Esophageal capsule endoscopy for evaluation of patients with chronic gastroesophageal reflux symptoms: findings and its image quality.

Esophageal capsule endoscopy (ECE) may offer an alternative approach to visualize esophageal lesions associated with gastroesophageal reflux (GER) disease. The objective of this study was to report the ECE findings in patients with GER symptoms and validate a new scoring system to assess ECE video quality. Five hundred two ECE were performed in patients with GER symptoms. We devised a new grading scale called ECE Utility score to assess the quality of images using five different parameters: anatomic landmarks visualized, esophageal transit time, image quality, illumination, and artifacts. The ECE cases were independently scored by two interpreters in a randomized, blinded fashion. Reflux esophagitis was diagnosed via ECE in 254 patients (50.5%). We identified 12 cases (2.4%) with suspected Barrett's esophagus and all of them had endoscopic evidence of Barrett's esophagus on esophagogastroduodenoscopy. Histologic confirmation Barrett's esophagus was found in six patients and dysplasia was found in one patient. From the 502 cases, mean ± standard deviation total ECE Utility score was 8.89 ± 0.96 for interpreter 1 and 8.96 ± 0.93 for interpreter 2. The concordance rate between the two interpreters for the ECE Utility score ranged from 75.9-96.8% across the parameters and the Pearson correlation rate of the total score was 0.81. ECE is shown to be a simple noninvasive valuable technique for evaluating esophageal mucosa and producing high quality images in patients with GER symptoms. ECE can help as an alternative screening tool for diagnosing Barrett's esophagus.

Endoscopic management of biliary leaks after T-tube removal in liver transplant recipients: nasobiliary drainage versus biliary stenting.

This study presents the long-term sequelae of endoscopic retrograde cholangiopancreatography (ERCP)-managed biliary leakage in patients who underwent orthotopic liver transplantation (OLT) and compares the relative efficacy, safety, and charges of nasobiliary drainage (NBD) versus biliary stenting (BS). We identified all orthotopic liver transplant recipients from January 1, 1993, to December 31, 1997, who had undergone ERCP for biliary leakage. Clinical outcome and charges were calculated on an intention-to-treat basis according to initial endoscopic therapy. Of the 1,166 adult OLTs performed during the study period, 442 patients underwent elective T-tube removal. ERCP was attempted in 69 patients (16%) who developed biliary leakage after T-tube removal. Three patients (5%) in whom initial ERCP was unsuccessful underwent surgery. NBD and BS were used as primary therapy in 45 (68%) and 21 patients (32%), respectively. Three patients initially treated with NBD required reendoscopy or surgery compared with 6 patients initially treated with BS (P <.05). Although not statistically significant, there was a trend toward greater expense in the BS group compared with the NBD group. ERCP is a safe and effective method of managing biliary leakage after T-tube removal in orthotopic liver transplant recipients. However, our results suggest NBD is the preferred method because recurrent leaks were more common in patients treated initially with BS. With prompt use of ERCP, surgery is rarely needed for this complication of OLT.

The current health care environment and stages of market development.

The history of medical payment strategies is reviewed with a historical perspective on the development of the health care system in the United States. The growth of managed care is discussed with sections detailing the effects on and responses of health care providers, the insurance industry, government, consumers, and employers. Current status and future market trends are discussed.

Violence the Western way.

Despite the quiet revolution in response to changing conceptualizations of gender in psychoanalysis, the Western has remained the domain of aggressive phallic masculinity. The iconic imagery of the Western, when combined with its narrative trajectory, is used to tell stories of violent encounters between men. The acceptance of the genre, and its duplication by other cultures and film makers, indicates that the Westerns' imagery and moral solutions tap into some basic deep structures of anxiety and pleasure in violence between men. As long as societies require subtle sublimations of aggressive and violent drives, it is likely that men will seek imaginary regressive experiences to discharge frustrations.

A new look at peptic ulcer.

There have been notable advances in knowledge about peptic ulcer recently. Gastrin-producing tumors have been recognized as a rare cause of ulcer, and multiple physiologic defects have been found in duodenal ulcer, including excessive release of gastrin after food intake, increased sensitivity to gastrin, and decreased inhibition by low pH. The tendency of gastric ulcer patients to reflux duodenal contents into the stomach may have pathogenetic significance. Two new classes of drugs strongly inhibit acid secretion in man: chemically modified prostaglandins and histamine analogues which block the action of histamine on acid secretion. Their value in treating ulcer is now being assessed in clinical trials. A new operation for duodenal ulcer shows promise: only those vagal fibers innervating the acid-secreting part of the stomach are severed, thus obviating the need for a drainage procedure and decreasing some of the undersirable side effects of earlier operations.