RESUMO
BACKGROUND & AIMS: Follow-up (FU) strategies after endoscopic eradication therapy (EET) for Barrett's neoplasia do not consider the risk of mortality from causes other than esophageal adenocarcinoma (EAC). We aimed to evaluate this risk during long-term FU, and to assess whether the Charlson Comorbidity Index (CCI) can predict mortality. METHODS: We included all patients with successful EET from the nationwide Barrett registry in the Netherlands. Data were merged with National Statistics for accurate mortality data. We evaluated annual mortality rates (AMRs, per 1000 person-years) and standardized mortality ratio for other-cause mortality. Performance of the CCI was evaluated by discrimination and calibration. RESULTS: We included 1154 patients with a mean age of 64 years (±9). During median 59 months (p25-p75 37-91; total 6375 person-years), 154 patients (13%) died from other causes than EAC (AMR, 24.1; 95% CI, 20.5-28.2), most commonly non-EAC cancers (n = 58), cardiovascular (n = 31), or pulmonary diseases (n = 26). Four patients died from recurrent EAC (AMR, 0.5; 95% CI, 0.1-1.4). Compared with the general Dutch population, mortality was significantly increased for patients in the lowest 3 age quartiles (ie, age <71 years). Validation of CCI in our population showed good discrimination (Concordance statistic, 0.78; 95% CI, 0.72-0.84) and fair calibration. CONCLUSION: The other-cause mortality risk after successful EET was more than 40 times higher (48; 95% CI, 15-99) than the risk of EAC-related mortality. Our findings reveal that younger post-EET patients exhibit a significantly reduced life expectancy when compared with the general population. Furthermore, they emphasize the strong predictive ability of CCI for long-term mortality after EET. This straightforward scoring system can inform decisions regarding personalized FU, including appropriate cessation timing. (NL7039).
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Adenocarcinoma , Esôfago de Barrett , Neoplasias Esofágicas , Sistema de Registros , Humanos , Pessoa de Meia-Idade , Masculino , Esôfago de Barrett/cirurgia , Esôfago de Barrett/mortalidade , Esôfago de Barrett/patologia , Feminino , Países Baixos/epidemiologia , Idoso , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/cirurgia , Incidência , Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Adenocarcinoma/patologia , Esofagoscopia/efeitos adversos , Causas de Morte , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Fatores de Tempo , ComorbidadeRESUMO
BACKGROUND & AIMS: Esophageal strictures are a leading cause of dysphagia, but data regarding the epidemiology of esophageal strictures are limited. This study aimed to investigate the prevalence, health care utilization, and financial burden of esophageal strictures in the United States. METHODS: We performed a retrospective cohort study using 2 large national insurance claims databases (MarketScan and Medicare). Using International Classification of Diseases-9 and -10 diagnostic codes, annual prevalence was calculated for both cohorts overall, and stratified by age and sex strata. Most common diagnostic and procedural codes associated with esophageal strictures were extracted and analyzed to estimate health care utilization. Direct annual medical costs of esophageal strictures were calculated. RESULTS: The annual prevalence of esophageal strictures in MarketScan in 2021 was 203.14 cases/100,000 people, whereas the annual prevalence in Medicare cohort in 2017 was 1123.47 cases/100,000. Although rates were relatively stable over time, esophageal stricture prevalence increased with advancing age. No prevalence differences were noticed between males and females. Gastroesophageal reflux disease/erosive esophagitis was the top diagnostic code associated with esophageal strictures, although an increase in the proportion of eosinophilic esophagitis codes was noted over time. Esophageal dilation codes were present in â¼50% of stricture cases. The total health care costs associated with esophageal strictures were estimated at $1.39 billion in 2017. CONCLUSIONS: Esophageal strictures are common, affecting between 1/100 and 1/1000 patients in the United States, with the highest rates seen in patients aged 75 years and older. Accordingly, strictures have a significant financial burden on the health care system, with costs greater than $1 billion annually.
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Estenose Esofágica , Custos de Cuidados de Saúde , Humanos , Masculino , Estenose Esofágica/epidemiologia , Estenose Esofágica/economia , Feminino , Estados Unidos/epidemiologia , Idoso , Estudos Retrospectivos , Prevalência , Pessoa de Meia-Idade , Adulto , Custos de Cuidados de Saúde/estatística & dados numéricos , Idoso de 80 Anos ou mais , Adulto Jovem , Adolescente , Pré-Escolar , Criança , Lactente , Efeitos Psicossociais da Doença , Recém-NascidoRESUMO
BACKGROUND AND AIMS: Liquid nitrogen spray cryotherapy (SCT) is an alternative to radiofrequency ablation (RFA) for eradication of dysplastic Barrett's esophagus (BE). We aimed to assess the safety, efficacy, and durability of SCT in a multicenter U.S. registry. METHODS: This is a multicenter prospective registry of adults with BE treated with truFreeze Spray Cryotherapy (Steris, Mentor, Ohio, USA) (4 community and 11 academic sites, 2013-2022). Complete eradication of intestinal metaplasia (CEIM) and dysplasia (CED) were assessed in BE with dysplasia or intramucosal adenocarcinoma. Kaplan-Meier analysis of CEIM and CED was performed. Hazard ratios for CEIM stratified by baseline risk factors were calculated. RESULTS: Among 138 subjects with low-grade dysplasia (24%), high-grade dysplasia (49%), and intramucosal adenocarcinoma (27%), 34% received prior RFA therapy. Subjects received a median of 2 SCT sessions. Adverse events were uncommon, with 5.5% reporting strictures and 0.7% a perforation. Rates of CEIM and CED, respectively, were 66% and 84% after 2 years and 67% and 92% after 3 years. In RFA-naïve patients, CEIM was 77% and CED was 96% at 3 years. Increasing BE length (per centimeter: adjusted hazard ratio, 0.90; 95% confidence interval, 0.83-0.96) and prior treatment with RFA (adjusted hazard ratio, 0.39; 95% confidence interval, 0.22-0.69) were associated with a lower rate of CEIM. Recurrence occurred in 8.8% (n = 6) at a mean follow-up of 2.5 years after CEIM. CONCLUSION: In this largest reported prospective cohort, liquid nitrogen SCT was safe and effective for the treatment of dysplastic and neoplastic BE. Response was lower in those with prior failed RFA; in that cohort, approximately 50% attained CEIM at 3 years.
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Adenocarcinoma , Esôfago de Barrett , Neoplasias Esofágicas , Nitrogênio , Sistema de Registros , Humanos , Esôfago de Barrett/cirurgia , Esôfago de Barrett/patologia , Esôfago de Barrett/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Estudos Prospectivos , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Adenocarcinoma/cirurgia , Neoplasias Esofágicas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Nitrogênio/uso terapêutico , Resultado do Tratamento , Criocirurgia/métodos , Metaplasia , Crioterapia/métodos , Esofagoscopia/métodos , AdultoRESUMO
BACKGROUND AND AIMS: Alpha-gal allergy causes a delayed reaction to mammalian meats and has been reported worldwide. Patients with the allergy may present with isolated gastrointestinal (GI) symptoms, but this phenotype is poorly understood. METHODS: We pooled and analyzed symptoms and demographics of patients from two prospective cohorts of patients with a diagnosis of alpha-gal allergy who reacted after eating mammalian meat under observation. We compared the characteristics of patients who demonstrated GI-isolated symptoms on a challenge with those who exhibited symptoms outside the GI tract (skin, respiratory, and circulatory). RESULTS: Among the 91 children and adult alpha-gal allergic patients who exhibited symptoms after oral challenge with mammalian meat, 72.5% experienced GI distress with one or more GI symptoms, which was the most frequent class of symptoms, compared with skin changes in 57.1% and respiratory distress in 5.5%. The most common GI symptoms were abdominal pain (71%) and vomiting (22.0%). GI-isolated symptoms occurred in 37 patients (40.7%) who reacted, and those patients reacted more quickly than patients who exhibited systemic symptoms (median onset of symptoms in GI-isolated group 90 min vs 120 min) and were more likely to be children than adults (relative risk=1.94, 95% CI: 1.04-3.63). CONCLUSIONS: Isolated-GI distress occurred in 4 in every 10 alpha-gal allergic individuals who developed symptoms on oral food challenge with mammalian meat. Alpha-gal allergic patients, particularly children, may exhibit GI distress alone, and adult and pediatric gastroenterologists should be aware of the diagnosis and management of the allergy.
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Dispepsia , Hipersensibilidade Alimentar , Adulto , Criança , Animais , Humanos , Estudos Prospectivos , Imunoglobulina E , Hipersensibilidade Alimentar/diagnóstico , Carne/efeitos adversos , MamíferosRESUMO
INTRODUCTION: In the United States, clinical guidelines recommend daily use of proton pump inhibitors (PPIs) amongst individuals diagnosed with Barrett's esophagus to decrease the risk of progression to dysplasia and neoplasia. Prior studies documenting adherence to PPIs in this population have not characterized heterogeneity in adherence patterns. Factors that may relate to adherence are incompletely described. METHODS: We used administrative claims data from the Merative MarketScan Commercial Claims and Encounters database to conduct a retrospective study of adherence to prescription PPIs. A cohort of individuals diagnosed with incident Barrett's esophagus between 2010 and 2019 was identified. Group-based trajectory models were generated to detect longitudinal adherence subgroups. RESULTS: 79 701 individuals with a new diagnosis of Barrett's esophagus were identified. The best fitting model detected five distinct adherence trajectory groups: consistently high (44% of the population), moderate decline (18%), slow decline (12%), rapid decline (10%), and decline-then-increase (16%). Compared to individuals starting PPIs, those already using PPIs were less likely to have a declining adherence pattern. Other factors associated with membership in a declining adherence group included (but were not limited to): female sex, having a past diagnosis of anxiety or depression, and having one or more emergency department visits in the past year. DISCUSSION: Using an exploratory method, we detected heterogeneity in adherence to prescription PPIs. Less than half of individuals were classified into the consistently high adherence group, suggesting that many individuals with Barrett's esophagus receive inadequate pharmacologic therapy.
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Esôfago de Barrett , Neoplasias Esofágicas , Feminino , Humanos , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/tratamento farmacológico , Esôfago de Barrett/epidemiologia , Inibidores da Bomba de Prótons/uso terapêutico , Neoplasias Esofágicas/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND: The presentation of eosinophilic esophagitis (EoE) is heterogeneous, but trends over time are not known. AIM: To determine whether clinical and endoscopic phenotypes at EoE diagnosis have changed over the past 2 decades. METHODS: In this retrospective cohort study, adults and children with newly diagnosed EoE were phenotyped as follows: (1) inflammatory vs fibrostenotic vs mixed on endoscopy; (2) atopic vs non-atopic; (3) age at symptom onset; (4) age at diagnosis; (5) presence of autoimmune or connective tissue disease; and (6) responsive to steroids. The prevalence of different phenotypes was categorized by 5-year intervals. Multivariate analysis was performed to assess for changes in patient features over time. RESULTS: Of 1187 EoE patients, age at diagnosis increased over time (from 22.0 years in 2002-2006 to 31.8 years in 2017-2021; p < 0.001) as did the frequency of dysphagia (67% to 92%; p < 0.001). Endoscopic phenotypes were increasingly mixed (26% vs 68%; p < 0.001) and an increasing proportion of patients had later onset of EoE. However, there were no significant trends for concomitant autoimmune/connective tissue disease or steroid responder phenotypes. On multivariate analysis, after accounting for age, dysphagia, and food impaction, the increase in the mixed endoscopic phenotype persisted (aOR 1.51 per each 5-year interval, 95% CI 1.31-1.73). CONCLUSION: EoE phenotypes have changed over the past two decades, with increasing age at diagnosis and age at symptom onset. The mixed endoscopic phenotype also increased, even after controlling for age and symptomatology. Whether this reflects changes in provider recognition or disease pathophysiology is yet to be elucidated.
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Doenças do Tecido Conjuntivo , Transtornos de Deglutição , Enterite , Eosinofilia , Esofagite Eosinofílica , Gastrite , Adulto , Criança , Humanos , Adulto Jovem , Esofagite Eosinofílica/diagnóstico , Esofagite Eosinofílica/epidemiologia , Esofagite Eosinofílica/complicações , Transtornos de Deglutição/etiologia , Estudos Retrospectivos , Fenótipo , Doenças do Tecido Conjuntivo/complicaçõesRESUMO
BACKGROUND AND AIMS: The Index of Severity for EoE (I-SEE) was recently developed. We aimed to determine the relationship between features of eosinophilic esophagitis and disease severity, and assess change in disease severity with topical corticosteroid treatment, using I-SEE. METHODS: We performed a post hoc analysis of an 8-week randomized trial comparing 2 topical corticosteroid formulations in newly diagnosed patients with eosinophilic esophagitis. I-SEE was calculated at baseline and posttreatment, and patients were classified as mild (1-6 points), moderate (7-14 points), severe (≥15 points), or inactive (0 points). We analyzed clinical, endoscopic, and histologic features at baseline by disease severity, and examined the change in severity before and after treatment, and by histologic response (<15 eosinophils per high-power field). RESULTS: Of 111 subjects randomized, 20 (18%) were classified as mild, 75 (68%) as moderate, and 16 (14%) as severe at baseline. Increasing severity was associated with lower body mass index (30 for mild, 27 for moderate, 24 for severe; P = .01), longer duration of dysphagia symptoms before diagnosis (9 years for mild, 9 for moderate, and 20 for severe; P < .001), and decreasing esophageal diameter (15 mm for mild, 13 for moderate, and 10 for severe; P < .001). Mean severity score decreased after treatment (11 vs 4; P < .001), with lower scores in histologic responders compared with nonresponders (2 vs 9; P < .001). The severity score at baseline predicted need for dilation at follow-up (C statistic, 0.81). CONCLUSIONS: The newly developed I-SEE correlates with many clinical features at diagnosis, and severity improves with successful topical corticosteroid treatment. Additional investigations in other populations can further confirm its utility.
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Transtornos de Deglutição , Esofagite Eosinofílica , Humanos , Esofagite Eosinofílica/diagnóstico , Esofagite Eosinofílica/tratamento farmacológico , Esofagite Eosinofílica/patologia , Esofagoscopia , Glucocorticoides/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVES: Feeding tubes can provide a temporary or long-term solution for nutritional therapy. Little is known regarding the use of feeding tubes in patients with eosinophilic esophagitis (EoE). We sought to describe the characteristics and outcomes in EoE patients requiring tube feeding. METHODS: This was a retrospective cohort study of EoE patients at a large tertiary care health system. Demographics, clinical characteristics, and endoscopic findings were extracted from medical records, and patients who had a feeding tube were identified. Patients with and without a feeding tube were compared. Details about the tube, complications, and treatment were extracted. Growth, global symptomatic, endoscopic, and histopathologic (<15 eos/hpf) responses were compared before and after the initiation of feeding tube therapy. RESULTS: We identified 39 of 1216 EoE patients who had a feeding tube (3%). Feeding tube patients were younger (mean age 6.3 years), reported more vomiting, and had a lower total endoscopic reference score than non-feeding tube patients ( P < 0.01 for all). Tubes were used for therapy for an average of 6.8 years, with most patients (95%) receiving both pharmacologic and formula treatment for EoE. An emergency department visit for a tube complication was required in 26%. Tube feeding improved body mass index z score ( P < 0.01), symptomatic response (42%), endoscopic response (53%), and histologic response (71%). CONCLUSIONS: Among EoE patients, only a small subset required a feeding tube and predominantly were young children with failure to thrive. Feeding tubes significantly improved growth and, when used in combination with other treatments, led to reduced esophageal eosinophilic inflammation.
Assuntos
Esofagite Eosinofílica , Criança , Humanos , Pré-Escolar , Esofagite Eosinofílica/terapia , Esofagite Eosinofílica/tratamento farmacológico , Estudos Retrospectivos , EndoscopiaRESUMO
BACKGROUND & AIMS: Achalasia is a debilitating chronic condition of the esophagus. Currently there are no national estimates on the epidemiologic and economic burden of disease. We sought to estimate trends in incidence and prevalence of achalasia by age-sex strata, and to estimate the total direct medical costs attributed to achalasia in the United States. METHODS: We conducted a cohort study using two administrative claims databases: IBM MarketScan Commercial Claims and Encounters database (2001-2018; age <65) and a 20% sample of nationwide Medicare enrollment and claims (2007-2015; age ≥65). Point prevalence was calculated on the first day of each calendar year; the incidence rate captured new cases developed in the ensuing year. Utilization rates of healthcare services and procedures were reported. Mean costs per patient were calculated and standardized to the corresponding U.S. Census Bureau population data to derive achalasia-specific total direct medical costs. RESULTS: The crude prevalence of achalasia per 100,000 persons was 18.0 (95% CI, 17.4, 18.7) in MarketScan and 162.1 (95% CI, 157.6, 166.6) in Medicare. The crude incidence rate per 100,000 person-years was 10.5 (95% CI, 9.9, 11.1) in MarketScan and 26.0 (95% CI, 24.9, 27.2) in Medicare. Incidence and prevalence increased substantially over time in the Medicare cohort, and increased with more advanced age in both cohorts. Utilization of achalasia-specific healthcare was high; national estimates of total direct medical costs exceeded $408 million in 2018. CONCLUSIONS: Achalasia has a higher epidemiologic and economic burden in the US than previously suggested, with diagnosis particularly increasing in older patients.
Assuntos
Acalasia Esofágica , Idoso , Estudos de Coortes , Acalasia Esofágica/epidemiologia , Estresse Financeiro , Custos de Cuidados de Saúde , Humanos , Medicare , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Endoscopic eradication therapy with radiofrequency ablation (RFA) and endoscopic mucosal resection is a safe and effective treatment for Barrett's esophagus. Although the outcomes of surveillance endoscopy after successful endoscopic eradication therapy have been described, no previous studies have modeled the natural history or the effect of surveillance endoscopy after successful ablation to prevent progression to invasive esophageal adenocarcinoma. METHODS: The US RFA Registry is a multicenter registry consisting of patients treated with RFA for Barrett's esophagus at 148 institutions (113 community-based and 35 academic-affiliated). The authors fit models to impute the natural history of recurrence and neoplastic progression after any recurrence or retreatment. Natural history estimates of invasive adenocarcinoma after ablation therapy were compared with as-treated estimates at 5 years to derive the preventive risk difference for surveillance. RESULTS: Natural history estimates for the postablation progression of high-grade dysplasia (HGD) or intramucosal adenocarcinoma to invasive adenocarcinoma after treatment were 6.3% at 5 years compared with 1.3% for low-grade dysplasia (LGD). The natural history model found a much higher preventative risk difference for surveillance for HGD/intramucosal adenocarcinoma (-4.8%), compared with LGD (-1.1%). The numbers needed to surveil at 5 years were 21 and 90 for these groups, respectively, to prevent one case of invasive esophageal adenocarcinoma, making surveillance after successful ablation of baseline HGD more than 4 times as effective at preventing invasive cancer than after successful ablation of baseline LGD. DISCUSSION: Endoscopic surveillance after successful ablation of baseline HGD or intramucosal cancer is much more effective than surveillance after successful treatment of baseline LGD in averting invasive adenocarcinoma. Although the modest benefits of surveillance for treated LGD may be greater than the risks for patients at average risk for adverse effects of endoscopy, clinicians should concentrate on retaining patients with baseline HGD or cancer in endoscopic surveillance programs.
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Adenocarcinoma , Esôfago de Barrett , Neoplasias Esofágicas , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Esôfago de Barrett/patologia , Esôfago de Barrett/cirurgia , Endoscopia Gastrointestinal , Neoplasias Esofágicas/patologia , Esofagoscopia , HumanosRESUMO
INTRODUCTION: The correlation between clinical and molecular treatment response thresholds in eosinophilic esophagitis (EoE) is not well understood. METHODS: We evaluated posttreatment EoE diagnostic panel gene expression profiles across histologic and endoscopic thresholds (EREFS) in a prospective adult EoE cohort. RESULTS: We observed a strong inverse correlation between posttreatment gene score and eosinophil count (R = -0.66; P < 0.001); biopsies with <15 eos/hpf had higher gene scores (≥425) vs those with ≥15 eos/hpf. Findings for EREFS were similar; EREFS ≤2 was associated with EoE diagnostic panel scores ≥395. DISCUSSION: Molecular signatures support the use of posttreatment response thresholds <15 eos/hpf and EREFS ≤2 in clinical practice and trials.
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Esofagite Eosinofílica , Adulto , Biópsia , Endoscopia , Esofagite Eosinofílica/diagnóstico , Eosinófilos/patologia , Humanos , Estudos ProspectivosRESUMO
INTRODUCTION: Despite societal recommendations supporting Barrett's esophagus (BE) screening, it is unknown what proportion of eligible patients is screened in primary care. We assessed the proportion of BE screening- eligible patients evaluated in the primary care setting receiving upper esophagogastroduodenoscopy (EGD) and identified factors associated with undergoing EGD. METHODS: This was a retrospective study of BE screening-eligible patients, as defined by the American College of Gastroenterology's BE guidelines, in a multipractice healthcare network consisting of 64 internal medicine practices and 94 family medicine (FM) practices. The proportion undergoing EGD, prevalence of BE and esophageal adenocarcinoma (EAC) in this group, and patient and provider factors associated with undergoing EGD were assessed. Multivariable logistic regression was performed to identify independent predictors of undergoing EGD. RESULTS: Of 1,127 screening-eligible patients, the mean age was 65.2 ± 8.6 years; 45% were obese; and 61% were smokers. Seventy-three percent were seeing FM; 94% were on proton pump inhibitors; and 44% took ≥1 gastroesophageal reflux disease (GERD) medication. Only 39% of patients (n = 436) had undergone EGD. The overall prevalence of BE or EAC was 9.9%. Of 39 (9%) referred for BE screening as the primary indication, BE/EAC prevalence was 35.1%. Factors associated with increased odds of having EGD were symptomatic GERD despite treatment (odds ratio [OR] 12.1, 95% confidence interval [CI] 9.1-16.3), being on ≥1 GERD medication (OR 1.4, 95% CI 1.0-1.9), and being an FM patient (OR 1.5, 95% CI 1.1-2.1). DISCUSSION: In this large, primary care population, only 39% of screening-eligible patients underwent EGD. Most of the examinations were triggered by refractory symptoms rather than screening referrals, highlighting a need for improved dissemination and implementation of BE screening.
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Esôfago de Barrett , Neoplasias Esofágicas , Refluxo Gastroesofágico , Humanos , Pessoa de Meia-Idade , Idoso , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/epidemiologia , Esôfago de Barrett/complicações , Prevalência , Estudos Retrospectivos , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/epidemiologia , Neoplasias Esofágicas/complicações , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/complicações , Atenção Primária à SaúdeRESUMO
BACKGROUND: Endoscopic features of eosinophilic esophagitis (EoE) are measured using the validated EoE Endoscopic Reference Score (EREFS); however, a threshold for treatment response has not been defined. We aimed to determine a cut-point for endoscopic response as measured by EREFS. METHODS: We performed a secondary analysis of a randomized clinical trial comparing budesonide slurry with swallowed fluticasone multidose inhaler for initial treatment of EoE. In the parent trial, EREFS was determined before and after treatment (score range 0-9), as were histologic findings and dysphagia symptoms. We performed tabular, flexible trend, and dependent mixture analyses of measures of treatment response to select the best clinical EREFS threshold. RESULTS: In the 111 included patients (mean age 39 years; 67â% male; 96â% white), an EREFS threshold of ≤â2 was 80â% sensitive (95â% confidence interval [CI] 69â% to 88â%) and 83â% specific (95â%CI 67â% to 94â%) for histologic response (peak ofâ<â15 eosinophils per high-power field). Flexible trend analysis and dependent mixture modeling similarly suggested that a threshold of ≤â2 best captured the correlation of EREFS with histologic and symptomatic measures. Dependent mixture modeling found near-total membership in the response class at EREFS of 0 or 1 and >â75â% at EREFS of 2 or 3. CONCLUSIONS: An EREFS of ≤â2 was the best clinical threshold for endoscopic response to topical steroid treatment, and was consistent with clinical and histologic response. Therefore, future studies can report a binary outcome of endoscopic response when EREFS is 2 or less.
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Transtornos de Deglutição , Esofagite Eosinofílica , Adulto , Transtornos de Deglutição/complicações , Esofagite Eosinofílica/tratamento farmacológico , Esofagite Eosinofílica/patologia , Eosinófilos/patologia , Esofagoscopia , Feminino , Fluticasona/uso terapêutico , Humanos , MasculinoRESUMO
BACKGROUND: Gender disparities remain in the field of gastroenterology (GI) despite the decreasing gender gap in the medical field overall. We sought to examine primary and last female authorship as a marker of academic opportunity and advancement to assess the proportion of women publishing in GI over 20 years (1997-2017). METHODS: In this observational study, we assessed the gender and nationality of primary and last authors of original research manuscripts in three GI journals (Gastroenterology, Gut, and American Journal of Gastroenterology) across a 20-year period in 5-year intervals (in 1997, 2002, 2007, and 2012). We used a validated gender-determining algorithm, genderize.io, to classify gender. Our primary outcome was the proportion of female primary and last authors, with secondary measures assessing trends in gender and nationality. RESULTS: Through the Genderize.io gender database, we were able to identify the gender for 3,673 (95.9%) of primary author names and 3,504 (95.4%) of last author names in the 3,615 manuscripts evaluated. Overall, there was a significant increase in female primary authors over time, from 18.1% in 1997 to 42.6% in 2017, a 6.0% increase per 5-year period (95% CI 4.8-7.2%). A similar trend was found for female last authors, however, at a slower rate, from 8.3% in 1997 to 24.7% in 2017, a 3.5% increase per 5 years (95% CI 2.5-4.4%). These trends were noted cumulatively, and in each journal individually. Manuscripts with a female last author were more likely to demonstrate a female primary author. CONCLUSION: Female authorship in high-impact gastroenterology journals has increased over time. Last authorship has lagged primary authorship in female representation and has increased more slowly over time. Interventions to reduce gender disparity in GI research should focus on the transition from first to last authorship.
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Autoria , Gastroenterologia , Publicações Periódicas como Assunto/tendências , Médicas , África , América , Ásia , Pesquisa Biomédica , Europa (Continente) , Humanos , Fator de Impacto de Revistas , Oceania , Pesquisa Translacional BiomédicaRESUMO
BACKGROUND AND AIMS: Updated diagnostic guidelines for eosinophilic esophagitis (EoE) have eliminated the requirement for a proton pump inhibitor (PPI) trial, but there are no models to identify patients with EoE based on these new criteria. We aimed to develop a predictive model for diagnosis of EoE based on the updated EoE diagnostic guidelines. METHODS: We performed a secondary analysis of a prospective study of adult patients referred for outpatient esophagogastroduodenoscopy at University of North Carolina who had symptoms of esophageal dysfunction; patients with prevalent EoE were excluded. We analyzed data from 206 EoE cases (mean age 40.1, 62.6% male, 93.2% white) and 306 controls (mean age 52.3, 37.9% male, 79.7% white). We built predictive models for case-control status, using clinical, endoscopic, and histologic features, and defining EoE by either the new or historical definition of PPI non-response. Model discrimination was assessed by the area under the receiver-operator characteristic curve (AUC). RESULTS: Before endoscopy, younger age, male sex, history of atopic condition or food allergy, and dysphagia identified patients with EoE with an AUC of 0.83. When we included endoscopy findings suggestive of EoE, the model identified patients with EoE with an AUC of 0.92; this increased to 0.99 when histology was included. CONCLUSION: We developed a model to identify patients with EoE, without a trial of PPIs, based on updated diagnostic guidelines. Clinical features and endoscopic findings identified patients with EoE with an AUC of 0.92-even without histologic data and in the absence of dysphagia. This model can be used to select patients with upper gastrointestinal symptoms but without dysphagia for early diagnostic endoscopy. The model can also be used to identify cases of EoE when eosinophil counts are greater than 15 in biopsies but other causes of esophageal eosinophilia cannot necessarily be excluded.
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Esofagite Eosinofílica , Adulto , Endoscopia , Esofagite Eosinofílica/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Inibidores da Bomba de PrótonsRESUMO
A cost-utility analysis in the current issue of AJG examines the ramifications of the overuse of surveillance endoscopy in Barrett's esophagus (BE). This study suggests that excess surveillance is expensive, increasing costs by 50% or more, with only nominal increases in quality-adjusted life expectancy. This study joins a growing literature of cost-utility analyses that suggest that more is not likely better when it comes to surveillance endoscopy. Given the plentiful literature showing overutilization of surveillance endoscopy in BE, the authors argue for a focus on the quality of endoscopy rather than increased frequency of surveillance to improve returns on our healthcare investment.
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Esôfago de Barrett , Neoplasias Esofágicas , Análise Custo-Benefício , Esofagoscopia , HumanosRESUMO
INTRODUCTION: We investigated whether dilation modifies the association between symptoms and esophageal eosinophilia (peak esophageal eosinophils/high-power field [eos/hpf]) in patients with eosinophilic esophagitis enrolled into a randomized trial comparing the efficacy of budesonide and fluticasone. METHODS: Baseline Dysphagia Symptom Questionnaire and Eosinophilic Esophagitis Activity Index were available in 102 and 73 patients, respectively, of whom 56 and 39 underwent dilation at screening endoscopy before symptom assessment. The pair-wise relationship between Dysphagia Symptom Questionnaire, Eosinophilic Esophagitis Activity Index, and eos/hpf was analyzed with nonparametric correlations. RESULTS: In nondilated patients, the association between baseline eos/hpf and symptoms was moderate and significant, although it was abolished in dilated patients. DISCUSSION: Dilation modifies association between symptoms and eos/hpf (clinicaltrials.gov NCT02019758).
Assuntos
Transtornos de Deglutição/terapia , Eosinofilia/terapia , Esofagite Eosinofílica/terapia , Esofagoscopia , Transtornos de Deglutição/complicações , Transtornos de Deglutição/diagnóstico , Dilatação/métodos , Eosinofilia/complicações , Eosinofilia/diagnóstico , Esofagite Eosinofílica/complicações , Esofagite Eosinofílica/diagnóstico , Esôfago , Feminino , Humanos , Masculino , Índice de Gravidade de Doença , Avaliação de SintomasRESUMO
PURPOSE OF REVIEW: Barrett's esophagus (BE) is a premalignant condition of the esophagus associated with an increased risk for esophageal adenocarcinoma (EAC). Radiofrequency ablation (RFA) is a safe and effective first-line treatment for dysplastic BE and early stage EAC. This report reviews clinically relevant evidence published over the last 3 years regarding RFA for BE. RECENT FINDINGS: Our use of this technology has simultaneously gone too far, in that many patients who may not derive a benefit from these treatments are receiving them, and not far enough, in that many patients who would be eligible for ablative therapy never undergo screening exams to assess them for dysplastic BE, or do not have endoscopic therapy considered part of the treatment of superficial invasive cancer. Research to better identify patients with BE, risk stratify those patients, improve the quality of RFA treatment, and inform surveillance practices has the potential to optimize the benefit of RFA, and minimize the harms, costs, and risks.
Assuntos
Adenocarcinoma/prevenção & controle , Esôfago de Barrett/cirurgia , Ablação por Cateter , Neoplasias Esofágicas/prevenção & controle , Esôfago/cirurgia , Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Neoplasias Esofágicas/patologia , Esofagoscopia , Esôfago/patologia , Humanos , Seleção de Pacientes , Conduta ExpectanteRESUMO
BACKGROUND: While the environment contributes to EoE pathogenesis, few environmental risk factors for EoE have been identified. AIM: To determine whether housing components such as exterior materials, heating systems, and house age are associated with EoE. METHODS: This case-control study used the UNC EoE clinicopathologic database to identify newly diagnosed EoE patients. Controls were patients without EoE who underwent endoscopy during the study time frame. Housing data were collected from publicly available online sources, and cases and controls were compared. The primary analysis was restricted to those living at their provided address at the time of diagnostic endoscopy. Multivariable logistical regression estimated associations after adjusting for potential confounders. RESULTS: Of 451 EoE cases and 2421 controls identified, the primary analysis included 158 cases and 769 controls. Compared to controls, EoE cases were more likely to have a house with a brick exterior (35% vs 26%; p = 0.04), gas heating (14% vs 8%; p = 0.06), or forced air (57% vs 45%; p = 0.009). In adjusted analysis, brick exterior was positively associated with EoE diagnosis [aOR 1.83 (95% CI 1.11-3.02)]. The average duration a patient lived in their house before EoE diagnosis was 7.2 ± 5.9 years, while symptom duration prior to diagnosis was 6.8 ± 8.4 years. CONCLUSION: EoE patients were more likely to have houses with a brick exterior, forced air, or gas heating, and brick exteriors were independently associated with EoE. Since symptoms generally started after moving into a house, housing-related environmental exposures may contribute to EoE disease development.
Assuntos
Materiais de Construção , Exposição Ambiental , Esofagite Eosinofílica , Calefação , Habitação/estatística & dados numéricos , Adulto , Estudos de Casos e Controles , Materiais de Construção/efeitos adversos , Materiais de Construção/estatística & dados numéricos , Endoscopia/métodos , Exposição Ambiental/efeitos adversos , Exposição Ambiental/estatística & dados numéricos , Esofagite Eosinofílica/diagnóstico , Esofagite Eosinofílica/epidemiologia , Feminino , Calefação/efeitos adversos , Calefação/métodos , Calefação/estatística & dados numéricos , Humanos , Masculino , North Carolina/epidemiologia , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND & AIMS: Barrett's esophagus (BE) recurs in 25% or more of patients treated successfully with radiofrequency ablation (RFA), so surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CEIM). The frequency of surveillance is informed only by expert opinion. We aimed to model the incidence of neoplastic recurrence, validate the model in an independent cohort, and propose evidence-based surveillance intervals. METHODS: We collected data from the United States Radiofrequency Ablation Registry (US RFA, 2004-2013) and the United Kingdom National Halo Registry (UK NHR, 2007-2015) to build and validate models to predict the incidence of neoplasia recurrence after initially successful RFA. We developed 3 categories of risk and modeled intervals to yield 0.1% risk of recurrence with invasive adenocarcinoma. We fit Cox proportional hazards models assessing discrimination by C statistic and 95% confidence limits. RESULTS: The incidence of neoplastic recurrence was associated with most severe histologic grade before CEIM, age, endoscopic mucosal resection, sex, and baseline BE segment length. In multivariate analysis, a model based solely on most severe pre-CEIM histology predicted neoplastic recurrence with a C statistic of 0.892 (95% confidence limit, 0.863-0.921) in the US RFA registry. This model also performed well when we used data from the UK NHR. Our model divided patients into 3 risk groups based on baseline histologic grade: non-dysplastic BE; indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia; or intramucosal adenocarcinoma. For patients with low-grade dysplasia, we propose surveillance endoscopy at 1 and 3 years after CEIM; for patients with high-grade dysplasia or intramucosal adenocarcinoma, we propose surveillance endoscopy at 0.25, 0.5, and 1 year after CEIM, then annually. CONCLUSION: In analyses of data from the US RFA and UK NHR for BE, a much-attenuated schedule of surveillance endoscopy would provide protection from invasive adenocarcinoma. Adherence to the recommended surveillance intervals could decrease the number of endoscopies performed yet identify unresectable cancers at rates less than 1/1000 endoscopies.