Risk of mortality and cancer incidence in Barrett's esophagus.

BACKGROUND: There are very few prospective follow-up studies of Barrett esophagus (BE) cohorts assessing the risk of extraesophageal cancer incidence or mortality. Such studies are necessary in order to understand the overall risks of cancer and death experienced by patients with BE. METHODS: A cohort of 502 patients with BE were identified at Leeds General Infirmary, England. Mortality and cancer incidence information were provided by the Office for National Statistics. Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) were calculated using indirect standardization. RESULTS: All-cause mortality was found to be elevated in patients with BE [SMR, 1.21; 95% confidence interval (95% CI), 1.06, 1.37] and remained so after esophageal cancers were excluded (SMR, 1.16; 95% CI, 1.01-1.32). Increased mortality risks were also found for malignant neoplasms of the esophagus (SMR, 7.26; 95% CI, 3.87-12.42) and diseases of the digestive system (SMR, 2.03; 95% CI, 1.11-3.40). The remaining disease categories produced no altered risk estimates. Circulatory disease mortality was borderline statistically significant (SMR, 1.24; 95% CI, 1.00-1.52; P = 0.053) for those with a specialized intestinal metaplasia diagnosis of BE. In the cancer incidence analyses, esophageal malignancies (SIR, 8.66; 95% CI, 4.73-14.53) and esophageal adenocarcinomas (SIR, 14.29; 95% CI, 7.13-22.56) were found to be increased in BE. All remaining analyses provided unaltered risks, including that of colorectal cancer. CONCLUSIONS: This study has shown evidence of an increased risk of esophageal cancer incidence and mortality in BE. It has also shown that those who have a histologic BE diagnosis may also have an increased risk of circulatory disease mortality.

Admission serum glucose level: an accurate predictor of outcome in gallstone pancreatitis.

OBJECTIVES: Early identification of patients at high risk of complications from acute pancreatitis is important; as yet, no simple and accurate method has been identified. The aim was to evaluate admission serum glucose as a prognostic marker in gallstone pancreatitis. METHODS: Retrospective review of consecutive admissions with gallstone pancreatitis to a large urban hospital was made. Serum glucose levels, Glasgow scores, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded. Outcomes considered were death, intensive care requirement, local complications, and length of hospital stay. RESULTS: There was a total of 184 admissions (122 women and 62 men; mean age, 55.4 years). Serum glucose of 8.3 mmol/L or higher was as good as APACHE II score of 8 or above (likelihood ratios [LRs] of 2.51 and 2.84, respectively) in predicting mortality (overall probability, 4.3%). Overall, 9.2% of the patients were admitted to intensive care units, and risk was significantly higher in patients with glucose of 8.3 mmol/L or higher (LR, 3.23; P < 0.001) or APACHE II score of 8 or above (LR, 1.9; P < 0.02). Local complications occurred in 12.0% of the patients, and the risk significantly increased in patients with glucose of 8.3 mmol/L or higher (LR, 2.61; P < 0.001) but not for APACHE II or Glasgow scores. Patients with admission serum glucose of 8.3 mmol/L or higher had a mean length of stay of 17.9 days as compared with 7.1 days for patients with admission serum glucose of less than 8.3 mmol/L (P < 0.001). CONCLUSIONS: In gallstone pancreatitis, an elevated admission serum glucose level offers more prognostic information than Glasgow and APACHE II scores.

Characteristics of patients with columnar-lined Barrett's esophagus and risk factors for progression to esophageal adenocarcinoma.

AIM: To determine the risk factors for the development of esophageal adenocarcinoma in these patients with columnar-lined esophagus (CLE). METHODS: Data collected retrospectively on 597 consecutive patients diagnosed at endoscopy and histology to have CLE at Leeds General Infirmary between 1984 and 1995 were analyzed. Factors evaluated included age, sex, length of columnar segment, smoking, and drinking habits, history of non-steroidal ingestion, presence of endoscopic esophagitis, ulceration or benign strictures and presence of Helicobacter pylori in esophageal biopsies. Univariate and multivariate analyses were performed to identify risk factors for the development of adenocarcinoma. RESULTS: Forty-four patients presented or developed esophageal adenocarcinoma during follow-up. Independent risk factors for the development of adenocarcinoma in patients with CLE were males (OR 5.12, 95%CI 2.04-12.84, P=0.0005), and benign esophageal stricture (OR 4.37, 95%CI 2.02-9.45, P=0.0002). Male subjects and patients who developed benign esophageal stricture constituted 86% (n=38) of all patients who presented or developed esophageal adenocarcinoma. The presence of esophagitis was associated with a significant reduction in the development of esophageal carcinoma (OR 0.28, 95%CI 0.13-0.57, P=0.0006). No other clinical characteristics differentiate between the non-malignant and malignant group. CONCLUSION: In patients with CLE, endoscopic surveillance for the early detection of adenocarcinoma may be restricted to male subjects, as well as patients who develop benign esophageal strictures.

Day-case laparoscopic cholecystectomy: a prospective evaluation of a 6-year experience.

BACKGROUND/PURPOSE: Day-case laparoscopic cholecystectomy (LC) offers convenience to patients and cost saving to the healthcare institutes. This article reviews our prospectively recorded experience with day-case LC to determine its applicability and safety, as well as patient satisfaction. METHODS: Of 744 consecutive patients who underwent LC over a 6-year period, 140 (19%) were scheduled for day-case surgery. Selection criteria included American Society of Anesthesiologists (ASA) score of 1 or 2, absence of morbid obesity, low risk for common bile duct stones, domicile within 50 km of the hospital, age greater than 18 and less than 75, and the ability to admit the patient on the day of surgery for operation during the morning. Patient satisfaction with day-case surgery was assessed by questionnaire at 4-6 weeks after operation. RESULTS: Some 117 of the 140 patients (84%) were discharged home on the same day of the operation. Two patients were re-admitted with abdominal pain, 1 of whom underwent a negative re-laparoscopy. There were no major complications. The reasons for overnight hospital stay were anesthetic in 12 (52%), surgical in 7 (30%), and social or logistic in 4 (18%) patients. There were no conversions. The proportion of patients scheduled for day-case remained static (median, 18.5%; range, 16%-22%). Some 99 of 105 patients (94%) who completed the questionnaire were satisfied with day-case surgery. CONCLUSIONS: In carefully selected patients, day-case LC is achievable and safe, and provides good patient satisfaction.

Boerhaave's syndrome: 10 years experience and review of the literature.

BACKGROUND: Spontaneous oesophageal rupture, also known as Boerhaave's syndrome, is a rare condition. It has a high mortality and its management is clouded with controversy. METHODS: A retrospective review of cases presenting to Middlemore Hospital over a period of 10 years was performed. RESULTS: A total of eight patients were found to have spontaneous oesophageal perforation. Six were managed operatively and two were managed non-operatively. There were seven men and one woman, whose ages ranged from 37 to 80 years (median: 64 years) at presentation. Six patients underwent thoracotomy. Five patients had primary closure of oesophageal perforation, two of these with tissue reinforcement. One patient underwent lavage alone without primary closure because there was widespread inflammation from the perforation. Two of the patients were managed non-operatively. Both subsequently died. The median postoperative stay was 36 days (range: 12-60 days). There was no postoperative mortality. CONCLUSION: Boerhaave's syndrome is rare and its management is not uniform. A review of the literature demonstrates wide disparity in management due to the rarity of the condition. Primary repair is appropriate for ruptures diagnosed early. Many are diagnosed late and T-tube drainage may be the simplest way to manage this difficult condition in this situation.

Survival from upper gastrointestinal cancer in New Zealand: The effect of distance from a major hospital, socio-economic status, ethnicity, age and gender.

BACKGROUND: Upper gastrointestinal cancer is the third most common cause of cancer mortality in New Zealand. Prognosis of these and other cancers is possibly affected by the accessibility of hospitals. Several studies have revealed a reduction in survival that correlates with increasing distance from a major cancer centre. The aim of the present study was to analyse any correlation between survival from upper gastrointestinal cancer and distance from a major centre, socio-economic status, gender, age and ethnicity. METHODS: Details of all 3351 patients diagnosed with cancers of the oesophagus, stomach, pancreas, liver and biliary tract between 1 January 1995 and 31 December 1997 were retrieved from the New Zealand cancer registry. The effect of age, gender, ethnicity, socio-economic status and distance from a major centre was analysed using univariate and multivariate regression analysis to identify any associations with survival. CONCLUSIONS: Increasing age and Maori descent were the only consistent indicators of poorer survival in this study. The relationship between distance and survival was shown to be complex and in this study deprivation had no effect on the prognosis of upper gastrointestinal cancer.

Predictive validity and estimated cut score of an objective structured clinical examination (OSCE) used as an assessment of clinical skills at the end of the first clinical year.

BACKGROUND: Assessment plays a key role in the learning process. The validity of any given assessment tool should ideally be established. If an assessment is to act as a guide to future teaching and learning then its predictive validity must be established. AIM: To assess the ability of an objective structured clinical examination (OSCE) taken at the end of the first clinical year of an undergraduate medical degree to predict later performance in clinical examinations. METHODS: Performance of two consecutive cohorts of year 3 medical undergraduates (n=138 and n=128) in a 23 station OSCE were compared with their performance in 5 subsequent clinical examinations in years 4 and 5 of the course. RESULTS: Poor performance in the OSCE was strongly associated with later poor performance in other clinical examinations. Students in the lowest three deciles of OSCE performance were 6 times more likely to fail another clinical examination. Receiver operating characteristic curves were constructed as a method to criterion reference the cut point for future examinations. CONCLUSION: Performance in an OSCE taken early in the clinical course strongly predicts later clinical performance. Assessing subsequent student performance is a powerful tool for assessing examination validity. The use of ROC curves represents a novel method for determining future criterion referenced examination cut points.

Gastro-oesophageal malignancy in New Zealand: 1995-97.

AIM: To assess the incidence, treatment and survival of patients with oesophago-gastric carcinoma in New Zealand. METHODS: All cases of oesophageal or gastric carcinoma diagnosed in 1995-97 were retrieved from the national cancer registry. Linked data describing all episodes of inpatient treatment for these patients were obtained from the New Zealand Health Information System. An analysis of demographics, treatment and survival was performed. RESULTS: A total of 1791 cases were recorded (616 oesophageal, 1175 gastric). Carcinomas of the gastrooesophageal junction made up the majority of cases. 1138 were male. The median age was 71 years. 78.6% were of European descent, 10.4% Maori, 3.6% Pacific Islanders and 7.4% of other ethnic backgrounds. There were a total of 3403 hospital admissions (median 1.0 per patient). Overall, 29% underwent a surgical resection (15% oesophageal, 36% gastric). Exploratory surgery alone was performed in 14% operated on for oesophageal cancer and 12.3% for gastric neoplasms. Following resection 90 day mortality was 11.8% (10.5% oesophageal, 12% gastric). Overall median survival was 6.3 months (5.8 months oesophageal, 6.6 months gastric) with 16.7% of patients alive at three years. Following resection median survival was 17.8 months ( 16.2 months oesophageal, 18.1 months gastric) with 35.8% of patients alive at three years (34.7% oesophageal, 36% gastric). CONCLUSIONS: These data provide a baseline for future studies of the evaluation and treatment of gastrooesophageal malignancy in New Zealand.

Engineered expression of the Coxsackie B and adenovirus receptor (CAR) in human dendritic cells enhances recombinant adenovirus-mediated gene transfer.

Dendritic cells (DCs) are key antigen-presenting cells (APCs) that act as central modulators of cellular immune responses. Genetic modification of DCs has considerable therapeutic potential in the treatment of a wide spectrum of diseases, including cancer and persistent viral infection. In this report, we show that pre-treatment of DCs with a recombinant adenovirus encoding the major adenovirus receptor, Coxsackie B and adenovirus receptor (CAR), significantly increased the uptake of recombinant adenoviruses (Ads) by primary immature monocyte-derived DCs. This could be correlated with CAR mRNA and surface protein expression. Transduction of DCs by recombinant adenoviruses did not significantly alter cellular viability. Therefore, we propose that pre-treatment of DCs with Ad5-CAR is one strategy to increase the susceptibility of DCs to transduction by recombinant Ads.