Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial.

BACKGROUND: In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness. METHODS: The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results. FINDINGS: 515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P<0·001). INTERPRETATION: This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

Gallstone disease in Peruvian coastal natives and highland migrants.

BACKGROUND: In a previous study, we found that gallstones were a common occurrence in the high altitude villages of the Peruvian Andes. AIMS: To determine if high altitude (> or = 1500 m) is a contributing risk factor for gallstone disease. METHODS: We conducted a cross sectional study in a periurban community in Lima, Peru, and compared the prevalence of gallstone disease between coastal natives, highland (Sierra) natives and Sierra natives who had migrated to the coast. We also compared the prevalence rates from this study with those from a previous study conducted at high altitude. We examined 1534 subjects >15 years of age for gallstone disease. Subjects were interviewed for the presence or absence of risk factors. RESULTS: Gallstone disease was more common in females (16.1 cases per 100, 95% CI 13.8-18.2) than in males (10.7 per 100, 95% CI 8.0-13.4). Females had a greater risk of gallstone disease, especially if they had used oral contraception and/or had four or more children. The age adjusted prevalence was not significantly different between coastal natives, Sierra migrants, and Andean villagers. The prevalence of gallstone disease was not associated with time since migration or with having native Sierra parents. After adjusting for other risk factors, Sierra natives who migrated to the coast had a lower prevalence of gallstone disease than coastal natives (odds ratio 0.74, 95% CI 0.58-0.94). CONCLUSIONS: This study indicates that high altitude is not a positive risk factor for gallstone disease and confirms that this disease is common in Peruvians, which may be attributable to Peruvian-Indian ethnicity.

Human hydatidosis in the central Andes of Peru: evolution of the disease over 3 years.

To document the natural history of Echinococcus granulosus infection and response to treatment of human hydatidosis, we reexamined 28 of 37 subjects with E. granulosus infection diagnosed in an epidemiological study conducted in 1994. Twenty-six (70%) of those 37 subjects underwent abdominal ultrasonography, chest radiography, and enzyme-linked immunoelectrotransfer blot assay in 1997. Medical records from two additional individuals were reviewed. Eight patients had their cysts surgically removed during the 3-year follow-up interval; no surgical complications or recurrences occurred. Among eight patients with cystic disease not treated by surgery, four had cyst-growth ranging from 0.4 to 1.4 cm during the 3-year interval. One patient developed a new cyst and another's simple cyst became septate; two developed new calcifications. Of 12 seropositive subjects with no cysts present in 1994, 10 reverted to seronegative, a finding that suggests a significant proportion of seropositive subjects in echinococcus-endemic regions may have only transient infection without disease. When cysts do develop, their growth rates and time courses are highly variable; over the 3-year period, we observed growth, septation, degeneration, and calcification of cysts.

Gallstone disease in high-altitude Peruvian rural populations.

OBJECTIVE: Cholelithiasis is a common problem in hospitals of the Peruvian Andes; however, its prevalence in Andean communities is unknown. To estimate the prevalence of gallstone disease in this locale, we conducted a cross-sectional community study in three high-altitude Peruvian rural villages (i.e., > 3000 m above sea level). METHODS: We examined 911 volunteers > 15 yr of age from three villages for gallstone disease by history and ultrasonography. Risk factors for gallstone disease were examined in 382 volunteers from one village. RESULTS: The age-adjusted prevalence of gallstone disease ranged from 4-10% in men and from 18-20% in women. Women had significantly higher age-adjusted prevalence rates than did men. The prevalence of gallstone disease increased significantly with age and decreased significantly with alcohol consumption. Although not statistically significant, we found a positive association between gallstone disease and body mass index. CONCLUSION: The results of this study indicate that gallstone disease, commonly perceived as a disease of the developed world, is also a common problem in high-altitude Peruvian communities.

Anatomic correction of dextrotransposition of the great arteries in a 36-year-old patient.

During the 1960s, the Mustard or Senning operation was the conventional palliative therapy for patients with transposition of the great arteries. Many of these patients are now adults, and the durability of the morphologic right ventricle to function as the systemic ventricle is being questioned. Surgical options for such adult patients have traditionally been limited to cardiac transplantation. More recently, an arterial switch operation with take-down of the Mustard or Senning baffles has been reported. Herein we describe the clinical course of a 36-year-old woman who underwent a successful single-stage Mustard take-down, atrial reconstruction, and arterial switch operation.

Clinical improvement after revision in Fontan patients.

BACKGROUND: Arrhythmias, decreased exercise tolerance, or malabsorption will develop in a significant number of Fontan patients. Fontan revision consisting of creation of lateral atrial tunnel, reconnection of the Glenn shunt when present, or both appears to improve these patients. METHODS: Over a 34-month period, 9 patients underwent Fontan revision. The mean age was 11 +/- 5 years and the mean interval from Fontan operation to revision was 3 +/- 2 years. The reason for revision included marked impairment in exercise capacity, inability to go to school consistently, and chronic fatigue in 6 patients, 3 of whom also had serious atrial arrhythmias. Five of the 6 patients had a classic Glenn shunt. The mean right atrial pressure was greater than the pressure of the Glenn shunt (20 +/- 1.6 versus 17 +/- 0.8 mm Hg). Three of the 6 patients also showed a significant gradient between the right or left pulmonary artery wedge and ventricular end-diastolic pressure, indicating pulmonary vein obstruction from the bulging atrial septum or partitioning patch (13 +/- 3 versus 6.8 +/- 1 mm Hg). The remaining 3 patients had revision because of malabsorption (1), hepatomegaly and obstructed right pulmonary veins from bulging atrial septum (1), and tricuspid insufficiency (1). Fontan revision was accomplished with creation of a lateral atrial tunnel and Glenn reconnection in 6 patients, Glenn reconnection in 2, and creation of a lateral atrial tunnel in 1. Four patients had additional procedures. RESULTS: One patient died of Pseudomonas pneumonia. Early extubation, chest tube removal, and postoperative hospital discharge were accomplished in 8 patients (mean = 1.4 +/- 1, 2.8 +/- 1, and 8 +/- 3 days, respectively). One patient died 8 months postoperatively of brain damage after ventricular fibrillation from attempted cardioversion for atrial flutter. The remaining patients had marked improvement in exercise capacity with ability to consistently go to school, improvement in duration and tolerance to arrhythmias on less medication, and resolution of malabsorption up to 37 months postoperatively (mean, 20 +/- 12 months). CONCLUSIONS: We conclude that creation of lateral atrial tunnel with excision of a bulging atrial septum or atrial partitioning patch that causes pulmonary venous obstruction, reconnection of the Glenn shunt, which allows better distribution of flow based on the pulmonary vascular bed and resistance of each lung, or a combination of these procedures will improve Fontan patients.

Comparison of three methods to obtain upper small bowel contents for culture.

In this study of 27 patients with dyspepsia, we compared three methods for obtaining upper small bowel contents for culture: 1) the Enterotest or string capsule method, 2) duodenal intubation using a closed polyethylene tube filled with water that had been boiled for sterilization and removal of dissolved oxygen, and 3) brushing of duodenal mucosa with a cytology brush protected by a sheath (the last two done during endoscopy). In 12 of the 27 patients, duplicate intubations and brushings were performed. The samples obtained were cultured aerobically. Parameters used to compare the three methods were: the contribution of each method to the diagnosis of upper small bowel bacterial overgrowth (USBBO), agreement between the methods in diagnosis of USBBO and in detailed microbiological findings, and the reproducibility of diagnosis of USBBO and of microbiological findings in duplicate intubation and brushing. Intubation and brushing were highly reproducible and superior to the Enterotest in all of the tested parameters. Intubation and brushing are equally efficacious, but intubation is preferred because of the slight cost advantage, ease of specimen processing, and the ability to obtain anaerobic specimens.

Hunger pain: a poor indicator of peptic ulcer in a developing country.

Endoscopy of the esophagus, stomach, and duodenum and stool examinations for ova and parasites were performed in 63 adult Peruvian patients with "hunger pain" (HP) and other dyspeptic symptoms. No lesion capable of provoking HP was found at endoscopy in 50 (78%) of the 63 patients. Only 7 (12%) of the patients had evidence of active or healed peptic ulcers. Another 6 patients (10%) had either gastric erosions or duodenitis. One (2%) of the patients was infected with hookworm, a parasite that produces epigastric pain mimicking HP. The 12% rate of peptic ulcer in Peruvian patients with HP contrasts strongly with accumulated experience in most developed countries, whose rates of peptic ulcer associated with HP range from 60 to 75%. As the frequency of peptic ulcer is so variable in patients with HP, we suggest that the simple term "hunger pain" be used instead of "peptic ulcer pain" or "ulcer dyspepsia" to refer to the complaint of such patients.