Palaniappan Manickam

Incidence of esophageal adenocarcinoma in Barrett's esophagus with low-grade dysplasia: a systematic review and meta-analysis

BACKGROUND The natural history of low-grade dysplasia (LGD) in patients with Barretts esophagus (BE) is unclear. OBJECTIVE We performed a systematic review and meta-analysis of studies that reported the incidence of esophageal adenocarcinoma (EAC) and/or high-grade dysplasia (HGD) among patients with BE with LGD. DESIGN Systematic review and meta-analysis of cohort studies. PATIENTS Patients with BE-LGD, with mean cohort follow-up ≥ 2 years. MAIN OUTCOME MEASUREMENTS Pooled incidence rates with 95% confidence intervals (CI) of EAC and/or BE-HGD. RESULTS We identified 24 studies reporting on 2694 patients with BE-LGD, with 119 cases of EAC. Pooled annual incidence rates of EAC alone and EAC and/or HGD in patients with BE-LGD were 0.54% (95% CI, 0.32-0.76; 24 studies) and 1.73% (95% CI, 0.99-2.47; 17 studies). The results were stable across study setting and location and in high-quality studies. Substantial heterogeneity was observed, which could be explained by stratifying based on LGD/BE ratio as a surrogate for quality of pathology; the pooled annual incidence rates of EAC were 0.76% (95% CI, 0.44-1.09; 14 studies) for LGD/BE ratio <0.15 and 0.32% (95% CI, 0.07-0.58; 10 studies) for LGD/BE ratio >0.15. The annual rate of mortality not related to esophageal disease in patients with BE-LGD was 4.7% (95% CI, 3.2-6.2; 4 studies). LIMITATIONS Substantial heterogeneity was observed in the overall analysis. CONCLUSION The incidence of EAC among patients with BE-LGD is 0.54% annually. The LGD/BE ratio appears to explain the variation observed in the reported incidence of EAC in different cohorts. Conditions not related to esophageal disease are a major cause of mortality in patients with BE-LGD, although additional studies are warranted.

Prognostic Importance of Defibrillator Shocks in Survivors of Sudden Cardiac Death

Implantable cardioverter-de fi brillator (ICD) implantation is standard of care for patients who have survived life threatening ventricular tachyarrhythmias (LTVA). ICD shocks predict future adverse events in patients with ICD implantation for primary prevention. However, the role of ICD shocks in prediction of adverse events in a secondary prevention population is unknown. The Antiarrhythmics Versus ICDs (AVID) Trial (n=1016) was a randomized controlled trial comparing ICD (n=507) and antiarrhythmic drugs (n=509) in the treatment of patients with LTVA. Mean follow-up duration was 916 ± 471 days. We analyzed the ICD arm of the AVID trial using the NHLBI limited access dataset. ICD shocks were categorized as appropriate if underlying rhythm triggering the shock was ventricular tachycardia or ventricular fibrillation. All other ICD shocks were considered as inappropriate. Data on ICD therapy was available for 420 patients. Any shock (n=380), any appropriate (n=296) or any inappropriate (n=72) shock was not associated with increased all cause, cardiac or arrhythmic mortality. However any appropriate shock was associated with increased LTVA. In conclusion, ICD shocks do not confer increased risk of death on follow up in LTVA survivors. Use of ICD shocks as surrogate marker for adverse outcomes is not viable in secondary prevention patients.

Prognostic implications of recipient or donor hepatitis B seropositivity in thoracic transplantation: analysis of 426 hepatitis B surface antigen-positive recipients

Prognostic data on survival of hepatitis B surface antigen‐positive (HBsAg+) recipients and of hepatitis B core antibody‐positive (HBcAb+) donors are limited in the thoracic transplantation (TT) cohort. Improved understanding of risks could potentially expand the recipient and donor pools.

Endoclips to Facilitate Cannulation and Sphincterotomy During ERCP in a Patient with an Ampulla Within a Large Duodenal Diverticulum: Case Report and Literature Review

Cannulation and sphincterotomy of the ampulla may be technically challenging at endoscopic retrograde cholangiopancreatography (ERCP) when the ampulla is located within a duodenal diverticulum because of obscuring of the ampulla and approaching it from an awkward angle. Successful application of endoclips to expose and facilitate cannulation of an ampulla within a duodenal diverticulum has been reported for three cases of diagnostic ERCP [1, 2] and one case of therapeutic ERCP [3]. A second case is hereby reported of clinically beneficial, successful, therapeutic ERCP using endoclips.

Narcotic Bowel Syndrome: Is It More Common Than Before?

TO THE EDITOR: We read the recent article Farmer et al 1 on narcotic bowel syndrome (NBS) with great interest. The authors have comprehensively described a case of NBS along with the exciting pathophysiology. It further illustrates the common vicious cycle we see in daily clinical practice: a patient with chronic abdominal pain being prescribed opiates, which further worsens the pain and thereby escalating opiate dosage which produces a paradoxical effect. We would like to share some comments on the article. Previous reports have shown that approximately 6% of patients taking narcotics will develop NBS chronically. 2 However, due to increased recognition of these cases, it might be more common than previously thought. The success of the detoxification regimen used for NBS could be short term as we have seen in our patient population. Though patients respond significantly in the initial weeks, most of the patients experience recurrent symptoms in a span of 2-3 months leading to a high recidivism rate. Furthermore, the authors mention that constipation may develop with opiate withdrawal and laxatives maybe used in the absence of an obstruction. However, it is usually diarrhea that is predominant in these patients in the acute phase of opioid withdrawal. 3 In addition, when patients on chronic opioids present with severe constipation, abdominal discomfort and post-prandial emesis, the possibility of generalized gastroparesis should be in the differential for the work up of these patients. 4 A trial of prokinetic drugs could be helpful in this subset of population before the use of selective opioid antagonist such as methylnaltrexone.

Safety and Efficacy of Endoscopic Therapy for Nonmalignant Duodenal Duplication Cysts: Case Report and Comprehensive Review of 28 Cases Reported in the Literature

AbstractAnalyze efficacy, safety of endoscopic therapy for duodenal duplication cysts (DDC) by comprehensively reviewing case reports.Tandem, independent, systematic, computerized, literature searches were performed via PubMed using medical subject headings or Keywords “cyst” and “duodenal” and “duplication”; or “cyst”, and “endoscopy” or “endoscopic”, and “therapy” or “decompression”; with reconciliation of generated references by two experts. Case report followed CARE guidelines.Literature review revealed 28 cases (mean = 1.3 ± 1.2 cases/report). Endoscopic therapy is increasingly reported recently (1984–1999: 3 cases, 2000–2015: 25 cases, P = 0.003, OR = 8.33, 95%-CI: 1.77–44.5). Fourteen (54%) of 26 patients were men (unknown-sex = 2). Mean age = 32.2 ± 18.3 years old. Procedure indications: acute pancreatitis-16, abdominal pain-8, jaundice-2, gastrointestinal (GI) obstruction-1, asymptomatic cyst-1. Mean maximal DDC dimension = 3.20 ± 1.53 cm (range, 1–6.5 cm). Endoscopic techniques included cyst puncture via needle knife papillotomy (NKP)/papillotome-18, snare resection of cyst-7, cystotome-2, and cyst needle aspiration/ligation-1. Endoscopic therapy was successful in all cases. Among 24 initially symptomatic patients, all remained asymptomatic post-therapy without relapses (mean follow-up = 36.5 ± 48.6 months, 3 others reported asymptomatic at follow-up of unknown duration; 1 initially asymptomatic patient remained asymptomatic 3 years post-therapy). Two complications occurred: mild intraprocedural duodenal bleeding related to NKP and treated locally endoscopically.A patient is reported who presented with vomiting, 15-kg-weight-loss, and profound dehydration for 1 month from extrinsic compression of duodenum by 14 × 6 cm DDC, underwent successful endosonographic cyst decompression with large fenestration of cyst and endoscopic aspiration of 1 L of fluid from cyst with rapid relief of symptoms. At endoscopy the DDC was intubated and visualized and random endoscopic mucosal biopsies were obtained to help exclude malignant or dysplastic DDC.Study limitations include retrospective literature review, potential reporting bias, limited patient number, variable follow-up.In conclusion, endoscopic therapy for DDC was efficacious in all 29 reported patients including current case, including patients presenting acutely with acute pancreatitis, or GI obstruction. Complications were rare and minor, suggesting that endoscopic therapy may be a useful alternative to surgery for nonmalignant DDC when performed by expert endoscopists.

Recurrent ischemic colitis associated with oral contraceptive therapy

In an interesting article Mosli et al. methodically reported the risk factors associated with ischemic colitis, as well as characterizing the clinical features, endoscopic findings, complications and prognosis of this disease. They noted a female predominance, but interestingly reported no association with oral contraceptive (OC) use or hormone replacement therapy (HRT). However, they acknowledged that this lack of association might have resulted from the underreporting of OC use or HRT, because patients often failed to voluntarily disclose their use of these agents, and physicians must therefore directly query patients about such use. We emphasize the clinical relevance of this omission by reporting a case of recurrent severe ischemic colitis after failing to discontinue OC medications after the first episode.

Conscious sedation: a dying practice?

Sedation practices vary according to countries with different health system regulations, the procedures done, and local circumstances. Interestingly, differences in the setting in which the practice of gastroenterology and endoscopy takes place (university-based vs academic practice) as well as other systematic practice differences influence the attitude of endoscopists concerning sedation practices. Conscious sedation using midazolam and opioids is the current standard method of sedation in diagnostic and therapeutic endoscopy. Interestingly, propofol is a commonly preferred sedation method by endoscopists due to higher satisfaction rates along with its short half-life and thus lower risk of hepatic encephalopathy. On the other hand, midazolam is the benzodiazepine of choice because of its shorter duration of action and better pharmacokinetic profile compared with diazepam. The administration of sedation under the supervision of a properly trained endoscopist could become the standard practice and the urgent development of an updated international consensus regarding the use of sedative agents like propofol is needed.

Association of Chronic Hepatitis C and Diabetes: Is There a Gender Difference?

To the Editor: Montenegro et al. (1) recently reported in the Journal an association between chronic hepatitis C (HCV) infection and development of diabetes mellitus (DM) type 2 in a cohort of patients in a Southern Italian town. We have three comments on their excellent article. First, we similarly evaluated the association between HCV antibodies and DM in the United States, using the National Ambulatory Medical Care Survey (NAMCS), a large nationally representative cohort, which provides outpatient data from physician offices in the United States for 2000–2009. All patients with complete data on HCV and DM status were analyzed. Among 252,450 patients initially analyzed, 220 patients had HCV and 18 of them were diabetic. A multivariate logistic regression model was used to adjust for age, hypertension, obesity, and any lipid therapy. On multivariate analysis, HCV was independently associated with DM (odds ratio (OR)=1.97; 95% confidence interval (CI) 1.29–3.07, P=0.02). These data support the authors’ conclusions by showing a similar association between HCV and DM in a different population: United States outpatients. However, unlike the authors, we did not analyze the relation of serum ALT (alanine aminotransferase) values to DM, and did not separate DM type 1 from DM type 2. However, the latter difference is unlikely to affect the conclusions because DM type 2 represents the overwhelming majority of DM in America. Second, 13 of 18 patients with DM and HCV were male, and only 5 were female. This represents a quantitatively large, statistically significant effect (OR for being male=6.67; 95% CI 2.05–21.79). Montenegro et al. (1) report the same phenomenon, incidentally without commenting about its significance (OR for being female=0.44, 95% CI 0.31–0.63, P<0.001, Table 3). Our data in conjunction with the authors’ data suggest there may be a gender difference in the proposed association. This gender difference is not surprising because many toxins affect the liver according to gender, e.g., different minimum levels of alcohol consumption/day to develop alcoholic cirrhosis for males vs. females (2); and difference in mortality from hepatitis E infection between females in third trimester of pregnancy vs. other females or males (3). This large difference between genders might offer clues to the pathophysiology of association between HCV and DM. Third, the authors describe taking blood samples from each participant in 1985 (as well as 1992 and 2005) for anti-HCV antibodies, assessed by immunoenzymatic enzyme-linked immunosorbent assay (Methods (1)). The authors may want to clarify that this blood test was performed subsequently (retrospectively) on the bloods drawn in 1985 because hepatitis C was only discovered in 1988–1989 (4) and the assays for it first became commercially available in 1992 (5).

Association of Helicobacter pylori seropositivity with all-cause mortality: fact or fiction?

We read the article by Chen et al with great interest and would like to congratulate them on their findings. Their analysis of the data from the National Health and Nutrition Examination Survey (NHANES III) have shown a lack of association between Helicobacter pylori seropositivity and all-cause mortality in patients more than 40 years of age.1 As there is an existing controversy2–4 in this area, evaluation of other large databases is clinically relevant, particularly if the analyses provides congruent data as in this instance, replicating findings that help consolidate the evidence base in the literature. The …