Jason C. Wills

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy

BACKGROUND Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia. OBJECTIVES To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy. DESIGN A prospective nonrandomized study. SETTING Tertiary-referral cancer center. PATIENTS Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years. INTERVENTIONS EUS followed by stent placement. MAIN OUTCOME MEASUREMENTS Dysphagia scores and patient weights. RESULTS There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%). LIMITATIONS A single center and small size of study. CONCLUSIONS Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

What Drives US Gastroenterology Fellows to Pursue Academic vs. Non-Academic Careers?: Results of a National Survey

OBJECTIVES:We conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision between an academic and a non-academic career.METHODS:A survey was e-mailed to all US GI fellowship program directors and distributed at fellows’ endoscopy courses. Data were evaluated via univariate and multivariate analysis.RESULTS:One hundred eighty-four fellows completed surveys. Univariate analysis identified one factor that predisposed fellows to pursue non-academic practice: the perception that a non-academic salary would meet their financial needs. Four factors were identified that predisposed fellows to pursue academic practice: age >35 years, prior attainment of a master’s or a PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. If salaries were equal, 60% of respondents would choose academic over non-academic practice. Fellows selecting academic practice were motivated to publish and conduct research. Level of debt and a positive relationship with a mentor were not significant factors.CONCLUSIONS:Fellows desiring more money strongly favor non-academic practice. Fellows choosing academic practice tend to be older, plan to pursue advanced training, desire fewer work hours per week, and have a higher rate of prior graduate study. If salaries were equal in academic medicine and non-academic practice, the majority of fellows would choose academic medicine.

Hot spots can burn you.

Abstract Germline mutation in the APC gene predisposes to the rare familial adenomatous polyposis syndrome, in which hundreds to thousands of adenomatous polyps develop in the large intestine, as well as early-onset colorectal cancers. APC gene mutations are also found in approximately 80% of all sporadic colon cancers and appear to be the earliest mutations in the adenoma-carcinoma sequence (1) . Once the APC gene is lost through mutations in both copies or alleles and adenoma formation is complete, mutations in other colon cancer genes are necessary to continue the transformation to carcinoma. Recently, a polymorphism (variations of a gene that are found in >1% of the population) in the APC gene, I1307K, was found to confer a nearly 2-fold risk of colon cancer in individuals heterozygous for the allele (2) . The I1307K APC polymorphism is rarely found in the general population, but occurs in the Ashkenazi Jew population with carrier frequencies ranging from 5.9% to 7.3%. The I1307K polymorphism is a T-to-A transversion at nucleotide 3920. Laken et al. found that the I1307K allele is frequently mutated or lost in colonic tumors, suggesting that the nonmutated allele does not directly participate in the tumorigenic process, but may indirectly cause an unstable, hypermutable sequence or “hot spot” in an adjacent portion of the APC gene. This may lead to mutations and deletions at nearby sequences in the APC allele, which may account for the absence of the I1307k allele in cancers arising in carriers of the allele. Thus, this polymorphism may ultimately lead to inactivation of the APC allele through deletions on the same chromosome. Stern et al. sought to determine any predisposition to colonic adenoma formation associated with being heterozygous for eh I1307K APC polymorphism. To accomplish this, 3540 households in the Jewish community of Ottawa were sent invitations to participate as well as family questionnaires. Two hundred forty-two respondents with personal or family histories of colorectal cancer were selected, and nearly 80% underwent colonoscopy. All had blood drawn for detection of the I1307K allele of the APC gene using an allele-specific polymerase chain reaction assay, with two previously known heterozygotes for APC I1307K used as controls. The participants were divided into three subgroups: I) 22 participants (9%) having personal histories of colorectal cancer; II) 11 participants (5%) having personal histories of extracolonic cancer including melanoma (three), breast (four), skin (two), and bladder (two); and III) the remaining 209 participants with family histories but no personal histories of cancer. Results: The I1307K allele was found in 25/242 participants (10.3%). All were heterozygous for I1307K. Those with personal histories of any type of cancer (groups I and II) were 2–3 times as likely to carry the mutation as those with no cancer history (I = 27.3%, II = 18.2%, III = 8.1%). The difference between those with personal histories of colorectal cancer (group I) and those with no personal histories of cancer (group III) was statistically significant. No difference was seen regarding gender or number of first-degree relatives with colorectal cancer. Polyps were found in 44/189 participants (23%) who agreed to colonoscopy. There was no statistically significant difference in adenoma development between the groups. Group I had six patients decline colonoscopy, but in the 16 who underwent exams, only two lesions (solitary adenomas) were found, in two participants. Neither carried the I1307K allele, and none of the five I1307K carriers had polyps. Although 6% of gene carriers younger than 57 from all groups developed polyps, all were diminutive and hyperplastic. To evaluate the role of the APC I1307K allele in those with no personal histories of colorectal cancer groups II and III were combined. There was no difference between I1307K allele carriers and noncarriers with regard to all polyps found (23% in both groups), adenomas (11.8% and 12.8%), or hyperplastic polyps (6% and 8%). Importantly, 10/12 patients (83%) with multiple polyps and all four with tubovillous adenomas were noncarriers. Polyp size, number, location, histological subtype, and early development of adenomas were not correlated with carrier status.

Endoscopic Celiac Plexus Blockade Via Direct Intraneuronal Injection Versus Perineuronal Injection: Results of a Pilot Study

Endoscopic Celiac Plexus Blockade Via Direct Intraneuronal Injection Versus Perineuronal Injection: Results of a Pilot Study

What's Hot in the Red Journal This Month?

Although it is assumed that financial incentives drive fellows’ decisions to pursue private practice, there is little empirical evidence to support this hypothesis. The authors of this study conducted a nationwide survey of US gastroenterology fellows to identify key demographic and job-related factors relevant to the decision-making process. The survey queried respondents on their personal, educational, professional, and financial backgrounds and goals. Univariate and multivariable analyses were used to compare responses from fellows who pursued academic vs. private practice positions. A sample of 184 of 1,292 US gastroenterology fellows (14%) completed surveys. As expected, the one factor that predisposed fellows to pursue non-academic practice was financial; the level of debt and a positive relationship with a mentor were not significant factors in the decision. Conversely, several factors were associated with the choice to pursue academic careers: age greater than 35 years, prior attainment of a master’s or PhD degree, and advanced fellowship. All factors were significant on multivariate analysis. Interestingly, if salaries were equal, 60% of fellows stated they would choose academic careers over non-academic practice. As expected, fellows desiring greater financial remuneration strongly favor non-academic practice; however, without the financial incentive of private practice, the majority of fellows would choose academic medicine. See page 1220