. Add lukewarm to the top line and mix until completely dissolved. Refrigerate. At around 5 PM, start drinking a cupful of the solution (about 8 oz.) down to the first mark on the container. Make sure you follow this with clear liquid of your choice. Keep drinking the solution down to the next line and so forth every 15 minutes until the liter is consumed. • The process will be repeated again for dose #2, but will not be taken until around 7:30 PM the same evening. • For individuals taking the sodium phosphate (NaP) prep, do the following: • Only clear liquids are consumed the day before the procedure. • For the aqueous NaP prep, take a 30 to 45 ml solution with at least 8 oz. of water (or any other preferred clear liquid) 10-12 hours prior to your scheduled exam. The second dose will be ingested at least 3-4 hours prior to your test the next day. • Continue to drink clear fluids until you go to bed. • Another recommended approach is to take the two doses of NaP, three hours apart in-between dose, starting at 4 PM or 5 PM for the first dose followed by the second dose around 9 PM, and supplemented around 10 PM by four bisacodyl (5mg) tablets. • For individuals prescribed the pill form (Osmo-Prep or Visicol: The recommended dose is 3 tablets every 15 minutes for 6 doses and then 2 tablets for a total of 20 tablets, the day before the procedure. This is again repeated the next day, 3 to 5 hours before the scheduled test. Osmo-Prep uses only 32 tablets in divided doses similar to Visicol. Again, these are taken with water or clear liquid. Dulcolax or magnesium citrate may also be added as an adjunct to ensure clear bowel return. www.intechopen.com Preparing for Colonoscopy 19 Tips: Do not be surprised if you do not have a bowel movement soon after ingesting your prep. It usually takes about 2-4 hours before you have your first bowel movement. Stay close to the bathroom as you will spend most of your day on the toilet. Try to use moistened wipes or a water spray instead of toilet paper to clean yourself to minimize irritation of the anal area. If you have a colostomy, be prepared to empty out your pouch often and liquid stool may leak around your pouch as well. Remember to keep drinking plenty of clear liquids to prevent dehydration. Follow your instructions for the prep as you do not want to repeat this procedure all over again because you did not get it right the first time. Day of the procedure: • Take your regular medications allowed by the physician with a small sip of water. You may have clear liquids three hours before your test. Refer to Table 3 for medication guidelines if you are a diabetic and remember to check your blood sugar in the morning before coming to the colonoscopy. Also bring your glucometer, extra test strips and your treatment for any hypoglycemic (low blood sugar) episodes. • Have your driver drive you to the colonoscopy place half-an-hour before your scheduled procedure or whatever time you were instructed to arrive. Remember to bring your paper work, medications, inhalers, CPAP or BiPAP machine, and health insurance card. • Make sure you wear comfortable clothing and bring extra clothes, underwear or peri- pads in case you have an accident and soil your clothes or underwear. Medications Morning Lunch Dinner/Supper Bedtime Actos, Actoplus Met, Avandamet, Avandia, Take your usual Take your usual Take your usual Metformin, dose dose dose Janumet, and Januvia Amaryl, Avandaryl, Duetact, Glipizide, Resume Glucovance, regularly Do not take Glyburide, prescribed dose Metaglip, Prandin, if allowed to eat Starlix Humalog, Regular Resume Resume regularly or Novolog Insulin regularly Do not Take prescribed dose if prescribed dose allowed to eat if allowed to eat Lantus or NPH Take your Take half of Insulin regularly your regularly prescribed prescribed dose dose Novolog Mix Resume Resume regularly 70/30, Novolin regularly Do not Take prescribed dose if 70/30, Premixed prescribed dose allowed to eat insulin 75/25 if allowed to eat Table 3. General guidelines for diabetic medications day of the colonoscopy www.intechopen.com 20 Colonoscopy Post procedure recovery: • You will be cared for by a nurse or a nurse's aide and your vital signs monitored for about half-an-hour to an hour immediately after the procedure in the recovery area. This will also allow for most of the effects of the sedatives to wear off. • During this time, your doctor will talk to you about the results of your colonoscopy. If a biopsy was performed, the results are usually not available until a few days later as the sample (s) will be sent to the lab for analysis. He will also provide you with any pertinent additional information or instructions for follow-up. • You will be discharged home with your designated driver once you are feeling okay and are able to tolerate oral fluids without being nauseous or vomiting. If you are diabetic, it is a good idea to check your blood sugar before going home. • Plan to rest for the remainder of the day. • Eat foods that are easy to digest to minimize or avoid nausea and vomiting which is mostly due to the lingering side effects of the sedatives received. Examples are, toast, soup, light sandwich (e.g. grilled cheese), tea, and coffee. • You may occasionally feel some bloating or be flatulent. This is normal and should disappear within 24 hours. If you had a biopsy done, it is not uncommon to see some flecks of blood in your stool for a couple of days following your colonoscopy. This is usually dark in color. Call your physician if you have bright red blood in your stool, experiencing persistent nausea, vomiting, and abdominal pain or bloating. 5. Safety and efficacy All colonoscopy bowel preparations are generally considered safe when properly dosed in individuals without contraindications to the specific product, but are not completely immune to the adverse reactions, and on occasion, severe negative outcomes. The safety of the bowel cleansing agent is related to the safety profile of the base agent, i.e, polyethylene glycol or sodium phosphate. The most commonly encountered side effects are bloating, abdominal pain, borborygmus, nausea, vomiting, dizziness, and fluid and electrolyte imbalance. Often the symptoms of nausea, vomiting and abdominal pain disappear once bowel movement commences. These symptoms have also been minimized and safety improved by splitting the dosages, adding adjuncts, administering low-volume preps, and increasing the interval time in-between dosages to 10-12 hours (ASGE, 2009; NGCH, 2006). Generally, the administration of isotonic polyethylene glycol solutions do not cause significant physiologic changes in vital signs, individual's weight, laboratory results (complete blood count, blood chemistries, and serum electrolytes). It has been safely administered in individuals with advanced liver and kidney failure, congestive heart failure, and fluid and electrolyte imbalances. Some concerns were raised with the use of some PEG solutions, HalfLytely, in particular, in patients taking angiotensin converting enzyme drugs (ACE) or potassium-sparing drugs such as aldactone, because of the small amount of potassium found in the solution. However, there were no clinical reports noted to date (ASGE, 2009; NGCH, 2006). Sodium phosphate, on the other hand, has been shown to alter both the macroscopic and microscopic (aphthoid erosions) mucosal lining of the intestine, which may mimic inflammatory bowel disease. This prep should then be avoided in individuals with or suspected to have inflammatory bowel disease. Serum electrolyte and fluid imbalances have www.intechopen.com Preparing for Colonoscopy 21 also been reported with sodium phosphate use. Hyperphosphatemia was seen in 40% of healthy individuals taking NaP. This could be significant for patients with renal failure. About 20% of individuals taking NaP preps have developed hypokalemia, elevated blood urea nitrogen, increased plasma osmolality, decreased exercise endurance, significant hyponatremia, hypocalcemia, and seizures. A rare adverse event, nephrocalcinosis, has been reported in patients with acute renal failure (Balaban, D., 2008; Gonlusen, G., Akgun, H., Ertan, A., et al., 2006; NGCH, 2006). As a result, the Federal Drug Administration (FDA) has recommended that over-the-counter use of sodium phosphate solutions be discontinued and a black box warning be included in prescription products. Manufacturers of sodium phosphate products were also required to perform a "risk evaluation and mitigation strategy, including a post marketing trial," to further assess occurrence of renal injury (ASGE, 2009). All bowel preps are contraindicated in individuals with known or suspected bowel obstruction, perforation or ileus. Bowel cleansing agents containing magnesium and phosphate should be used with caution or avoided in individuals with kidney failure. To minimize or avoid fluid and electrolyte imbalance, it is necessary to screen patients carefully and to instruct them to hydrate themselves, pre- and post-procedure. Intravenous fluids are usually given during the procedure. 6. Conclusion Colonoscopy remains the gold standard in the screening and evaluation of the colon for colorectal disorders and diseases. For maximum visualization of the colon, it is imperative that the bowel is thoroughly cleaned. Several commercially prepared agents are available on the market, but the most commonly used ones are the polyethylene glycol and sodium phosphate preps. Adjuncts have also been recommended in addition to the main prep to make it easier to administer. The choice of an appropriate bowel cleansing agent is influenced by its safety, ease of administration and completion, cleansing effectiveness, patient tolerance, adverse effects, palatability, reimbursed by health insurance, will not interact with regularly prescribed medications, and cost. It should be tailored to every individual based on his or her state of health, comorbidities, and medications taken on a regular basis. Kidney function should be evaluated prior to choosing a bowel cleansing agent particularly in the elderly. Thus, careful screening of the patients prior to colonoscopy, prescribing the appropriate dose and bowel cleansing agent, patient education and adequate hydration before and after colonoscopy will help ensure the safety and efficacy of the procedure. 7. Acknowledgement The author wishes to thank Kira Hulse, BS for her review of the article, Dr. Jonathan Russo, Chief of Endoscopy, for his expert advice regarding colonoscopy, and to my good friend, Marian de la Cour, BSN, MLS, for all her efforts in obtaining most of the literature referred to in this chapter. 8. References Abaskharoun, R., Depew, W. & Vanner, S. (2007, April). Changes in renal function following administration of oral sodium phosphate or polyethylene glycol for colon cleansing before colonoscopy. Canadian Journal of Gastroenterology, 21(4), 227-231. ISSN 0835- 7900 www.intechopen.com 22 Colonoscopy Abdullah, M., Aziz Rani, A., Fauzi, A., et al. (2010, January). A randomized, controlled, double-bind trial of the adjunct use of clebopride in polyethylene glycol electrolyte (PEG) solution for colonoscopy preparation. Acta Med Indones-Indonesian Journal of Internal medicine, 42(1), 27-30.ISSN 0125-9326 Ainley, E., Winwood, P. & Begley, J. (2005, July). Measurement of serum electrolytes and phosphate after sodium phosphate colonoscopy bowel preparation: An evaluation. Digestive Diseases and Sciences, 50(7), 1319-1323. ISSN 0163-2116 American Cancer Society. Colon and rectal cancer. Retrieved Feb. 14, 2011 from http://www.cancer.gov/cancertopics/types/colon-and-rectal American Cancer Society. Cancer trends progress report-2005 update. Retrieved Feb. 14, 2011 from http://progressreport.cancer.gov/doc.asp?pid=1&did=2005&mid=vcol&chid=22 American Society for Gastrointestinal Endoscopy (ASGE) (2009, June) . Technology status evaluation report. Colonoscopy preparation. Gastrointestinal Endoscopy, 69(7), 1201- 1209. ISSN 0016-5107 Atreja, A., Nepal, S. & Lashner, B. (2010, May). Making the most of currently available bowel preparations for colonoscopy. Cleveland Clinic Journal of Medicine, 77(5), 317- 326. ISSN 0891-1150 Balaban, D. (2008, September/October). Guidelines for the safe and effective use of sodium phosphate solution for bowel cleansing prior to colonoscopy. Gastroenterology Nursing, 31(5),327-334. ISSN 1042-895x Barkun, A., Chiba, N., Enns, R., et al. (2006, November). Commonly used preparations for colonoscopy: Efficacy, tolerability and safety – A Canadian Association of Gastroenterology position paper. Canadian Journal of Gastroenterology, 20(11), 699- 710. ISSN 0835-7900 Bitoun, A., Ponchon, T., Barther, M. et al. on behalf of the Norcol Group (2006, December). Results of a prospective randomized multicenter controlled trial comparing a new 2-L ascorbic acid plus polyethylene glycol and electrolyte solution vs. sodium phosphate solution in patients undergoing elective colonoscopy. Alimentary Pharmacology & Therapeutics, 24 (11-12),1631-1642. ISSN 1365-2036 Bucher, P., Gervaz, P., Egger, J., et al., (2006 January). Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery: A randomized trial. Diseases of the Colon and Rectum, 49(1), 109-112.ISSN 0012-3706 Casais, M., Guillermo, R-D., Perez, S. et al. (2009, December). Hyperphosphatemia after sodium phosphate laxatives in low risk patients: Prospective study. World Journal of Gastroenterology, 15(47), 5960-5965. ISSN 1007-9327 Curran, M. & Plosker, G. (2004,). Oral phosphate solution: A review of its use as a colorectal cleanser. Drugs, 64(15), 1697-1714. ISSN 0012-6667 Davis, G., Santa Ana, C., Morawski, S. & Fordtran, J. (1980, May). Development of a Lavage solution associated with minimal water and electrolyte absorption or secretion. Gastroenterology, 78, 991-995. ISSN 0016-5085 DiPalma, J., Wolff, B., Meagher, A. & Cleveland, M., (2003, October). Comparison of reduced volume versus four liters sulfate-free electrolyte lavage solutions for colonoscopy colon cleansing. American Journal of Gastroenterology, 98(10), 2187-2191. ISSN 0002- 9270 Dong Choon, S., Sung Noh, H., Jeong Hwan, K. et al. (2010, April). Change in renal function after sodium phosphate preparation for screening colonoscopy. World Journal of Gastroenterology, 16(16), 2010-2016.ISSN 1007-9327 www.intechopen.com Preparing for Colonoscopy 23 Dykes, C. & Cash, B. (2007, January). Key safety issues of bowel preparations for colonoscopy and importance of adequate hydration. Gastroenterology Nursing, 31(1), 30-37. ISSN 1042-895x Ell, C., Fischbach, W., Bronisch, H. et al. (2008, April). Randomized trial of low-volume PEG solution versus standard PEG + electrolytes for bowel cleansing before colonoscopy. American Journal of Gastroenterology, 103(4), 883-893. ISSN 0002-9270 Froelich, F., Wietlisbach, V., Gonvers, F., et al. (2005,March ). Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: The European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointestinal Endoscopy, 61(3), 378-384. ISSN 0016-5107 Gonlusen, G., Akgun, H., Ertan, A. et al. (2006, January). Renal failure and nephrocalcinosis associated with oral sodium phosphate bowel cleansing: Clinical patterns and renal biopsy findings. Archives of Pathology and Laboratory Medicine, 130(1) 101-106. ISSN 0003-9985 Hendry, P., Jenkins, J. & Diament, R. (2007, October). The impact of poor bowel preparation on colonoscopy: a prospective single centre study of 10,571 colonoscopies. Colorectal Diseases, 9(8), 745-748. ISSN 1463-1318 Hookey, L., Depew, W. & Vanner, S. (2002,December). The safety profile of oral sodium phosphate for colonic cleansing before colonoscopy in adults. Gastrointestinal Endoscopy, 56(12), 895-902. ISSN 0016-5107 Khashab, M & Rex, D. (2005,February). Efficacy and tolerability of a new formulation of sodium phosphate tablets and a reduced sodium phosphate dose, in colon cleansing: A single center open-label pilot trial. Alimentary Pharmacology & Therapeutics, 21(4), 465-468. ISSN 1365-2036 Ker, T. (2006, October). Comparison of reduced volume versus four-liter electrolyte lavage solutions for colon cleansing. American Surgeon, 72(10), 909-911. ISSN 0003-1348 Khurana, A., McLean, L., Atkinson, S. et al. (2008, March 24). The effect of oral sodium phosphate drug products on renal function in adults undergoing bowel endoscopy. Archives of Internal Medicine, 168(6) 593-597.ISSN0003-9926 Lawrence, E. & Pickhardt, P. (2010, August).Low volume hybrid bowel preparation combining saline laxatives with oral contrast agents versus standard polyethylene glycol lavage for colonoscopy. Diseases of the Colon & Rectum, 53(8), 1176-1181. ISSN 0012-3706 Lichtenstein, G., Cohen, L. & Uribarri, J. (2007,September). Review article: Bowel preparation for colonoscopy-the importance of adequate hydration. Alimentary Pharmacology & Therapeutics, 26(5), 633-641. ISSN 1365-2036 Marmo, R., Rotondano, G., Riccio, G. et al. (2010,August). Effective bowel cleansing before colonoscopy: A randomized study of split-dosage versus non-split dosage regimens of high-volume versus low-volume polyethylene glycol solutions. Gastrointestinal Endoscopy, 72(2), 313-320. ISSN 0016-5107 Makkar, R. & Shen, B. (2008, March). What are the caveats to using sodium phosphate agents for bowel preparation? Cleveland Clinic Journal of Medicine, 75(3), 173-176. ISSN 0891-1150 National Guideline Clearinghouse (NGCH), (2006). A consensus document on bowel preparation before colonoscopy. Retrieved on Feb. 24, 2011 from http://www.guideline.gov/content.aspx?id=9619&search=colonoscopy. www.intechopen.com 24 Colonoscopy Ness ,R., Manam, R., Hoen,H. et al (2001, June). Predictors of inadequate bowel preparation for colonoscopy. American Journal of Gastroenterology, 96(6), 1797-1802. ISSN 0002- 9270 Rejchrt, S., Bures, J., Siroky, M. et al. (2004,May). A prospective, observational study of colonic mucosal abnormalities associated with orally administered sodium phosphate for colon cleansing before colonoscopy. Gastrointestinal Endoscopy, 59(5), 651-654. ISSN 0016-5107 Rex,D., Di Palma, J.,Rodriguez, R. et al. (2010, August). A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate- free electrolyte lavage solution as preparation for colonoscopy. Gastrointestinal Endoscopy, 72(2), 328-336. ISSN 0016-5107 Rex, D. (2007, September). Dosing considerations in the use of sodium phosphate bowel preparations for colonoscopy. Annals of Pharmacotherpy, 41(9), 1466-1475. ISSN 1060- 0280 Sanaka, M., Shah,N., Mullen,K. et al (2006 December). Afternoon colonoscopies have higher failure rates than morning colonoscopies. American Journal of Gastroenterology, 101(12), 2726-2730. ISSN 0002-9270 Sohn, N. & Weinstein, M. (2008,April). Management of the poorly prepared colonoscopy patient: Colonoscopic colon enemas as a preparation for colonoscopy. Diseases of the Colon & Rectum, 51(4), 462-466. ISSN 0012-3706 The Harvard Medical School Family Health Guide (2006). Retrieved February 14, 2010 from http://www.health.harvard.edu/fhg/updates/preparing-for-a-colonoscopy.shtml Tongprasert, S., Sobhonslidsuk, A. & Rattanasiri, S. (2009, June 28). Improving quality of colonoscopy by adding simethicone to sodium phosphate bowel preparation. World Journal of Gastroenterology, 15(24), 3032-3037.ISSN 1007-9327 US Food and Drug Administration (FDA) (2008, December 11). Oral sodium phosphate (OSP) products for bowel cleansing (marketed as Visicol and OsmoPrep, and oral sodium phosphate products available without a prescription. FDA Alert. Retrieved March 01, 2011 from http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHuma nMedicalProducts/ucm094900.htm. Varughese, S., Kumar,A.,George, A., & Castro, F., (2010,November). Morning-only one- gallon polyethylene glycol improves bowel cleansing for afternoon colonoscopies: A randomized endoscopist-blinded prospective study. The American Journal of Gastroenterology, 105(11), 2368-2374. ISSN 0002-9270 Vradelis, S., Kalaitzakis, E., Sharifi, Y. et al (2009,April 14). Addition of senna improves quality of colonoscopy preparation with magnesium citrate. World Journal of Gastroenterology, 15(14), 1759-1763. ISSN 1007-9327 Wexner, S., Beck, D., Baron, T., et al. (2006,June). A consensus document on bowel preparation before colonoscopy : Prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointesinal and Endoscopic Surgeons (SAGES). Diseases of the Colon and Rectum, 49(6), 792-809. ISSN 0012-3706 Yakut, M., Kubilay, Ç., Gülseren, S. et al. (2010,June). The efficacy and safety of colonoscopy with oral sodium phosphate in elderly patients. Turkish Journal of Gastroenterology. 21(2), 140-145. ISSN 1300-4948 www.intechopen.com Colonoscopy Edited by Prof. Paul Miskovitz ISBN 978-953-307-568-6 Hard cover, 326 pages Publisher InTech Published online 29, August, 2011 Published in print edition August, 2011 To publish a book on colonoscopy suitable for an international medical audience, drawing upon the expertise and talents of many outstanding world-wide clinicians, is a daunting task. New developments in videocolonoscope instruments, procedural technique, patient selection and preparation, and moderate sedation and monitoring are being made and reported daily in both the medical and the lay press. Just as over the last several decades colonoscopy has largely supplanted the use of barium enema x-ray study of the colon, new developments in gastrointestinal imaging such as computerized tomographic colonography and video transmitted capsule study of the colonic lumen and new discoveries in cellular and molecular biology that may facilitate the early detection of colon cancer, colon polyps and other gastrointestinal pathology threaten to relegate the role of screening colonoscopy to the side lines of medical practice. This book draws on the talents of renowned physicians who convey a sense of the history, the present state-of-the art and ongoing confronting issues, and the predicted future of this discipline. How to reference In order to correctly reference this scholarly work, feel free to copy and paste the following: Rosalinda S. Hulse (2011). Preparing for Colonoscopy, Colonoscopy, Prof. Paul Miskovitz (Ed.), ISBN: 978- 953-307-568-6, InTech, Available from: http://www.intechopen.com/books/colonoscopy/preparing-for- colonoscopy InTech Europe InTech China University Campus STeP Ri Unit 405, Office Block, Hotel Equatorial Shanghai Slavka Krautzeka 83/A No.65, Yan An Road (West), Shanghai, 200040, China 51000 Rijeka, Croatia Phone: +385 (51) 770 447 Phone: +86-21-62489820 Fax: +385 (51) 686 166 Fax: +86-21-62489821 www.intechopen.com
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Ecology and Environment, Inc. Welcomes Michael S. Betrus, CPA to Board of Directors LANCASTER, N.Y., May 29, 2014 (GLOBE NEWSWIRE) -- Ecology and Environment, Inc. (E & E) (Nasdaq:EEI) has announced that Michael S. Betrus, CPA, will be joining the Board of Directors as an Independent Director and as a member of the Audit Committee. Mr. Betrus brings over 35 years of experience in accounting, financial management, contractual oversight, and budget forecasting to his role as a Director of E & E. He is currently the Senior Vice President and Chief Financial Officer of Power Drives, Inc., a manufacturing and industrial distribution company located in Buffalo, NY. He previously served as E & E's Accounting and Contracts Manager from 1994 to 2005. Headquartered in Lancaster, N.Y., E & E has completed thousands of projects for a wide variety of clients, including some of the most iconic, high-profile projects in the world. E & E is listed on the NASDAQ under the symbol EEI, and the information contained in this press release is available on the Company's website at www.ene.com. CONTACT: Mr. Frank Silvestro Chairman, Board of Directors (716) 684-8060 email@example.com
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[ROOT] sEFix (lag reduction)
So this fix seems to reduce some lag in the Android OS (XDA thread: http://forum.xda-developers.com/showthread.php?t=1987032 )
However, the initial post makes some changes that are 'artificial' which probably affects battery duration, so I just created an app that applies a more natural method based on this post: ( http://forum.xda-developers.com/showthread.php?p=36093065#post36093065 )
It just modifies the system's wakeup threshold to update /dev/random values when the entropy is too low. And it's completely reversible :)
NOTE: To modify the threshold ROOT permissions are required.
android.permission.ACCESS_NETWORK_STATE -> for ad banner.
android.permission.RECEIVE_BOOT_COMPLETED -> for applying the fix on boot.
Button Savior (Root)
You will need to upgrade your SuperSU to latest version if you have problem with Home, Back, and Menu keys
Top 1 Software key App on Android Market
Top 10 Must have app for root devices
Top 1 Must have app on HTC HD2
Top 1 Software key app with best customization features
Works from 1.5 to 4.0(ICS)
If you are afraid of breaking your hardware keys or you have broken keys or you simply just don't have any key on your device, get Button Savior to make your life easier.
Button Savior V2.1 is even better. If you have a Kitkat device, you get the ability to turn off statusbar or bottom navigation bar to release more screen area!
This app will display a floating software key panel which can be summoned everywhere anytime. Button Savior 1.1.6 or later now suppports E-INK display with specially made themes provided by XDA member Berlinski.
For non root user: You can still use power off, Home, Camera, Call , and volume keys or you can get Button Savior non root if you are running Jelly Bean or newer.
☆ (NEW) Immersive mode and full screen mode to get rid of Android navigation bar completely!
☆ (NEW) PopControl that allows you to add favourite action and use instantly.
☆ (NEW) Hover control supported for automatic Software Button visibility control with mouse or Samsung S-Pen
☆ (NEW) Free floatable trigger icon
☆ (NEW) Swipe to show Button Savior panel from both sides
☆ Simulates 'Home' 'Back' 'Search' 'Back' 'Recent Task' 'Screen Off' 'Volume', 'Directional Key'
☆ Can set to always open or auto hide based on user customizable timer
☆ Two types of trigger action to choose from (Gesture trigger and Click trigger)
☆ Added Camera key and Call key simulation
☆ Customizable trigger position
☆ Also provides themese to support e-ink display
☆ Can change it to one click mode for super fast button action in option
☆ Can create shortcut action such as call someone or go to bookmark on Call or Camera keys. (With PRO)
[Not Root?]
☆ Home key is supported
☆ Power key is supported
☆ Volume key is supported
☆ Camera key is supported
☆ Call key is supported
If your device is rooted and still cannot use keys except home, please update su binary and superuser apk.
You need to disable screen off feature first. To disable, go to setting/location secuirty/device admin to remove Button Savior from the list.
Theme contribution list:
(1) Default (XDA member stefen)
(2) Froyo (XDA member hlvl)
(3) Sense UI (XDA member internauta2000)
(4) Honeycomb (XDA member securecrt)
(5) Pen's Ginger (XDA member Pens and DreamS)
(6) Pen's Honeycomb (XDA member Pens and DreamS)
(7) Pen's Sense UI (XDA member Pens and DreamS)
(8) Contrast for E-INK (XDA member OMGWTF_BBQ aka BerlinSki)
(9) Metro for E-INK (XDA member OMGWTF_BBQ aka BerlinSki)
(10) Subtle for E-INK (XDA member OMGWTF_BBQ aka BerlinSki)
(11) K3 ICS (XDA member kam333)
(12) K3 Honeycomb (XDA member kam333)
(13) Rajiv's Windows RT (XDA member rajiv)
[This app requires following permission because]
☆ GET TASK: Need to display recent app
☆ VIBRATE: For hepatic feedback
☆ INTERNET: For ads and for shortcut with internet action
☆ ACCESS NETWORK: For ads
☆ MAKE CALL: For direct dial shortcut
Translate Free
2. Regardless of the language of the text input language you select is automatically recognized and translated into the language is translated.
3. Translated data is stored in an environment where the Internet can call and can be used as dictionary.
4. English To Play feature Main menu> Settings> TTS (text-to-speech) voice data from the installation should proceed. Or Downloads the voice data for the SVOX Pico Engine by getting the language pack from the Android Market.
5. For voice input feature [Google Voice Search] application in the market for search and install the required support.
Some of the languages below the current translation is not supported. Please note.
- Translation support language
Haitian Creole
Hmong Daw
Chinese (Simplified)
Chinese (Traditional)
- Speech Support Languages
Android platform 2.1(Eclair) support
Android platform 2.2(Froyo) support
Android platform 2.3(Gingerbread) support
Android platform 2.3.3 support
Android platform 3.0(Honeycomb) support
Android platform 3.1 support
Android platform 4.0(Icecream sandwich) support
Android platform 4.1 support
DO Button by IFTTT
Popular ways to use DO Button
+ Turn on your lights with just a tap
+ Get yourself out of awkward situations with a phonecall
+ Set your Nest Thermostat to the perfect temperature
+ Email your roommates when you're at the local grocery
+ Block off the next hour as busy in Google Calendar
+ Track your work hours in a Google Drive spreadsheet
+ Get a text with the location of where you parked the car
+ Ask colleagues on Slack if they want coffee
+ Toggle on or off most internet enabled devices
+ Tweet a map of your current location
+ Turn off your oven with a push of a button
+ Thousands more Recipes!
More apps you can connect with DO Button
Facebook, Gmail, Evernote, Google Calendar, Dropbox, Life360, UP by Jawbone, WordPress, Blogger, Tumblr, GroupMe, Pushbullet, Wink, littleBits, and over 180 more apps and devices.
What people are saying
"With the DO Button, IFTTT has found the winning formula: an app with just one big button per screen to do the tasks you return to most frequently." —Financial Times
"Great Big Buttons That Do Everything… DO is all about using your phone deliberately to accomplish specific tasks. It's somewhat like a widget, but far more powerful and customizable." —Buzzfeed
"DO Button is all about making something happen. Turn your Philips Hue lights on and off, program it to set your Nest Thermostat to a certain temperature, track your next journey in Google Drive, or send an email to your wife that you're on your way home." —Business Insider
Learn more about what DO Button can do for you at https://ifttt.com/do/button
–The IFTTT Team
Notepad To Do
The philosophy of this application is unique across the mobile world. The main differences from ordinary notepads and calendar applications are:
1. The colorful design, playful environment.
2. Categorized notes.
3. There are buttons representing categories instead of OK button – the note is always saved into a category without an extra click.
4. A very quick navigation by category buttons (there is also an option of sorting by event time or time of adding).
5. Notepad and calendar hybrid - you can add start and end time for each note.
6. No unnecessary jumping screens.
7. Widget displays notes which are about to expire shortly.
8. A special mode for quick deleting and checking notes.
9. The easy things can be done very simply and mainly quickly.
10. There is a very helpful illustrated help*.
* There are many non-basic functions which are nicely described in help – for example changing positions of main buttons, sorting notes by time of event or time of adding (ascend or descend), adding only date (without time), etc.
App not require Internet permission! You can be sure that nobody can't read your notes! Nevertheless, you can send your friend your note by e-mail and your friend can import that note to his CatNotes. You can migrate to another device by creating backup.
Do you have any questions, concerns or feedback? Send us an email: firstname.lastname@example.com. We'd be happy to answer your questions.
Clipboard Manager
Clipboard Manager is simple and powerful application to manage your clipboard, keep history, fast access to your notes in history, etc.
Check out features:
* Create unlimited categories.
* Save unlimited notes.
* Automaticaly save note from clipboard.
* New note confirmation.
* Auto clean up default category.
* Auto clean trash.
* Search in your notes.
Check it out and give us feedback!
Ctrl: Microsoft Word Shortcuts
Lists shortcut codes for Windows and now for Mac.
Clipper - Clipboard Manager
✔ Automatic & seamless clipboard history and extension. All copied text is collected and saved for later use. Don't worry about copying over anything important.
✔ Easy clipping organization and editing. Copy a clipping back to the clipboard with a single tap. Define custom folders for storing your collected clippings. View, edit and extract contents.
✔ Quick and easy access. Open Clipper through your status bar for quick access to your collection. Predefine quick snippets for easy copying and take your notes in Clipper.
✔ And much more. Customize clipboard collection, notification functionality, the user interface and more through the settings. Clipboard management couldn't be easier.
+ Upgrade to Clipper Plus to get online clipping sync, unlimited clippings, search, dynamic values and new options.
Copy and Paste 2.0 is here!
(After installing Clipper, you will need to start it once to activate monitoring. You will see a quick start tutorial. Task killers may interfere with Clipper.)
If you need help or have any suggestions or complaints, please don't hesitate to e-mail us at email@example.com. Your feedback is invaluable to us.
Used permissions:
✔ Photos/media/files: import & export backup functionality to internal storage or SD card
Booster for Android - FREE
Booster for Android Advantages
☆Phone Boost☆
► One-tap Boost: A single touch to boost your phone and release memory
► Regular Cleaning: Automatically closes background apps, keeping your phone at best speed
► Whitelist: You can add frequently-used apps to your whitelist
► Powerful Speed Booster: Boosts your Android system
► Home Screen Rocket Man: Brings you fun while cleaning memory
☆Easy to use☆
Lightweight, power saving and easy to use; quickly releases memory and boosts your phone
☆Totally free and no ads☆
All features are free without any advertisement plug-ins
☆Compatible with low-end phones☆
Supports lower Android versions and is compatible with small-screen phones
Booster for Android Features
☆Intelligent Power Saving☆
► Battery Status: Detects battery status in real time and shows usage time
► Power-saving Mode: You can customize various power-saving modes or choose from four different modes to extend stand-by time
☆App Management☆
► App List: Lists all apps and their footprints in different categories
► Easy Uninstall: Uninstalls third-party apps to free more storage space for speed boost
Supported Languages:
English, Simplified Chinese, Traditional Chinese, Spanish, Japanese, Korean, Russian, Indonesian, Portuguese Brazil.
Follow us on Facebook to get updates
Facebook: www.facebook.com/NQLab
Why does my phone become slow?
A new phone can run really fast but it gets slower as time goes by since the apps installed on the phone might run lots of services and processes in the background, and these services and processes always consume a great number of CPU and RAM resources.
How does the Booster for Android work?
By using an intelligent processes and memory management technique, Booster can release occupied system resources and make them available for actual program services, thereby greatly boosting your phone.
If you encounter any problems using the product, please send feedback and help us make the app better. Booster for Android helps you control and optimize background apps, memory and battery life to effectively boost your phone.
Email: firstname.lastname@example.com
You can use this for your study, bussiness etc...!
・You can make MemotyTree easily!
・Cut and Paste by Drag & Drop!
・Manage MemotyTrees with folder
・Add comment,tag,color to node
・Search nodes by tag, title
・Save MemotyTree as image file(jpg,png)
・Add an image to nodes
・Add a URL to nodes
・Able to import/export FreeMind(.mm) files
・Able to import/export MemotyTree(.mtr) file and send your MemotyTree to another smartphone/tablet
Copy is the easiest way to store, protect, and share all your amazing things. With FREE storage for new accounts and competitive pricing plans, you have enough space to store virtually everything you need. And anything you save with Copy is instantly accessible on your computers, smartphones, tablet and the Copy website.
App Features:
• Chromecast support! You can now stream any audio, video, or photos stored in your Copy account to a Chromecast-connected television.
• PhotoCopy: A quick, easy way to sync your photos and videos with your Copy account
- PhotoCopy automatically uploads any photo or video you take with your device's camera for a safe and fast backup
- Enable PhotoCopy in your preferences
• On-demand access to all your files
• Easy file sharing without big attachments
• Invite other people to join your folders for even easier sharing
• Upload your photos, videos, or anything from your SD Card
- Now upload a photo straight from your camera!
• Download past versions of any file
Game Booster & Launcher
■ Steps
• Select the games that you want to boost
• Tap the game icon to boost launching it
• Play the game
Q: How does this app work?
A: It kills useless running apps and free up memory before launching your game, so your game will run more smoothly.
Q: Can this app boost non-game apps?
A: Sure, you can add non-game apps and boost them as well.
AutoKiller Memory Optimizer
Forget task killers! AutoKiller Memory Optimizer is not a regular task manager, it is an award winner memory (minfree) tweaker, it fine tunes android systems inner memory manager to keep your device fast over time. As a side effect it also lowers battery consumption. Also includes a manual process/service manager and a DashClock extension.
- ROOT REQUIRED to set minfree values, unrooted devices will only have an emulation of this feature
- if you have questions or you face errors please check home page or write a mail
- for more details see home page http://andrs.w3pla.net
PRO key app is available on the play store!
Donators and PRO users receive additional features:
- no ads
- Chuck Norris mode enabled
- apply kernel tweaks on boot
- alternate preset (while screen is off)
- all widgets
- quick restart
- memory reclaim
- low intervals selectable for minfree emulators
Please be careful, apps with very similar look and name are distributed, they can be malicious.
-- MobiWIA - a cooperation with EclipSim --
touchqode pro
View and edit source code on Android phone. Touchqode PRO is a true mobile code editor that comes with syntax highlighting, autocomplete and other features found in a desktop IDE.
We support Java, HTML, JavaScript, Python, C++, C#, Ruby and PHP. Now with integrated FTP and SFTP client, simple GitHub viewer.
You can try free edition before buying. Support touchqode development by buying this PRO version.
Alternative to vim or emacs over the terminal. Works great as text editor, notepad or HTML editor. Install and start programming now.
More info on: http://goo.gl/00A1E
Tip of the day: if you need more symbols ($, #, |, @, %) press ALT+Tab on the keyboard to access symbol keyboard.
DroidEdit Pro (code editor)
★ Syntax Highlighting for several languages (C, C++, C#, Java, HTML, CSS, Javascript, Python, Ruby, Lua, LaTeX, SQL, ...)
★ Several color themes
★ Infinite undo & redo
★ Search & replace
★ Auto & block indentation
★ Keep opened files and changes between sessions
★ Open files directly from dropbox or a file manager
★ Character encoding support
★ Keyboard shortcuts (List below)
★ Share documents with other services (dropbox, email, ...)
★ Preview HTML files in browser
★ Bracket matching
★ Go to line
★ Run Scripts in SL4A directly
★ Configurable Shortcuts
Pro version only features:
★ SFTP/FTP support
★ Dropbox, Drive, Box support
★ Custom themes
★ Run external commands through SSH
★ Root mode
Using different character encodings:
★ To open a document with a different character encoding than the default: long press the open file button
★ To create a new document with a different character encoding than the default: long press the new file button
★ You can make this behavior the default in the preference screen
Long pressing the save document button allows you to save a document with a different filename
DroidEdit is specially useful for new generation android tablets with external keyboards like the Asus Transformer.
Try Hacker's Keyboard for a developer friendly virtual keyboard.
You should try the ad supported DroidEdit Free before buying this app. The ad supported version has exactly the same functionality as the paid version except it doesn't have SFTP support, Dropbox support, Custom themes and root mode.
Please rate the app in the market. For bug reports, feature requests or any other subject please use the following contacts:
Mail: droideditapp (at) gmail.com
Twitter: http://twitter.com/DroidEdit
Page: http://www.droidedit.com/
User Support: http://www.droidedit.com/support/
Facebook: http://facebook.com/droidedit
More from developer
LagFix (fstrim) Free
LagFix DOES NOT HANG! Trimming process might take many minutes! Like five or ten. Don' panic, make some tea and wait.
Read FAQ before using! http://bit.ly/SKLMBw
★ Premium version is now ON SALE! ★
You asked, we delivered! Premium version comes without ads and have an option to auto-run trimming at specified schedule - set it once, forget about lags forever! You can find it here http://bit.ly/Vx4ATs
It comes from different publisher because Google does not allow publishing of paid apps from my country.
Warning! This app should only be used by ADVANCED users! If you do not understand what it does - DO NOT USE IT! You can find fstrim() man in Google and more information on XDA - http://bit.ly/10VJRPt. RTFM before asking any questions or rating this app bad!
Some Android users suffer from poor performance after some days/weeks of heavy usage. This is due to a well-known TRIM bug affecting these devices (users report Nexus devices and HTC One devices are affected). Kernels with -discard mount option are NOT affected!
The source of the problem is that internal storage is not properly TRIMmed when needed. You can find lots of information on XDA - http://bit.ly/11VUJvQ and http://bit.ly/14gMsBg It is also well-known fact that running fstrim Linux tool from time to time fixes the issue until internal memory runs out of free blocks. Other solutions like mounting with -discard or disabling fsync may be slow or dangerous.
LagFix is a user-friendly implementation of fstrim utility. It allows you to select which partitions to trim (you should leave defaults unless you know what you are doing) and run the process easily.
Please note that fstrim output depends on kernel and device. It works fine unless you see errors. You might see big amounts of bytes, zero amount or repeating amount. All are fine! Read fstrim manual to understand why all these outputs are valid.
It is also advised to reboot your device after the TRIM process so that kernel could reinitialize block data.


text:
Easy Holiday Breakfast Bake Recipe
I have a few secrets for surviving the holidays. The first is I let go of perfection years ago. I no longer strive for the perfect decor, or over the top decorations. In fact now there are some years I barely get a tree up. But the secret is I do what I fits the time and energy we have and I'm OK with that.
Read More


text:
Toyota FJ Cruiser Problem Report
Toyota FJ Cruiser Fan belt type noise from the front engine area
(6 reports)
A fan belt type noise me develop from the front of the engine. This is commonly caused by belt idler or pulley issues. Our technicians tell us proper diagnoses of the noise concern should be completed before repairs are attempted.
Started the FJ after not driving it for 2 days, and this crazy whining noise started coming from the engine area. It's due for service, so I'm going to have it repaired, whatever it is. I just thought it was weird to spring up out of nowhere like that. - Visitor
1 person likes this
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text:
HSBC "lift" by Grey London
Agency: Grey London
Rating: 5.0
Executive creative director
McCann Erickson
(020) 7961 2758
Communications House, 7-11 Herbrand Street, London, WC1N 1EX
On a Saturday night in Greenwich.
The internet.
Sketchbook Pro.
I'm happy with the one I've got!
Can't do only three. I have lots of good friends, so that's not fair on them.
Terence Donovan. Because of his amazing energy and resilience.
I wouldn't presume that they did. But if they did, maybe for my honesty.
Doing a job I love doing!
I don't think there is such a thing as perfect happiness. You can be very happy though.
People will stop using the word digital!
Agency: Grey London
Rating: 5.0


text:
Let's get the sizzle on with these fiery recipes.
The sun is shining and it's time to get the heat on.Grab a beer and let's get some tingle on those tongues.Try any of these delicious recipes to get spicy this summer.Spicy ratatouille – this is a beautiful vegetarian dish with
a nice kick.
Cajun spice mix – heat up your calamari or chicken with this
homemade Cajun spice mix.
Chilli, garlic and cumin paste – a great spicy paste
to add to a sauce or jazz up any dish.
Chicken with chilli and peanuts - a quick stir-fry that's
packed with flavour.
Peri-peri recipes – blow your hair back with these 5
peri-peri recipes.
Chilli con carne – a great classic dish of spicy mince and
Lemongrass Thai chicken curry – sassy Thai spicy sauce on the side.
Chilli beef and basil stir-fry – a fantastic hot and healthy
dish.Coriander and chilli sweetcorn fritters – serve with creamy
guacamole or tzatsiki.
Mussels with ginger and chilli – a beautiful Asian inspired
dish with mussles.
- Caro de Waal
Comfort food doesn't always have to make you feel guilty.
Di Bibby has a solution for those who are starved of time.
24.com publishes all comments posted on articles provided that they adhere to our Comments Policy. Should you wish to report a comment for editorial review, please do so by clicking the 'Report Comment' button to the right of each comment.
Open Door is a contemporary restaurant set on Constantia Uitsig wine estate in South Africa.
Emborg Brie
Find out more
Wyke Mature Cheddar
Find out more
Emborg Camembert
South AfricaGroup Risk
South AfricaCorporate
South AfricaMurray & Roberts
TownhousesR 2 550 000
HousesR 2 550 000
HousesR 8 500 000


text:
Garden Tour
- Travel & Outdoor
- 10 Keats Grove, London, NW3 2RR
Poems on the Underground
Keats House
Wednesday, 9 July 2014 from 19:00 to 20:30 (BST)
A celebration of Dylan Thomas with guest poets Dannie Abse and Owen Sheers; readers Piers Plowright and Cicely Herbert; and music by Welsh composers, performed by the Apollo Chamber Players.
The summer set of Poems on the Underground, posted in July 2014, celebrates the centenary of the great Welsh poet Dylan Thomas. The set includes poems by Dylan Thomas and four living Welsh poets: Dannie Abse, Gwyneth Lewis, Owen Sheers and Gillian Clarke, along with a poem by Gerard Benson, co-founder of Poems on the Underground, who died on April 28, 2014.
In partnership with the Keats Community Library.
£5 - Booking recommended
Keats House is a beautiful Georgian villa where the poet John Keats found inspiration, friendship and love.
Keats House is open to visitors (check website for opening hours) and hosts a diverse programme of literary, musical and family events.
In order to purchase these tickets in installments, you'll need an Eventbrite account. Log in or sign up for a free account to continue.


text:
I have lived in sac for 22 years and just now have discovered this little hide away. I am a pastry loving person and Freeport does not disappoint. They may not be "known" for there esspreso or coffee, but it was one of the best cappuccino. With the amount of people they have on staff the line moves along so fast it's almost a shock when you realize after a few seconds that you are already being helped. I love this place. Sad I'm moving away.
If you own or manage Freeport Bakery, register now for free tools to enhance your listing, attract new reviews, and respond to reviewers.


text:
Einstein–Cartan–Evans theory
Einstein–Cartan–Evans theory was an attempted unified theory of physics proposed by Myron W. Evans, which claimed to unify general relativity, quantum mechanics and electromagnetism.[1][2][3][4] The hypothesis was largely published in the journal Foundations of Physics Letters between 2003 and 2005. Several of Evans' central claims were later shown to be mathematically incorrect[5][6][7][8] and, in 2008, the editor of Foundations of Physics published an editorial note effectively retracting the journal's support for the hypothesis.[9]
In the synopsis of his first book,[1] Evans writes:
This book is the first to describe a very successful objective unified field theory which emerged in 2003 and which is already mainstream physics – Einstein Cartan Evans (ECE) field theory. The latter completes the well known work of Einstein and Cartan, who from 1925 to 1955 sought to unify field theory in physics with the principles of general relativity. These principles are based on the need for objectivity in natural philosophy, were first suggested by Francis Bacon in the sixteenth century and developed into general relativity in about 1915. In this year, using Riemann geometry, Einstein and Hilbert independently arrived at an objective field equation for gravitation. Since then there have been many attempts to unify the 1915 gravitational theory with the other three fundamental fields: electromagnetism, the weak and strong fields. As described for the first time in this book, unification is achieved straightforwardly with the principles of standard Cartan geometry and the Evans Ansatz. The latter shows that electromagnetism is spinning spacetime, gravitation is curving spacetime and that they are unified with the structure (or master) equations of Cartan. Quantum mechanics is unified with general relativity using the Evans Lemma and wave equation. Technical appendices and charts are provided which show how all the major equations of physics are obtained from the ECE field theory, and two introductory chapters describe the background mathematics from an elementary level. The mathematical structure of ECE field theory is standard Cartan geometry, also known as differential geometry. The main topics of contemporary physics are covered in individual chapters, which also describe the conditions under which ECE theory reduces to Einstein Hilbert (EH) theory, and to Maxwell Heaviside field theory in classical electrodynamics. The Dirac equation is derived as a limit of the wave equation of ECE theory. The Schrodinger and Newton equations then follow as limits of the Dirac equation. It is therefore shown that ECE field theory provides, for the first time, a structure for the objective unification of field theory in natural philosophy.
Earlier versions of the theory were called "O(3) dynamics".
The theory has been used to justify the motionless electromagnetic generator, a perpetual motion machine.[10]
In 1998 Evans founded the Alpha Institute for Advanced Studies (AIAS) to keep developing his theory.[11] Its website collects papers on the theory and recent developments.[11]
Evans' claims are not accepted by the mainstream physics community. In an editorial note in Foundations of Physics the Nobel laureate Gerard 't Hooft discussed the "revolutionary paradigm switch in theoretical physics" promised by ECE theory. He concluded that activities in the subject "have remained limited to personal web pages and are absent from the standard electronic archives, while no reference to ECE theory can be spotted in any of the peer reviewed scientific journals".[9]
Several of the published contributions in this theory have been shown to be mathematically incorrect.[5][6][7][8] In response to these demonstrations, 't Hooft's editorial note concludes, "Taking into account the findings of Bruhn, Hehl and Obukhhov, the discussion of ECE theory in the journal Foundations of Physics will be concluded herewith unless very good arguments are presented to resume the matter."[9]
See also[edit]
- ^ a b Evans 2005
- ^ Evans 2006a
- ^ Evans 2006b
- ^ Evans 2007
- ^ a b Bruhn 2008
- ^ a b Bruhn, Hehl & Jadczyk 2008
- ^ a b Rodrigues & Souza 2005
- ^ a b Trovon de Carvalho & Rodrigues 2001
- ^ a b c 't Hooft 2008
- ^ Anastasovski, P. K.; Bearden, T. E.; Ciubotariu, C.; Coffey, W. T.; Crowell, L. B.; Evans, G. J.; Evans, M. W.; Flower, R.; Labounsky, A.; Lehnert, B.; Mészáros, M.; Molnár, P. R.; Moscicki, J. K.; Roy, S.; Vigier, J.P. (2001), "Explanation of the motionless electromagnetic generator with O(3) dynamics", Foundations of Physics Letters 14 (1): 87–94, doi:10.1023/A:1012085429802
- ^ a b Alpha Institute for Advanced Studies (AIAS)
- Evans, Myron W. (2005), Generally Covariant Unified Field Theory, Abramis, ISBN 1-84549-054-1
- Evans, Myron W. (2006a), Generally Covariant Unified Field Theory, II, Abramis, ISBN 1-84549-123-8
- Evans, Myron W. (2006b), Generally Covariant Unified Field Theory, III, Abramis, ISBN 1-84549-131-9
- Evans, Myron W. (2007), Generally Covariant Unified Field Theory, IV, Abramis, ISBN 1-84549-248-X
- Bruhn, Gerhard W. (2008), "On the non-Lorentz-invariance of M. W. Evans' O(3)-symmetry law", Found. Phys. 38 (1): 3–6, arXiv:physics/0607186, Bibcode:2008FoPh...38....3B, doi:10.1007/s10701-007-9189-6, MR 2387497
- Bruhn, Gerhard W.; Hehl, Friedrich W.; Jadczyk, Arkadiusz (2008), "Comments on: "Spin connection resonance in gravitational general relativity" by M.W. Evans", Acta Phys. Polon. B 39: 51–58, arXiv:0707.4433, Bibcode:2008AcPPB..39...51B, MR 2372785
- Rodrigues, Waldyr A.; Souza, Quintino A. G. (2005), "An ambiguous statement called the "tetrad postulate" and the correct field equations satisfied by the tetrad fields", Int. J. Mod. Phys. D 14: 2095–2150, arXiv:math-ph/0411085, Bibcode:2005IJMPD..14.2095R, doi:10.1142/S0218271805008157, MR 2218579
- Trovon de Carvalho, A. L.; Rodrigues, W. A. (2001), "The non sequitur mathematics and physics of the "new electrodynamics" proposed by the AIAS group", Random Oper. Stochastic Equations 9 (2): 161–206, doi:10.1515/rose.2001.9.2.161, MR 1832162
- 't Hooft, Gerard (2008), "Editorial note", Foundations of Physics 38 (1): 1–2, Bibcode:2008FoPh...38....1T, doi:10.1007/s10701-007-9187-8
External links[edit]
- Alpha Institute for Advanced Study (AIAS), Myron Evans' website.


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