Long-term follow-up of Barrett's high-grade dysplasia

OBJECTIVE

The management of Barrett's high-grade dysplasia (HGD) remains controversial. The aims of this study were to evaluate prospectively the outcome of unifocal HGD (uHGD) in patients with Barrett's esophagus, and to determine demographic and endoscopic features predictive of progression to multifocal HGD (mHGD) and/or adenocarcinoma.

METHODS

Consecutive Barrett's patients in whom uHGD was found at initial endoscopy or during surveillance underwent intensification of medical treatment and repeat endoscopy. The study endpoint was progression to mHGD or adenocarcinoma or HGD in conjunction with a dysplasia-associated lesion or mass (DALM). HGD diagnosis was confirmed by a second, blinded pathologist.

RESULTS

A total of 15 Barrett's patients with uHGD met inclusion criteria and have been prospectively followed for a mean +/- SD of 36.8 +/- 23.2 months. All were white and male, with a mean age +/- SD of 61.4 +/- 14.9 yr. Barrett's length varied from 1 to 13 cm (mean, +/- SD, 6.8 +/- 4 cm). Overall, eight (53.3%) uHGD progressed: four of 15 (26.7%) to frank cancer between 17 and 35 months of follow-up, two of 15 (13.3%) to mHGD with DALM in conjunction with one or more foci of possible intramucosal cancer after 12-91 months of follow-up, one of 15 (6.7%) to mHGD with a focus of possible intramucosal cancer after 14 months, and one of 15 (6.7%) to mHGD after 29 months. Seven of 15 (46.7%) uHGD have regressed, five to no dysplasia and two to LGD, over the course of follow-up ranging from 24 to 73 months (mean +/- SD, 43.3 +/- 19.9). All three patients with short-segment Barrett's esophagus with uHGD regressed. Fisher's exact test revealed that Barrett's length > or =3 cm and presence of hiatal hernia approached significance (p < 0.08) in predicting uHGD progression to mHGD/DALM/cancer. However, use of the log-rank test to account for differences in length of follow-up show no significance for hiatal hernia or Barrett's length.

CONCLUSIONS

Barrett's uHGD has a high risk for progressing to mHGD or cancer. Justification of an observational approach to uHGD should be discouraged. Markers of uHGD progression, as well as regression, are needed.

Two unusual presentations of urogenital histoplasmosis and a review of the literature

Two unusual clinical presentations of urogenital histoplasmosis are described. A review of the literature on urogenital histoplasmosis is provided.

Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma

OBJECTIVE

This study was undertaken to prospectively determine the prevalence of gastric H. pylori infection in Barrett's esophagus and Barrett's complicated by dysplasia or adenocarcinoma.

METHODS

The prevalence of H. pylori was determined in Barrett's esophagus patients compared to a control population of patients with gastroesophageal reflux disease (GERD) only. All patients had a minimum of 10 gastric surveillance biopsies obtained. H. pylori colonization was determined upon the basis of hematoxylin and eosin and use of a modified Giemsa and or Steiner's silver stain of all gastric biopsy specimens.

RESULTS

Two hundred and eighty-nine Barrett's patients and 217 GERD control patients were included in the study. H. pylori was found in 95/289 (32.9%) of the Barrett's patients, compared with 96/217 (44.2%) of the GERD controls (NS). Forty-seven of the Barrett's patients had low-grade dysplasia/indefinite dysplasia, 14 high-grade dysplasia, and 20 Barrett's adenocarcinoma. When Barrett's was subgrouped according to absence of dysplasia, and presence of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma, H. pylori prevalence was found to be significantly less for patients with Barrett's high-grade dysplasia (14.3%) and adenocarcinoma (15.0%) versus patients with GERD alone (44.2%), Barrett's alone (35.1%), or Barrett's with low-grade dysplasia (36.2%) (p = 0.016). This difference could not be explained by differences between Barrett's esophagus patients infected with H. pylori and those who were not with respect to gender, smoking history, alcohol consumption, use of proton pump inhibitor, or length of Barrett's mucosa.

CONCLUSIONS

Barrett's high-grade dysplasia and adenocarcinoma are significantly more prevalent in patients who are not infected with H. pylori. H. pylori appears to have a protective effect against the development of Barrett's adenocarcinoma.

Multiple cutaneous metaplastic synovial cysts

The cutaneous metaplastic synovial cyst is a recently described lesion that characteristically presents as a solitary, tender subcutaneous nodule. On histopathologic examination, the lesion is characterized by a cystic structure with villous-like projections and a lining resembling hyperlastic synovium. The cause of cutaneous metaplastic synovial cysts is unclear, but trauma is presumed to be a precipitating factor, as most reported cases have a history of antecedent cutaneous injury. Here we present a case of multiple, bilateral cutaneous metaplastic synovial cysts in a 72-year-old white man with rheumatoid arthritis. This is the first reported case of a patient with multiple lesions. The characteristic clinical and pathologic features of this lesion, along with proposed cause, are reviewed herein.

Partnership and managed care: a way forward

As the programme of health reform in New Zealand gains momentum the number of new concepts and terms used to describe them is increasing to an extent where it would be easy for nurses, on whom the changes have major impact, to become overwhelmed. Most prominent and influential among the current ideas are managed care, evidence based practice, critical pathways and cultural safety. All these are permeated by the change process. In this paper critical issues surrounding aforementioned terms are discussed from both a professional and a consumer viewpoint, with reference to both the literature and media sources. The purpose is clarification, with the aim of assisting nurses to be more engaged in the debate.

Infection due to Paecilomyces lilacinus: a challenging clinical identification

We describe a case of noninvasive sinusitis caused by Paecilomyces lilacinus in a patient with diabetes mellitus. Cure was achieved by endoscopic drainage and aspiration of the fungal mass. We discuss the difficulty in and clinical importance of distinguishing Paecilomyces from Aspergillus.

Prospective, multivariate evaluation of CLOtest performance

OBJECTIVES

To determine prospectively the effect of aspirin, nonsteroidal anti-inflammatory drugs, H2-receptor antagonists, proton pump inhibitors, alcohol intake, race, age, history of Helicobacter pylori eradication attempts, and gastric biopsy location on CLOtest performance.

METHODS

Biopsy specimens were obtained from the antrum, greater curve, and proximal stomach. One biopsy specimen from each site (except for the proximal stomach) was used for the CLOtest and two or more specimens were used for histopathology. Giemsa staining was used for the definitive determination of H. pylori status.

RESULTS

One hundred seventeen patients were included in the study, and 50 of these were infected with H. pylori. The sensitivity and specificity of an antral CLOtest, based on the results of Giemsa-stained sections from the antrum alone, were 72.7 and 98.6%, respectively, whereas they were 66.0 and 100% when based on the results of Giemsa-stained sections from all three gastric biopsy sites. The sensitivity and specificity of a body CLOtest, based on the results of Giemsa-stained sections from the body alone, were 80.5% and 93.4%, whereas they were 76.0% and 100% when based on the results of Giemsa-stained sections from all three gastric biopsy sites. Combining CLOtest results from the antrum and body increased CLOtest sensitivity to 82.0%. Univariate analysis revealed only one factor significantly associated with CLOtest concordance: absence of alcohol consumption (p < 0.02). Stepwise logistic regression demonstrated that absence of alcohol use again was independently associated with the concordance between overall CLOtest and all Giemsa-stained biopsy specimen results (p < 0.03) as well as between body CLOtest and body Giemsa-stained biopsy specimen results (p < 0.03). Additional independent and significant associations were noted between antral CLOtest-antral Giemsa-stained biopsy specimen results and no history of H. pylori eradication attempts (p = 0.04) and between body CLOtest-body Giemsa-stained biopsy specimen results and race (African-American) (p < 0.03).

CONCLUSIONS

Obtaining a gastric biopsy specimen from the antrum as well as from the body increased CLOtest detection of H. pylori. CLOtest performance was shown to be affected by several demographic and clinical factors.

Mucosa-associated lymphoid tissue (MALT) in Barrett's esophagus: prospective evaluation and association with gastric MALT, MALT lymphoma, and Helicobacter pylori

OBJECTIVES

Prospective evaluation of the prevalence of mucosa-associated lymphoid tissue (MALT) within Barrett's esophagus and its association with gastric MALT, gastric MALT lymphoma, and H. pylori infection.

METHODS

From Barrett's esophagus patients, a minimum of six gastric biopsies were obtained, in addition to Barrett's surveillance biopsies. Additional gastric biopsies were taken from any ulcer(s), nodule(s), polyp(s), or other lesions. Patients with gastroesophageal reflux symptoms without Barrett's esophagus served as controls.

RESULTS

One hundred and thirty-nine Barrett's patients were included in the study. One hundred and twenty-two of these patients had gastric biopsies for gastric MALT and H. pylori determination. H. pylori was noted in the stomach of 48 patients and within Barrett's mucosa in 14. Barrett's MALT was noted in seven cases, gastric MALT in 16, and gastric MALT lymphoma in two. None of the 101 control patients had esophageal MALT. Two of the seven patients with Barrett's MALT had gastric MALT. Barrett's MALT was associated with esophageal H. pylori in 57.1% cases and gastric H. pylori in 71.4%. The prevalence of gastric and esophageal H. pylori in patients with Barrett's MALT was significantly higher compared to patients with Barrett's without MALT (p < 0.0001 and p < 0.007, respectively). Barrett's MALT was very focal and its esophageal location variable.

CONCLUSIONS

Barrett's MALT was associated with both esophageal and gastric H. pylori colonization. Esophageal MALT was associated with Barrett's esophagus. Gastric biopsy sampling is warranted in any patient with Barrett's MALT to detect gastric MALT and H. pylori, which, if found, should be eradicated.

Gastroduodenal pneumatosis: endoscopic and histological findings

The case described herein underscores the importance of early endoscopy when intramural gastric air is detected by radiography. Although gastric pneumatosis is an uncommon finding, when it is detected, clinicians must be aggressive in determining the underlying etiology so that appropriate interventions are initiated in a timely manner. In this case, the gross endoscopic appearance of the mucosa and the unique histological findings were critical in establishing the correct diagnosis. Although gastric pneumatosis has been found in surgically resected specimens, the first description of histological findings associated with gastric pneumatosis in endoscopically obtained biopsies is presented in this report. This report also documents how rapidly both endoscopic and histological abnormalities, associated with this entity, can resolve.

Prospective evaluation of intestinal metaplasia and dysplasia within the cardia of patients with Barrett's esophagus

The prevalence of cardia versus noncardia gastric intestinal metaplasia in patients with Barrett's esophagus was assessed prospectively. Four-quadrant biopsies were obtained from the cardia from 119 consecutive patients with Barrett's esophagus and 64 control patients. Gastric surveillance biopsies were obtained in 108 of the Barrett's patients and 58 control patients. There was a significantly greater prevalence of cardia intestinal metaplasia in short-segment Barrett's (10.2%), but not traditional Barrett's (3.3%), compared to control patients (0%) (P = 0.009). Dysplastic changes were significantly more frequent in the metaplastic epithelium within the esophagus than in the cardia (P < 0.0001). A significantly greater prevalence of noncardia intestinal metaplasia compared to cardia intestinal metaplasia was found in each of the three groups of patients; however, the prevalence of noncardia intestinal metaplasia between short-segment, traditional, and control patients was not significantly different. Cardia intestinal metaplasia was an infrequent finding in patients with Barrett's esophagus and appears to develop independently from that in the remainder of the stomach.

Chronic meningitis with cranial neuropathies in Wegener's granulomatosis. Case report and review of the literature

We report the case of a 41-year-old man with chronic meningitis and cranial neuropathies in whom leptomeningeal biopsy demonstrated Wegener's granulomatosis. The literature on meningitis in this disease is reviewed. This case illustrates that Wegener's granulomatosis can cause chronic meningitis.

Prospective long-term endoscopic and histological follow-up of short segment Barrett's esophagus: comparison with traditional long segment Barrett's esophagus

OBJECTIVES

Barrett's esophagus is associated with adenocarcinoma of the cardia and esophagus, regardless of its extent. The aim of this study was to compare the prevalence and incidence of dysplasia and adenocarcinoma in short segment and traditional long segment Barrett's esophagus.

METHODS

Seventy-four patients with short segment Barrett's and 78 with traditional Barrett's entered the study.

RESULTS

There were no significant differences in age or gender between the two groups of patients with Barrett's esophagus. A greater percentage of patients with short segment barrett's were black (p = 0.04). The prevalence of dysplasia at diagnosis in patients with short segment Barrett's was 8.1% versus 24.4% in patients with traditional Barrett's (p < 0.007). Adenocarcinoma was noted at diagnosis only in patients with traditional Barrett's (p < 0.0005). Twenty-six patients with short segment Barrett's and 29 with traditional Barrett's were followed prospectively for 12-40 months. Dysplasia developed during follow-up in two patients with short segment Barrett's and in six patients with traditional Barrett's (p < 0.05). Neither high grade dysplasia nor cancer developed in any patients with short segment Barrett's. High grade dysplasia did develop in two patients with traditional Barrett's esophagus, and mucosal adenocarcinoma developed in one. The frequency of dysplasia on the latest surveillance examination continued to be significantly higher for patients with traditional Barrett's (p = 0.03). Follow-up surveillance biopsy specimens of Barrett's mucosa frequently demonstrated an absence of goblet cells in patients with short segment Barrett's compared with patients with traditional Barrett's (p < 0.0001).

CONCLUSIONS

The prevalence of dysplasia or adenocarcinoma and the incidence of dysplasia in patients with traditional Barrett's esophagus are significantly higher than in patients with short segment Barrett's esophagus. Further prospective surveillance is required to determine whether the incidence of adenocarcinoma in patients with short segment Barrett's esophagus is significantly lower.

Cloning, chromosomal mapping and expression pattern of the mouse Brca2 gene

A proportion of human breast cancers result from an inherited predisposition to the disease. Mutations in the BRCA2 gene confer a high risk of breast cancer and are responsible for almost half of these cases. The recent cloning of the human BRCA2 gene has revealed that it encodes a large protein having little significant homology to known proteins. Here we describe the mouse Brca2 gene. The gene maps to mouse chromosome 5, consistent with its location on human chromosome 13q12. We have sequenced cDNA for the entire 3329 amino acid Brca2 protein and this has revealed that, like Brca1, Brca2 is relatively poorly conserved between humans and mice. Brca2 is transcribed in a diverse range of mouse tissues, and the pattern of expression is strikingly similar to that of Brca1. Taken together, our data highlight some intriguing similarities between two genes involved in inherited breast cancer susceptibility.

Uptake, excretion and respiration of sucrose and amino acids in the pea aphid Acyrthosiphon pisum

Ingestion, excretion and respiration in aphids were studied using artificial diets labelled with radioactive sucrose or amino acids. The rate of ingestion of a 25 % w/v sucrose diet was 12.4 nl mg-1 h-1 and the honeydew excretion rate was 5.3 nl mg-1 h-1, about 43 % of the volume ingested during the same period. The concentration of sugars in the honeydew was equivalent to 0.53 mol l-1 sucrose and 69 % of the sucrose ingested was assimilated. The amino acid concentration of honeydew was 24.6 mmol l-1 and 94 % of the ingested amino acids were assimilated. Respiration was measured by collecting respired 14CO2 using a chamber which allowed the aphids to feed during the experiments on 14C-labelled artificial diets. While feeding on a 25 % w/v sucrose diet, sucrose was respired at the rate of 1.32x10(-6) mmol mg-1 h-1, equivalent to 0.354 &micro;l O2 mg-1 h-1, which was 14.6 % of the rate of ingestion. There was no evidence that reducing the dietary sucrose concentration from 22 to 11 % w/v had any effect on the rate at which sucrose was respired. Amino acids were respired at a rate of 0.14x10(-6) mmol mg-1 h-1, which was 6.4 % of the rate of ingestion. Dietary sucrose was oxidised in preference to amino acids.

Short segment Barrett's esophagus: clinical and histological features, associated endoscopic findings, and association with gastric intestinal metaplasia

OBJECTIVES

To prospectively determine the clinical features, associated esophageal endoscopic lesions, associated gastric intestinal metaplasia, and prevalence of dysplasia and adenocarcinoma of short segment Barrett's.

METHODS

All patients undergoing upper endoscopy over a 5-month period were scrutinized for endoscopic features suggestive of short segment Barrett's, and, if present, multiple biopsies were obtained from the suspicious areas. Prevalence of gastric intestinal metaplasia was determined by obtaining biopsies from the antrum, body, and cardia.

RESULTS

Two hundred thirty seven patients were examined. Short segment Barrett's was suspected in only 42 patients, and traditional Barrett's was noted in 45 patients. Short segment Barrett's was confirmed by biopsy in 48%. Clinical presentation of short segment Barrett's was that of typical or complicated gastroesophageal reflux disease in 53%. A hiatal hernia was the most common associated esophageal endoscopic finding; however, none of the endoscopic findings differed significantly from findings of patients who did not have short segment Barrett's. Diagnosis of short segment Barrett's required histological analysis. A significant difference was noted in the prevalence of intestinal metaplasia between the esophagus and stomach in patients with Barrett's. No dysplasia or adenocarcinoma was detected in patients with short segment Barrett's.

CONCLUSIONS

Short segment Barrett's is a frequent finding in patients undergoing upper endoscopy. All patients with short tongues or patches of red mucosa lying less than 2 cm above the esophagogastric junction should be biopsied to exclude short segment Barrett's. Large scale endoscopic and histological surveillance studies along with long-term follow-up are required to clarify short segment Barrett's prevalence and cancer risk.

Environmental health in minority and other underserved populations: Benign methods for identifying lead hazards at day care centres of New Orleans

This study tests the hypothesis that exterior sources of lead dust are more important than interior sources in the route of exposure of children. Benign field methods were used to distinguish between potential and actual lead exposure problems. Utilising hand wipe and surface wipe techniques, hand and environmental samples were obtained from selected day care centres at different locations within New Orleans. Previous research has shown that soil lead is determined by location within the city. Private and public day care centres were selected from inner and outer city areas to estimate the extent of hand lead exposure. To measure and identify the extent of environmental lead exposure, hand wipes were taken before and after playing outdoors. Results of preliminary findings show that outdoor lead dust is a more potent contaminant of hands than indoor lead dust. An association was found between the amount of lead on children's hands after playing outdoors and the lead content in the exterior dust and soil. Although two girls out of forty children had exceptionally high hand lead quantities after playing outdoors, in general, boys have higher hand lead levels than girls. The private inner-city day care centre had a severe contamination problem in its outdoor play area. By contrast, the outdoor play area of the public inner city day care centre is of such a high quality that the quantity of lead dust is independent of location in the city.

Pre- and postnatal development of the catecholamine innervation of the hypoglossal nucleus in the rat: an immunocytochemical study

The pre- and postnatal development of the catecholamine (CA) innervation to the hypoglossal nucleus (nXII) in the rat was investigated immunocytochemically with antisera to tyrosine hydroxylase (TH). Immunoreactive profiles positive for TH were first identified in nXII on gestational day (GD) 16. By GD 18, the adult-like distribution pattern was evident, characterized by the preferential targeting of the ventromedial region of nXII, but this pattern was not consistently found in all fetuses until GD 19. From GD 19 to postnatal day (PD) 180, the overall density of TH immunoreactivity, particularly in the ventromedial region, increased with further growth and maturation of nXII. These results establish the early prenatal CA innervation of nXII and support the hypothesis that CA are important in regulating motor tongue behavior in the newborn. Moreover, because the ventral compartment of nXII contains motoneurons that innervate protrusor muscles of the tongue, and tongue protrusor mechanisms play an essential role in suckling, deglutition, and respiratory (maintaining a patent upper airway) behaviors, it is further proposed that the CA innervation of nXII is critical to the survival of the newborn.

Potential for cost economies in guiding therapy in patients with metastatic breast cancer

Therapeutic response in patients with advanced breast cancer is conventionally assessed with reference to criteria devised by the International Union Against Cancer. Evidence to date suggests, however, that assessments of equivalent quality may be obtained at lower cost from the use of serum markers. The paper presents estimates of potential cost savings resulting from the use of serum markers in place of conventional assessment and argues that the size of these savings merits the establishment of a randomised controlled trial.