Kenneth J. Vega

Overuse of acid suppression therapy in hospitalized patients

Background: Acid suppression therapy (AST) is one of the most commonly prescribed classes of medications in hospitalized patients. Multiple studies have shown that AST is overused during inpatient admissions. However, minimal data is available regarding the frequency and patient characteristics of those discharged on unnecessary AST. The aims of the study were to examine administration of AST on admission, to characterize the patient population discharged on unnecessary AST and to determine predictive factors for inappropriate administration of AST in hospitalized patients. Methods: A retrospective chart review of randomly selected patients admitted to the general medicine service at University of Florida Health Science Center/Jacksonville from August to October 2006 for appropriateness of AST was done. The admitting diagnosis, indications for starting AST, type of AST used, and discharge on these medications was recorded on a case by case basis. Results: Seventy percent of patients were started on AST on admission. Of these, 73% were unnecessary. Stress ulcers prophylaxis in low risk patients or the concomitant use of ulcerogenic drugs motivated initiation of therapy most frequently. Sixty nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs did not predict continuation of unnecessary AST at discharge. Conclusion: AST is overused in hospitalized patients. This primarily occurred in low risk patients and was compounded by continuation at discharge. This significantly increases cost to the health care system and the risk of drug interactions.

Identification of the putative intestinal stem cell marker doublecortin and CaM kinase-like-1 in Barrett's esophagus and esophageal adenocarcinoma.

Background and Aim:u2002 In Barretts esophagus (BE), the normal esophageal squamous epithelium is replaced with a specialized metaplastic columnar epithelium. BE is a premalignant lesion that can progress to esophageal adenocarcinoma (EAC). Currently, there are no early molecular indicators that would predict progression from BE to EAC. As the only permanent residents of the epithelium, stem cells have been implicated in this metaplastic progression. The aim of the present study was to determine the expression of doublecortin and CaM kinase‐like‐1 (DCAMKL‐1) and other putative gastrointestinal stem cell markers in normal esophageal mucosa (NEM), BE, and EAC.

Intestinal stem cells and the colorectal cancer microenvironment

Colorectal cancer (CRC) remains a highly fatal condition in part due to its resilience to treatment and its propensity to spread beyond the site of primary occurrence. One possible avenue for cancer to escape eradication is via stem-like cancer cells that, through phenotypic heterogeneity, are more resilient than other tumor constituents and are key contributors to cancer growth and metastasis. These proliferative tumor cells are theorized to possess many properties akin to normal intestinal stem cells. Not only do these CRC stem cells demonstrate similar restorative ability, they also share many cell pathways and surface markers in common, as well as respond to the same key niche stimuli. With the improvement of techniques for epithelial stem cell identification, our understanding of CRC behavior is also evolving. Emerging evidence about cellular plasticity and epithelial mesenchymal transition are shedding light onto metastatic CRC processes and are also challenging fundamental concepts about unidirectional epithelial proliferation. This review aims to reappraise evidence supporting the existence and behavior of CRC stem cells, their relationship to normal stem cells, and their possible dependence on the stem cell niche.

Neuroendocrine tumors of the gastrointestinal tract: Case reports and literature review

Neuroendocrine tumors (NET) previously called carcinoid tumors are neoplasms of enterochromaffin/neuroendocrine cell origin which display neurosecretory capacity that may result in the carcinoid syndrome. The annual incidence of patients with NET is 8.4 per 100000; yet many NET remain asymptomatic and clinically undetected. A majority of NET follows a benign course; however, some will display malignant characteristics. NET most commonly occur in the gastrointestinal tract (67%) and bronchopulmonary system (25%). Gastrointestinal NET occur within the stomach, small intestine, liver, and rectum. We report a retrospective study of 11 subjects: Eight with benign carcinoid tumors: duodenal bulb (n = 2), terminal ileum (n = 1), sigmoid colon (n = 2), and rectum (n = 3); three with malignant carcinoid: liver (n = 1) and intra-abdominal site (n = 2). The diagnosis, endoscopic images, outcome, treatment and review of the literature are presented.

Poorly treated or unrecognized GERD reduces quality of life in patients with COPD.

BackgroundThe effect of gastroesophageal reflux disease (GERD) on health-related quality of life (HRQL) in COPD has never been assessed.AimTo evaluate HRQL in patients with COPD alone compared with those with both COPD and continuing GERD symptoms.MethodsA questionnaire-based, cross-sectional survey was performed. Subjects were recruited from the outpatient pulmonary clinics at the University of Florida Health Science Center/Jacksonville. Included patients had an established diagnosis of COPD. Exclusion criteria were respiratory disorders other than COPD, known esophageal disease, active peptic ulcer disease, Zollinger–Ellison syndrome, mastocytosis, scleroderma, and current alcohol abuse. Those meeting the criteria and agreeing to participate were asked to complete the Mayo Clinic GERQ and SF-36 questionnaires, by either personal or telephone interview. Clinically significant reflux was defined as heartburn and/or acid regurgitation weekly. Study patients were divided into two groups for HRQL analysis based on the GERQ response: COPD+/GERD+ and COPD only. Statistical analysis was performed using the Mann–Whitney–Wilcoxon T test for unequal variables and linear regression was performed using ANOVA. All data are expressed as mean and standard deviation.ResultsEighty-six patients completed both questionnaires. Males were 55% and COPD+/GERD+ patients comprised 37% of the study group. Compared with COPD only, HRQL was reduced across all measures for the COPD+ GERD+ patients and achieved significance for bodily pain (Pxa0<xa00.02), mental health (Pxa0<xa00.05), and physical component score (Pxa0<xa00.05).ConclusionPatients with COPD and continuing GERD symptoms have reduced HRQL in comparison with those with COPD alone.

African Americans with Barrett's esophagus are less likely to have dysplasia at biopsy

BackgroundBarrett’s Esophagus (BE) is a pre-malignant condition. Limited data on BE dysplasia prevalence exists among United States ethnic groups.AimThe purpose of this study was to determine if the frequency of BE with dysplasia varies among the major ethnic groups presenting to our institution.MethodsThe University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to August 2007. Histologic BE was diagnosed if salmon colored esophageal mucosa was endoscopically seen at least 1xa0cm above the top of the gastric folds and biopsy revealed intestinal metaplasia with Alcian blue-containing goblet cells. Demographic data collected for all included: age at diagnosis, ethnicity, sex, previous history of esophageal reflux, atypical manifestations (chronic cough, aspiration), endoscopic length of BE, presence or absence of hiatal hernia, esophageal stricture or ulcer, and presence or absence of dysplasia.ResultsSalmon colored esophageal mucosa was observed in 405 of 7,308 patients (5.5%) and histologically confirmed in 115 of 405 patients (28%) reflecting an overall prevalence of BE of 115/7308 (1.6%) in this cohort. Ethnic distribution of histologic BE patients was as follows: 95 (83%) non-Hispanic white (nHw), 16 (14%) African American (AA) and 4 (3%) other. Long segment BE (LSBE) and any form of dysplasia was observed less frequently in AA than nHw (LSBE: 12% vs. 26% and dysplasia: 0% vs. 7%).ConclusionsLSBE and dysplasia are less frequent in AA than nHw. Studies in AA with BE may illustrate factors limiting dysplasia and LSBE risk.

Gender variation in oesophageal motor function: analysis of 129 healthy individuals.

BACKGROUNDnOesophageal manometry is the standard for diagnosis of oesophageal motor disorders. Minimal data exist assessing the effect of gender on normal oesophageal manometry values.nnnAIMnEvaluate the impact of gender on normal oesophageal manometry values.nnnMETHODSnHealthy volunteers were recruited from the Jacksonville metropolitan area. Exclusion criteria were symptoms suggestive of oesophageal disease, medication use or concurrent illness that could affect oesophageal manometry. All underwent oesophageal manometry using a solid-state system with wet swallows.nnnRESULTSnSixty-three males and 66 females were enrolled. All completed oesophageal manometry without difficulty. Resting lower oesophageal sphincter pressure, distal oesophageal contraction duration and distal oesophageal body contraction amplitude values were significantly higher in females while distal oesophageal body contraction velocity was significantly lower in females (p<0.05). No differences were seen in other oesophageal manometry parameters.nnnCONCLUSIONnSignificant gender differences exist in normal oesophageal manometry. Gender-specific reference values for oesophageal manometry are needed for accurate diagnosis of oesophageal motility disorders.

Do HbA1C Levels Correlate With Delayed Gastric Emptying in Diabetic Patients

Background/Aims Gastroparesis is characterized by delayed gastric emptying without obstruction. Diabetes is frequently associated with poor glycemic control and delayed gastric emptying. Gastric emptying scintigraphy (GES) is the standard for measuring gastric emptying. Serum hemoglobin A1C (HbA1C) measures prolonged glycemic control with normal as < 7% glycated. To date, no correlation of serum HbA1C level with gastric emptying, demonstrated by GES, in diabetics has been performed. The aim of the present investigation is to determine if a relationship exists between serum HbA1C levels and gastric emptying, assessed by GES, in diabetics. Methods All diabetics, having both GES and serum HbA1C level within 3 months from July 1, 2003 - June 30, 2008 were eligible for study. Demographic data collected included gender, age and ethnicity. Abnormal gastric emptying was defined as T½ > 120 minutes and serum HbA1C as percent glycated. Results Nuclear Medicine GES database review revealed 431 examinations performed during the study interval. A total of 181 were not eligible due to the following: 29 duplicates, 22 diabetes not documented and 130 without HbA1C levels, resulting a study group of 250 cases. No significant correlation was observed between gastric emptying time, HbA1C or age. Among patients with HbA1C ≥ 7%, HbA1C was inversely related to age with a coefficient of correlation of r = -0.175 (p = 0.038). Conclusions There is no correlation observed between gastric emptying time, using GES, and serum HbA1C levels. In diabetics, serum HbA1C is not as important as daily glycemic control regarding gastric emptying.

Hepatitis C infection and the risk of bacteremia in hemodialysis patients with tunneled vascular access catheters.

Background: The major complication of tunneled vascular catheters in dialysis patients is infection. In preliminary work, an association was noted between hepatitis C virus (HCV) infection and bacteremia in these patients. On this basis, we theorized that HCV infection may be associated with bacteremia in dialysis patients with tunneled catheters. Methods: We conducted a two-phase clinical study to define the association between HCV infection and bacteremia in hemodialysis patients with catheters. Phase 1 was a cross-sectional study designed to assess the association between HCV serologic status and bacteremia. Phase 2 was a prospective study that examined the relationship between HCV viral load and bacteremia. Results: In Phase 1, HCV (+) patients had a significantly greater prevalence of bacteremia than HCV (−) patients (61 vs 7.7% respectively, P < 0.05). In Phase 2, the presence of detectable virus was associated with a numerical trend toward an increase in the incidence of bacteremia (40 vs 0% for patients with and without detectable virus, respectively, P = 0.09). Conclusion: These studies suggest that HCV infection may be associated with the development of bacteremia in hemodialysis patients with tunneled catheters.

DCLK1 Is Detectable in Plasma of Patients with Barrett’s Esophagus and Esophageal Adenocarcinoma

BackgroundDoublecortin-like kinase 1 (DCLK1), a putative tumor stem cell marker has been shown to be highly expressed in the stromal and epithelial compartments in colon and pancreatic cancer as well as Barrett’s esophagus (BE) and esophageal adenocarcinoma (EAC).AimTo prospectively investigate whether the immunohistochemical expression of DCLK1 was associated with detectable DCLK1 plasma expression in patients with existing BE and EAC.MethodsImmunohistochemistry was performed on paraffin-embedded sections using DCLK1 antibody and scored based on staining intensity and tissue involvement. Purified human plasma samples were subjected to Western blot and ELISA analysis.ResultsForty (40) patients were enrolled: 10 controls (normal endoscopy) and 30 with BE/EAC (13 nondysplastic BE [NDBE], 9 dysplastic BE [DBE] and 8 EAC). Mean epithelial DCLK1 staining was as follows: controlsxa0=xa00.11, NDBExa0=xa03.83, DBExa0=xa06.0, EACxa0=xa07.17. Mean stromal DCLK1 staining was as follows: NDBExa0=xa05.83, DBExa0=xa05.375, EACxa0=xa010.83. DCLK1 was detected by plasma Western blot in 1 control and in all patients with BE/EAC pxa0<xa00.0005. Plasma DCLK1 was elevated by ELISA in EAC compared to other groups, pxa0<xa00.05.ConclusionsIncreased expression of DCLK1 was observed in the epithelium, stroma and plasma of patients with BE/EAC. Furthermore, the presence of detectable DCLK1 in plasma of BE/EAC patients may provide a less invasive, detection tool in those patients as well as represent a novel molecular marker distinguishing between normal esophageal mucosa and BE or EAC.