Rajesh Krishnamoorthi

Purulent Pericardial Effusion From Community-Acquired Methicillin-Resistant Staphylococcus aureus

Abstract: Although the incidence of purulent pericarditis has decreased significantly in the modern antibiotic era, a high index of clinical suspicion should be maintained to diagnose this life-threatening illness at an early stage. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a global pathogen and notorious for its ability to cause infection in otherwise healthy individuals. However, it has been associated with purulent pericarditis only in some sporadic case reports. The authors describe a case of purulent pericardial effusion caused by CA-MRSA infection. To the best of our knowledge, this is only the fourth case of CA-MRSA pericarditis to be reported in English literature.

Sa1068 Predictors of Progression in Barrett's Esophagus: A Systematic Review and Meta-Analysis

Background: The overall risk of progression to esophageal adenocarcinoma (EAC) in BE subjects without dysplasia is lower than previously estimated. There is hence lack of consensus on the effectiveness of current surveillance programs. Stratification of risk of progression is appealing, as it may help identify BE patients at higher risk who can be monitored more intensively or offered endoscopic therapy. Though several studies have identified factors predicting progression, evidence on several clinically relevant risk factors influencing progression is not consistent. We aimed to identify the predictors of progression in BE subjects without high grade dysplasia by performing a systematic review and meta-analysis of relevant studies. Methods: A comprehensive search of several databases including PubMed, EMBASE, and Web of Science databases (earliest inception to July 28th, 2014) was performed and studies reporting outcomes of BE cohorts under surveillance were identified. We included studies that reported predictors of progression to HGD/ EAC as an outcome in patients with non-dysplastic BE (NDBE) and BE-low grade dysplasia (LGD). A pooled estimate (odds ratio) of the potential of age, sex, smoking, alcohol use, BMI, baseline LGD (vs NDBE), BE length, and medication use in predicting progression to HGD/EAC in NDBE/ LGD patients was calculated. Results: 23 studies reporting predictors of progression as an outcome were identified from the systematic review. 1231 events in 74943 patients in 204926.2 patient years of follow-up were analyzed. Table 1 shows the pooled odds ratio (OR) of predictors analyzed. Increasing age, male sex, ever smoking (current or past), and increasing BE segment length were predictive of increased risk of progression to HGD/EAC with low heterogeneity (9-13 studies). Patients with LGD had an almost four fold increased risk of progression compared to those with no dysplasia. NSAID and statin use were protective against progression to HGD/EAC without heterogeneity. Alcohol use and obesity as measured by BMI did not influence progression rates. Conclusion: Age, male sex, ever smoking (current or past), and BE length are predictive of increased risk of progression to HGD/ EAC. Subjects with baseline LGD are at 4 times increased risk of progression compared to those without dysplasia. These factors may be used to risk stratify BE subjects as part of a prediction score, to identify those who could potentially benefit from intensive surveillance or endoscopic therapy. Smoking is a modifiable risk factor for cancer prevention in BE subjects. Table 1: Pooled odds ratio (OR) of predictors of progression to HGD / EAC.

Sa1067 Rates and Predictors of Progression in Barrett's Esophagus With Low Grade Dysplasia: Results From a Prospective U.S. Registry

BACKGROUND Estimates of progression in BE-LGD are limited by heterogeneity in pathological diagnoses. While recent data show that ablation in BE-LGD reduces risk of progression to HGD/EAC, they are limited by high rates of progression not seen in most studies. Identification of risk factors for progression in BE-LGD may help in selecting subjects for endoscopic therapy. We aimed to assess the rates and predictors of progression in a cohort of BE-LGD subjects who were part of a large prospective BE-EAC registry in a tertiary care center. METHODS Subjects with a histologic diagnosis of LGD (made by expert GI pathologists) were identified from a prospective BE registry at our institution. The registry database has records of demographic details, endoscopic findings and histologic data from esophageal biopsies. Index date was defined as the first date of LGD diagnosis. Progressors were defined as BE-LGD subjects who developed HGD / EAC more than 12 months after the index date. Risk factors assessed included demographic variables, family history of BE/ EAC, GERD symptoms, duration of BE, medication use, endoscopic findings and histological findings (multifocal vs unifocal LGD, H pylori status in gastric biopsy). Univariate and multivariable analyses were performed to identify predictors of progression using Cox Proportional Hazards models. RESULTS 353 BE-LGD subjects were identified, of which 337 were included after excluding those with missing data. The mean (SD) age of these subjects was 63.2 (11.2) years. 283 (84 %) were males. Baseline characteristics are summarized in table 1. Of the 337 BE-LGD patients, 21 (6.2 %) subjects progressed to HGD / EAC. The mean (SD) follow up of subjects was 7 (5) years. The annual incidence of HGD/EAC in subjects with BE-LGD was 0.8%. Univariate and multivariable predictors of progression to HGD/ EAC are presented in table 2. On univariate analysis, longer BE segment length and presence of nodularity increased risk of progression, while a longer follow up duration after LGD diagnosis reduced the risk of progression. Multifocal dysplasia (dysplasia at multiple levels) approached statistical significance as a predictor of progression. On multivariable analysis, increased BE segment length remained a predictor of progression while older age and longer LGD follow up (likely reflecting persistent LGD) reduced the risk of progression. CONCLUSIONS: In this well-defined cohort of BE-LGD patients with all histology confirmed by expert GI pathologists, progression rates for LGD subjects were substantially lower than those reported in some European studies. Longer BE segment length and younger age at LGD diagnosis predicted a higher risk of progression. These subjects may be candidates for intensive surveillance or endoscopic therapy.