Race, ethnicity, sex and temporal differences in Barrett's oesophagus diagnosis: a large community-based study, 1994-2006.

OBJECTIVE: To evaluate the demographics and incidence of Barrett's oesophagus diagnosis using community-based data. DESIGN: Observational study. SETTING: Kaiser Permanente, Northern California healthcare membership, 1994-2006. PATIENTS: Members with an electronic diagnosis of Barrett's oesophagus. MAIN OUTCOME MEASURES: Incidence and prevalence of a new Barrett's oesophagus diagnosis by race, sex, age and calendar year. RESULTS: 4205 persons met the study definition for a diagnosis of Barrett's oesophagus. The annual incidence in 2006 was highest among non-Hispanic whites (39/100,000 race-specific member-years, 95% confidence interval (95% CI) 35 to 43), with lower rates among Hispanics (22/100,000, 95% CI 16 to 29), Asians (16/100,000, 95% CI 11 to 22), and blacks (6/100,000, 95% CI 2 to 12). The annual incidence was higher among men than women (31 vs 17/100,000, respectively, year 2006; p<0.01). The incidence increased with age from 2 per 100,000 for persons aged 21-30 years, to a peak of 31 per 100,000 member-years for persons aged 61-70 years (year 2006). There was no increase in the incidence of new diagnoses until the last two observation years, which coincided with changes in data collection methods and may be due to bias. The overall prevalence among active members increased almost linearly to 131/100,000 member-years by 2006. CONCLUSIONS: The demographic distributions of Barrett's oesophagus differ markedly by race, age and sex and were comparable to those for oesophageal adenocarcinoma. Thus, demographic disparities in oesophageal adenocarcinoma risk may arise partly from the risk of having Barrett's oesophagus, rather than from differing risks of progression from Barrett's oesophagus to cancer. There has been an almost linear increase in the prevalence of diagnosed disease.

Helicobacter pylori infection and the risk of Barrett's oesophagus: a community-based study.

OBJECTIVE: Gastric colonisation with the Helicobacter pylori bacterium is a proposed protective factor against oesophageal adenocarcinoma, but its point of action is unknown. Its associations with Barrett's oesophagus, a metaplastic change that is a probable early event in the carcinogenesis of oesophageal adenocarcinoma, were evaluated METHODS: A case-control study was carried out in the Kaiser Permanente Northern California population, a large health services delivery organisation. Persons with a new Barrett's oesophagus diagnosis (cases) were matched to subjects with gastro-oesophageal reflux disease (GORD) without Barrett's oesophagus and to population controls. Subjects completed direct in-person interviews and antibody testing for H pylori and its CagA (cytotoxin-associated gene product A) protein. RESULTS: Serological data were available on 318 Barrett's oesophagus cases, 312 GORD patients and 299 population controls. Patients with Barrett's oesophagus were substantially less likely to have antibodies for H pylori (OR = 0.42, 95% CI 0.26 to 0.70) than population controls; this inverse association was stronger among those with lower body mass indexes (BMIs < 25, OR = 0.03, 95% CI 0.00 to 0.20) and those with CagA+ strains (OR = 0.08, 95% CI 0.02 to 0.35). The associations were diminished after adjustment for GORD symptoms. The H pylori status was not an independent risk factor for Barrett's oesophagus compared with the GORD controls. CONCLUSIONS: Helicobacter pylori infection and CagA+ status were inversely associated with a new diagnosis of Barrett's oesophagus. The findings are consistent with the hypothesis that H pylori colonisation protects against Barrett's oesophagus and that the association may be at least partially mediated through GORD.

Hemochromatosis screening in asymptomatic ambulatory men 30 years of age and older.

OBJECTIVE: To perform a cost-benefit analysis of screening for hereditary hemochromatosis. PATIENTS AND METHODS: A total of 3,977 consecutive men > or = 30 years of age who presented for routine health checkups at a health maintenance organization medical center were screened for hereditary hemochromatosis by measuring transferrin saturation. Subjects with repeated transferrin saturation > or = 62% and ferritin level > or = 500 ng/mL (> or = 500 micrograms/L) were referred for liver biopsy. Subjects with transferrin saturation < 15% were referred for evaluation. Laboratory testing, screening, and abnormal screening test evaluation procedures were identified by chart review. RESULTS: Forty patients had transferrin saturation > or = 62%. One hundred seventy-two had transferrin saturation < 15%. Eight patients with hemochromatosis were identified. The 3 patients most seriously affected had hepatic iron concentrations > 250 mumol/g dry weight. Two of them had hepatic fibrosis. Seven cases of hemochromatosis were found among 1,974 white subjects who were screened. Only 1 case was found among the remaining subjects. CONCLUSIONS: Our observations support routine screening with transferrin saturation for white men > or = 30 years of age.

Breast biopsy techniques and adequacy of margins.

The change toward breast-conserving surgery for cancer has altered the role of the initial biopsy. We retrospectively analyzed two methods, traditional excisional biopsy (n = 47) and lumpectomy (n = 44) to evaluate their usefulness as the initial procedure for breast-conserving surgery. Lumpectomy required more time (mean +/- SEM, 53 +/- 3 minutes) than traditional biopsy (37 +/- 2 minutes). Margins were verified by microscopic examination to be clear in 73% of the patients in the lumpectomy group and in only 17% of patients in the traditional biopsy group. Patients in the lumpectomy group subsequently underwent more axillary dissections than patients in the traditional biopsy group (31% vs 4%, respectively) and fewer modified radical mastectomies (49% vs 71%, respectively). A correlation between extensive intraductal components and positive margins was found in the lumpectomy group. These data suggest that as the initial biopsy method, lumpectomy more often provides adequate margins and may decrease the number of subsequent procedures on the breast for breast-conserving surgery.

Efficacy and cost-effectiveness of multihole fine-needle aspiration of head and neck masses.

To determine whether the specimen from fine-needle aspiration (FNA) biopsy of head and neck masses has greater diagnostic accuracy when using multihole needles than when using conventional, single-hole needles, we did a prospective, randomized, single-blinded study comparing diagnoses obtained using both types of needles in FNA biopsies of head and neck masses. Eighty-eight patients served as their own controls and had 91 FNA biopsies with both multihole and single-hole, 22-gauge needles. Order of biopsy was randomized and was unknown to the cytopathologist. No statistically significant differences were noted in quantity of specimen material obtained, quality of fixation, or diagnostic value between the multihole and conventional needle. We found no advantage in using the more costly multihole needle in FNA biopsy of head and neck masses.

Skull metastasis from renal cell carcinoma. Case report and literature review.

Metastatic tumors to the head and neck are uncommon. We report a case of renal cell carcinoma that presented as an epidermal inclusion cyst on the forehead. The forehead is an exceedingly uncommon site for renal cell metastases. We review the biology of tumor metastases and explore the pathways by which infraclavicular tumors spread to the head and neck. We then discuss the clinical appearance and management of metastatic renal cell carcinoma.

Predicting advanced proximal colonic neoplasia with screening sigmoidoscopy.

CONTEXT: Indications are not well defined for follow-up colonoscopy for all patients with distal colonic tubular adenomas (TAs) found at screening sigmoidoscopy. OBJECTIVE: To determine whether distal adenoma size, number, and villous histology, along with family history and age, are predictors of advanced proximal colonic neoplasia. DESIGN: Cross-sectional analysis conducted between January 1, 1994, and December 31, 1995. SETTING: Large group-model health maintenance organization in northern California. PATIENTS: A total of 2972 asymptomatic subjects aged 50 years or older undergoing colonoscopy as follow-up to a screening sigmoidoscopy. MAIN OUTCOME MEASURE: Based on sigmoidoscopy, colonoscopy, and pathology reports, occurrence of advanced proximal neoplasia, defined as adenocarcinoma or TAs 1 cm or larger or with villous features or severe dysplasia located beyond sigmoidoscopic view. RESULTS: The prevalence of advanced proximal neoplasia was similar among patients with no TAs at sigmoidoscopy, those with TAs less than 1 cm in diameter, and those with TAs 1 cm in diameter or larger (prevalence, 5.3%, 5.5%, and 5.6%, respectively). Of patients with a distal tubulovillous or villous adenoma, 12.1% had advanced proximal neoplasia. In multivariate analyses, having a distal tubulovillous adenoma or villous adenoma was the strongest predictor of advanced proximal neoplasia (odds ratio, 2.30; 95% confidence interval, 1.69-3.14). Age of 65 years or older, having more than 1 adenoma, and a positive family history of colorectal cancer were also significant predictors. Distal adenoma size was not a significant predictor in any multivariate analyses. CONCLUSIONS: Advanced proximal neoplasia is not uncommon in subjects with or without distal TAs, but subjects with advanced distal histology and those older than 65 years are at increased risk. Age-specific screening using sigmoidoscopy starting at ages 50 to 55 years and colonoscopy after age 65 years may be justified.