Gregory J. Rumore

Race, ethnicity, sex and temporal differences in Barrett’s oesophagus diagnosis: a large community-based study, 1994–2006

Objective: To evaluate the demographics and incidence of Barrett’s oesophagus diagnosis using community-based data. Design: Observational study. Setting: Kaiser Permanente, Northern California healthcare membership, 1994–2006. Patients: Members with an electronic diagnosis of Barrett’s oesophagus. Main outcome measures: Incidence and prevalence of a new Barrett’s oesophagus diagnosis by race, sex, age and calendar year. Results: 4205 persons met the study definition for a diagnosis of Barrett’s oesophagus. The annual incidence in 2006 was highest among non-Hispanic whites (39/100 000 race-specific member-years, 95% confidence interval (95% CI) 35 to 43), with lower rates among Hispanics (22/100 000, 95% CI 16 to 29), Asians (16/100 000, 95% CI 11 to 22), and blacks (6/100 000, 95% CI 2 to 12). The annual incidence was higher among men than women (31 vs 17/100 000, respectively, year 2006; p<0.01). The incidence increased with age from 2 per 100 000 for persons aged 21–30 years, to a peak of 31 per 100 000 member-years for persons aged 61–70 years (year 2006). There was no increase in the incidence of new diagnoses until the last two observation years, which coincided with changes in data collection methods and may be due to bias. The overall prevalence among active members increased almost linearly to 131/100 000 member-years by 2006. Conclusions: The demographic distributions of Barrett’s oesophagus differ markedly by race, age and sex and were comparable to those for oesophageal adenocarcinoma. Thus, demographic disparities in oesophageal adenocarcinoma risk may arise partly from the risk of having Barrett’s oesophagus, rather than from differing risks of progression from Barrett’s oesophagus to cancer. There has been an almost linear increase in the prevalence of diagnosed disease.

Hemochromatosis screening in asymptomatic ambulatory men 30 years of age and older

OBJECTIVE To perform a cost-benefit analysis of screening for hereditary hemochromatosis. PATIENTS AND METHODS A total of 3,977 consecutive men > or = 30 years of age who presented for routine health checkups at a health maintenance organization medical center were screened for hereditary hemochromatosis by measuring transferrin saturation. Subjects with repeated transferrin saturation > or = 62% and ferritin level > or = 500 ng/mL (> or = 500 micrograms/L) were referred for liver biopsy. Subjects with transferrin saturation < 15% were referred for evaluation. Laboratory testing, screening, and abnormal screening test evaluation procedures were identified by chart review. RESULTS Forty patients had transferrin saturation > or = 62%. One hundred seventy-two had transferrin saturation < 15%. Eight patients with hemochromatosis were identified. The 3 patients most seriously affected had hepatic iron concentrations > 250 mumol/g dry weight. Two of them had hepatic fibrosis. Seven cases of hemochromatosis were found among 1,974 white subjects who were screened. Only 1 case was found among the remaining subjects. CONCLUSIONS Our observations support routine screening with transferrin saturation for white men > or = 30 years of age.

Helicobacter Pylori Infection and the Risk of Barrett's Oesophagus: A Community-Based Study

Objective: Gastric colonisation with the Helicobacter pylori bacterium is a proposed protective factor against oesophageal adenocarcinoma, but its point of action is unknown. Its associations with Barrett’s oesophagus, a metaplastic change that is a probable early event in the carcinogenesis of oesophageal adenocarcinoma, were evaluated Methods: A case–control study was carried out in the Kaiser Permanente Northern California population, a large health services delivery organisation. Persons with a new Barrett’s oesophagus diagnosis (cases) were matched to subjects with gastro-oesophageal reflux disease (GORD) without Barrett’s oesophagus and to population controls. Subjects completed direct in-person interviews and antibody testing for H pylori and its CagA (cytotoxin-associated gene product A) protein. Results: Serological data were available on 318 Barrett’s oesophagus cases, 312 GORD patients and 299 population controls. Patients with Barrett’s oesophagus were substantially less likely to have antibodies for H pylori (OR = 0.42, 95% CI 0.26 to 0.70) than population controls; this inverse association was stronger among those with lower body mass indexes (BMIs <25, OR = 0.03, 95% CI 0.00 to 0.20) and those with CagA+ strains (OR = 0.08, 95% CI 0.02 to 0.35). The associations were diminished after adjustment for GORD symptoms. The H pylori status was not an independent risk factor for Barrett’s oesophagus compared with the GORD controls. Conclusions: Helicobacter pylori infection and CagA+ status were inversely associated with a new diagnosis of Barrett’s oesophagus. The findings are consistent with the hypothesis that H pylori colonisation protects against Barrett’s oesophagus and that the association may be at least partially mediated through GORD.

Alcohol types and sociodemographic characteristics as risk factors for Barrett's esophagus.

BACKGROUND & AIMS Little is known about the effects of alcohol use and sociodemographics on the risk of Barretts esophagus, a precursor to esophageal adenocarcinoma. We evaluated the association between alcohol use, alcohol type, sociodemographic profiles, other lifestyle factors, and the risk of Barretts esophagus. METHODS With the use of a case-control study within the Kaiser Permanente Northern California membership, patients with a new diagnosis of Barretts esophagus (n = 320) diagnosed between 2002 and 2005 were matched to persons with gastroesophageal reflux disease (GERD; n = 316) and to population controls (n = 317). We collected information using validated questionnaires during direct in-person interviews. Analyses used multivariate unconditional logistic regression. RESULTS Total alcohol use was not significantly associated with the risk of Barretts esophagus, although stratification by beverage type showed an inverse association for wine drinkers compared with nondrinkers (>/=7 drinks of wine per week vs none: odds ratio, 0.44; 95% confidence interval, 0.20-0.99; multivariate analysis). Among population controls, those who preferred wine were more likely to have college degrees and regularly take vitamin supplements than those who preferred beer or liquor, although adjustment for these factors or GERD symptoms did not eliminate the inverse association between wine consumption and Barretts esophagus. Education status was significantly inversely associated with the risk of Barretts esophagus. CONCLUSIONS There are associations between alcohol types, socioeconomic status, and the risk of Barretts esophagus. Although choice of alcoholic beverages was associated with several factors, multiple adjustments (including for GERD) did not eliminate the association between alcohol and Barretts esophagus. Further research to evaluate the associations among socioeconomic status, GERD, and Barretts esophagus is warranted.

Dietary Antioxidants, Fruits, and Vegetables and the Risk of Barrett's Esophagus

OBJECTIVE:The present study evaluated the associations among antioxidants, fruit and vegetable intake, and the risk of Barretts esophagus (BE), a potential precursor to esophageal adenocarcinoma.METHODS:We conducted a case–control study within the Kaiser Permanente Northern California population. Incident BE cases (N = 296) were matched to persons with gastroesophageal reflux disease (GERD) (GERD controls N = 308) and to population controls (N = 309). Nutrient intake was measured using a validated 110-item food frequency questionnaire. The antioxidant results were stratified by dietary versus total intake of antioxidants.RESULTS:Comparing cases to population controls, dietary intake of vitamin C and beta-carotene were inversely associated with the risk of BE (4th vs 1st quartile, adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.26–0.90; OR 0.56, 95% CI 0.32–0.99, respectively), and the inverse association was strongest for vitamin E (OR 0.25, 95% CI 0.11–0.59). The inverse trends for antioxidant index (total and dietary) and fruit and vegetable intake were statistically significant, while most total intakes were not associated with reduced risk. The use of antioxidant supplements did not influence the risk of BE, and antioxidants and fruits and vegetables were inversely associated with a GERD diagnosis.CONCLUSION:Dietary antioxidants, fruits, and vegetables are inversely associated with the risk of BE, while no association was observed for supplement intake. Our results suggest that fruits and vegetables themselves or associated undetected confounders may influence early events in the carcinogenesis of esophageal adenocarcinoma.

Helicobacter pylori and Gastroesophageal Reflux Disease: A Case–Control Study

Background:  Gastric colonization with Helicobacter pylori is a proposed protective factor against gastroesophageal reflux disease (GERD), but little population‐based data exist and other data conflict.

Diagnosing Barrett's esophagus: reliability of clinical and pathologic diagnoses

BACKGROUND The accuracy of a Barretts esophagus diagnosis is not well studied. OBJECTIVE Our purpose was to evaluate the accuracy of a clinical Barretts esophagus diagnosis and the reproducibility of an esophageal intestinal metaplasia diagnosis. METHODS All patients with a Barretts esophagus diagnosis between 1994 and 2005 were identified by use of International Classification of Disease (ICD) and Systematized Nomenclature of Medicine (SNOMED) coding. Subsets received manual record review (endoscopy/pathology reports), slide review by a referral pathologist (interrater reliability), and 2 blinded reviews by the same pathologist (intrarater reliability). SETTING An integrated health services delivery system. MAIN OUTCOME MEASUREMENTS Accuracy of electronic clinical diagnosis and reproducibility of esophageal intestinal metaplasia diagnosis. RESULTS A total of 2470 patients coded with Barretts esophagus underwent record review; a subgroup (616) received manual pathology slide review. Review confirmed a Barretts esophagus diagnosis for 1533 (61.9%) patients: 437 of 798 subjects (54.8%) with a SNOMED diagnosis alone, 153 of 671 subjects (26.8%) with an ICD diagnosis alone, and 940 of 1101 subjects (85%) who had both a SNOMED and an ICD diagnosis. The same metaplasia diagnosis occurred with 88.3% of subjects (original vs referral pathologist, interrater reliability; kappa = .42, 95% CI, 0.34-0.48). The referral pathologist made the same metaplasia diagnosis twice for a given patient for 88.6% of subjects (intrarater reliability, 2 reviews by same pathologist; kappa = 0.65, 95% CI, 0.35-0.93). LIMITATIONS The accuracy of a Barretts esophagus diagnosis likely represents the minimum number, given the strict criteria. CONCLUSIONS A community pathologists diagnosis of esophageal intestinal metaplasia is likely to be confirmed by a referral pathologist. Electronic diagnoses of Barretts esophagus overestimate the prevalence, although they are usually confirmed in patients with both a SNOMED and ICD diagnosis of Barretts esophagus.

Comparison of ThinPrep versus conventional smear cytopreparatory techniques for fine-needle aspiration specimens of head and neck masses.

OBJECTIVES: Diagnostic accuracy of the ThinPrep process (Cytyc, Boxborough, MA) was compared with that of conventional (smear) cytopreparation for fine-needle aspiration (FNA) of head and neck masses. METHODS: In a prospective, randomized, single-blinded study, 209 patients served as their own controls and underwent 236 FNAs using ThinPrep and conventional (smear) cytopreparatory techniques. RESULTS: ThinPrep produced less air-drying artifact and less mechanical distortion than the conventional method. The conventional technique was diagnostic in 63% of samples; the ThinPrep technique was diagnostic in 55% of samples. When all results were combined, pathologists subjectively preferred the conventional technique but accepted use of ThinPrep as the only cytopreparatory technique for most head and neck masses. CONCLUSIONS: For adequately experienced cytopathologists, ThinPrep is acceptable for FNA of salivary masses, neck cysts, metastatic lymph nodes, and thyroid lesions. Conventional smear technique should be used for FNA of nonmetastatic lymphoid lesions. Use of ThinPrep can complement use of the conventional (smear) cytopreparatory technique when aspirate is nondiagnostic or bloody, when the patient has a blood-borne infectious disease, when the clinician is inexperienced, or when aspirate has entered the syringe.

Malignant chondroid syringoma of the face: a first reported case.

First described by Hirsch and Helwig in 1961, chondroid syringomas are rare, benign tumors of the skin that arise from the eccrine sweat glands. They occur most commonly in the head and neck, though they have also been found in the axilla, trunk, extremities, and genitalia. Malignant chondroid syringomas (MCS), also called malignant mixed tumors of the skin, are exceedingly uncommon. Only 29 cases have been previously reported in the world literature. Unlike their benign counterparts, MCS are most common in the extremities and seldom occur in the head and neck. We describe the first case to our knowledge of a MCS that arose from the skin of the face.

Iron Intake and Body Iron Stores as Risk Factors for Barrett’s Esophagus: A Community-Based Study

OBJECTIVE:High iron stores are a proposed modifiable risk factor for esophageal adenocarcinoma, but minimal human data exist. We evaluated whether iron intake and iron stores were associated with Barretts esophagus, a metaplastic change that is a strong risk factor for esophageal adenocarcinoma.METHODS:We conducted a case-control study within the Kaiser Permanente Northern California population. We identified all persons with a new diagnosis of Barretts esophagus (cases); they were matched to persons with GERD (without Barretts esophagus) and to population controls. Subjects completed examinations, dietary questionnaires, and testing for serum iron stores (ferritin and transferrin saturation). Analyses used unconditional logistic regression.RESULTS:We evaluated 319 cases, 312 GERD patients, and 313 population controls. Compared with population controls, Barretts esophagus patients had lower dietary iron intakes (4th vs 1st quartiles, odds ratio [OR] = 0.37, 95% confidence interval [CI] 0.17–0.80), similar total iron intakes (including supplement use), and lower iron stores (4th vs 1st quartiles, ferritin OR = 0.24, 95% CI 0.14–0.40;% transferrin saturation OR = 0.66, 95% CI 0.41–1.04; P value trend <0.01 and 0.03, respectively). Similar associations were observed in comparisons with GERD controls and among subjects without clear sources of blood loss on endoscopy.CONCLUSIONS:Patients with Barretts esophagus had lower dietary iron intakes and lower serum iron stores than controls in our population. These findings do not provide support for the current hypothesis that high iron stores or a high iron intake are risk factors for Barretts esophagus, a potential early event in the carcinogenic sequence for esophageal adenocarcinoma.