James C. Gregor

Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients

Eosinophilic esophagitis in adults is a recently described entity occurring in young males with dysphagia, in whom esophageal biopsies show eosinophilic infiltration. This study defines the clinical and histological features of patients with eosinophilic esophagitis, distinguishing it from gastroesophageal reflux disease. Esophageal biopsies from patients with dysphagia or esophagitis were reviewed blindly, and assessed for: epithelial eosinophil counts, presence of eosinophilic microabscesses, edema, basal zone hyperplasia, lamina propria papillae elongation, eosinophils and fibrosis. Clinical and endoscopic findings were obtained. Eosinophilic esophagitis was diagnosed with epithelial eosinophils ≥15 in ≥2 high-power fields (hpfs) or ≥25 in any hpf. Analysis was performed with Mann–Whitney, χ2 and ANOVA tests. Of 157 cases, 41 had eosinophilic esophagitis. Male gender (81%) and age ≤45 (54%) were commoner in patients with eosinophilic esophagitis (P=0.001, 0.010, respectively). Dysphagia was more common in eosinophilic esophagitis patients (63%, P<0.001); heartburn was more common in noneosinophilic esophagitis patients (53%, P<0.001). Endoscopic rings were more common in eosinophilic esophagitis patients (27%, P=0.023); hiatus hernia was more common in noneosinophilic esophagitis patients (11%, P=0.022). Eosinophils were more numerous in eosinophilic esophagitis biopsies (mean 39/hpf, P≤0.001). Only eosinophilic esophagitis biopsies had eosinophilic microabscesses (42%, P≤0.001). Edema, basal zone hyperplasia, lamina propria papillae elongation and lamina propria eosinophils were commoner in eosinophilic esophagitis (P=<0.001–0.002), while lamina propria fibrosis was specific for eosinophilic esophagitis (39%, P<0.001). Eosinophilic esophagitis is a disease with a predilection for young males with dysphagia and rings on endoscopy. Biopsies in eosinophilic esophagitis have high epithelial eosinophil counts, averaging nearly 40/hpf. Increased awareness of eosinophilic esophagitis is necessary, since treatment with allergen elimination or anti-inflammatory therapy may be more effective than acid suppression.

Screening Blood Donors for Hereditary Hemochromatosis: Decision Analysis Model Based on a 30-Year Database

BACKGROUND & AIMS The high prevalence, morbidity, premature death, and benefit of early diagnosis and treatment make hemochromatosis a prime target for screening in the white population. Decision analysis techniques were used to compare the outcome, utility, and incremental cost savings of a plan to screen voluntary blood donors for hemochromatosis. METHODS The screening strategy includes sequential testing of serum unsaturated iron-binding capacity, serum transferrin saturation, serum ferritin, and either hepatic iron index or venesections to measure exchangeable body iron. Estimates of prevalence, asymptomatic intervals, probabilities of life-threatening clinical complications, symptom-specific life expectancy, and sensitivity and specificity of screening tests are based on our database of 170 hemochromatosis homozygotes and the published literature. RESULTS The screening strategy led to an incremental increase in utility of 0.84 quality-adjusted life days with an incremental cost savings of

Should ERCP be routine after an episode of idiopathic pancreatitis ? A cost-utility analysis

3.19 per blood donor screened. When the potential of identifying asymptomatic homozygous siblings was included, these values increased to 1.18 quality-adjusted life days and

Diaphragm-like strictures of the right colon induced by indomethacin suppositories : evidence of a systemic effect

12.57 per person screened. Screening remained a dominant strategy given a prevalence of hemochromatosis of > 0.0026 or an initial screening test cost of <

A cost-utility analysis comparing omeprazole with ranitidine in the maintenance therapy of peptic esophageal stricture

8. CONCLUSIONS Screening blood donors for hemochromatosis has the potential to improve overall societal health status and decrease third-party payer health care costs over the long-term.

Biliary Sludge: A Risk Factor for ‘Idiopathic’ Pancreatitis?

BACKGROUND Patients often recover from an episode of acute pancreatitis with conservative therapy and without an identified cause. The options include proceeding with ERCP to identify and treat an occult common bile duct stone or performing the procedure only after a second episode of idiopathic pancreatitis occurs. METHODS Decision analysis (SMLTREE software) was used to determine incremental cost-utility. Variables were estimated from a search of the literature, a utility analysis involving health professionals familiar with the question, and a retrospective review of hospital charts and costs. RESULTS This model estimates an incremental utility gain for the prompt ERCP approach of 1.0 quality-adjusted life weeks per patient at an incremental cost of

A Survey of Canadian Gastroenterologists about the Use of Methotrexate in Patients with Crohn’s Disease

245 (Canadian). This yields a cost-utility ratio of

Computer-based virtual reality colonoscopy simulation improves patient-based colonoscopy performance.

12,740 (Canadian) per quality-adjusted life year. The result was highly sensitive to the probability of finding an occult common bile duct stone. CONCLUSION Routine ERCP is of marginal overall benefit, but is of more substantial benefit and is more cost-effective in a subgroup of patients with a greater probability of having an occult common duct stone.

Resource Implications for a Population-Based Colorectal Cancer Screening Program in Canada: A Study of the Impact on Colonoscopy Capacity and Costs in London, Ontario

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Evaluation of the Endomysial Antibody for Celiac Disease: Operating Properties and Associated Cost Implications in Clinical Practice

BACKGROUND Recent studies have suggested that patients receiving omeprazole for prophylaxis against peptic esophageal stricture recurrence have less dysphagia and require fewer repeat dilations than patients receiving ranitidine. OBJECTIVE To estimate the incremental utility gain and associated incremental cost of omeprazole compared with those of ranitidine for the maintenance therapy of patients with peptic stricture who required esophageal dilation. METHODS Decision analysis using SMLTREE software was used to compare the incremental cost-utility of omeprazole 20 mg once daily with that of ranitidine 150 mg bid for one year. Variables were estimated from the literature, hospital data, and utility analyses involving patients with peptic stricture and health professionals. The primary outcome measure was cost per quality-adjusted life-years (QALYs) gained. RESULTS The incremental cost of omeprazole compared with that of ranitidine was