Case report of a successful multidisciplinary approach to a giant scrotal malformation.

INTRODUCTION: Congenital pelvic malformations are rare and represent a difficult therapeutic challenge. Scrotal arteriovenous malformations are quite unusual, with only a few such cases reported in the literature. Only one case of scrotal malformation? due to an arteriovenous fistula resulting in azoospermia has been described. PRESENTATION OF CASE: The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences. DISCUSSION: Angio-CT performed using reconstructions with MIP and SSD algorithms provided more detailed data about the extension of the afferents and efferents of the arteriovenous malformation, thus enabling us to plan the endovascular treatment of the lesion. CONCLUSION: A multidisciplinary approach is mandatory to achieve good results in these cases.

Carotid plaque instability is not related to quantity but to elemental composition of calcification.

BACKGROUND AND AIMS: Recent studies highlighted the role of calcification processes in the clinical progression of chronic cardiovascular diseases. In this study we investigated the relationship between the chemical composition of calcification and atherosclerotic plaque stability in carotid arteries. METHODS AND RESULTS: To this end, we characterized the calcification on 229 carotid plaques, by morphology, immunohistochemistry, transmission electron microscopy and energy dispersive X-ray microanalysis. Plaques were classified into two categories: unstable and stable. No significant differences were found in the incidence of the various risk factors between patients with and without carotid calcification, with the exception of diabetes. The energy dispersive X-ray microanalysis allowed us to identify two types of calcium salts in the atheromatous plaques, hydroxyapatite (HA) and calcium oxalate (CO). Our results showed that calcification is a common finding in carotid plaques, being present in 77.3% of cases, and the amount of calcium is not a factor of vulnerability. Noteworthy, we observed an association between HA calcification and unstable plaques. On the contrary, CO calcifications were mainly detected in stable plaques. CONCLUSIONS: The presence of different types of calcification in atheromatous plaques may open new perspectives in understanding the molecular mechanisms of atheroma formation and plaque instability.

EVAR and OPEN treatment of abdominal aortic aneurysm: What is the role of MMP-9 in the follow-up?

INTRODUCTION: The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up. MATERIAL AND METHOD: From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups. RESULTS: The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak. CONCLUSIONS: This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients.

Italian Percutaneous EVAR (IPER) Registry: outcomes of 2381 percutaneous femoral access sites' closure for aortic stent-graft.

AIM: The aim of this paper was to report outcomes of endovascular aneurysm repair with percutaneous femoral access (pEVAR) using Prostar XL and Proglide closure systems (Abbot Vascular, Santa Clara, CA, USA), from the multicenter Italian Percutaneous EVAR (IPER) registry. METHODS: Consecutive patients affected by aortic pathology treated by EVAR with percutaneous access (pEVAR) between January 2010 and December 2014 at seven Italian centers were enrolled in this multicenter registry. All the operators had an experience of at least 50 percutaneous femoral access procedures. Data were prospectively collected into a dedicated online database including patient's demographics, anatomical features, intra- and postoperative outcomes. A retrospective analysis was carried out to report intraoperative and 30-day technical success and access-related complication rate. Uni- and multivariate analyses were performed to identify factors potentially associated with an increased risk of percutaneous pEVAR failure. RESULTS: A total of 2381 accesses were collected in 1322 patients, 1249 (94.4%) male with a mean age of 73.5±8.3 years (range 45-97). The overall technical success rate was 96.8% (2305/2381). Major intraoperative access-related complications requiring conversion to surgical cut-down were observed in 3.2% of the cases (76/2381). One-month pEVAR failure-rate was 0.25% (6/2381). Presence of femoral artery calcifications resulted to be a significant predictor of technical failure (OR: 1.69; 95% CI: 1.03-2.77; P=0.036) at multivariate analysis. No significant association was observed with sex (P=0.28), obesity (P=0.64), CFA diameter (P=0.32), level of CFA bifurcation (P=0.94) and sheath size >18 F (P=0.24). The use of Proglide was associated with a lower failure rate compared to Prostar XL (2.5% vs. 3.3%) despite not statistically significant (P=0.33). CONCLUSION: The results of the IPER registry confirm the high technical success rate of percutaneous EVAR when performed by experienced operators, even in presence of demanding anatomies. Femoral calcification represents the only predictor of percutaneous access failure.

Long-term outcomes of thalidomide in refractory Crohn's disease.

BACKGROUND: Several open-label and retrospective studies have indicated that thalidomide may be beneficial in patients with refractory Crohn's disease (CD). AIM: To report our long-term experience with the use of thalidomide for adults with refractory Crohn's disease. METHODS: We conducted a retrospective study of long-term clinical and safety outcomes among adults treated with thalidomide for refractory Crohn's disease. Response was defined as a clinician's assessment of improvement after at least 7 days treatment of one or more of the following: bowel movement frequency, fistula output, rectal bleeding, abdominal pain, extraintestinal manifestations, or well-being. Remission required all of the following: <3 stools/day, no bleeding, abdominal pain or extraintestinal manifestations and increased well-being. RESULTS: Thirty-seven adults with refractory Crohn's disease were treated with thalidomide for a median of 4.4 months and followed up for a median of 58 months. Clinical response and remission rates were 54% and 19%, respectively. About 40% of patients were able to stop steroids. Response rates were higher for those treated with more than 50 mg/day (85%) than for those treated with a maximum of 50 mg/day (40%; P = 0.01). An adverse event occurred in 68% of patients. Approximately one-third of patients (38%) experienced neuropathy. CONCLUSIONS: Thalidomide appears to be safe and effective in some patients with refractory Crohn's disease. Although side effects may limit long-term use, thalidomide has potential to induce significant clinical responses.

MiR-216a: a link between endothelial dysfunction and autophagy.

Endothelial dysfunction and impaired autophagic activity have a crucial role in aging-related diseases such as cardiovascular dysfunction and atherosclerosis. We have identified miR-216a as a microRNA that is induced during endothelial aging and, according to the computational analysis, among its targets includes two autophagy-related genes, Beclin1 (BECN1) and ATG5. Therefore, we have evaluated the role of miR-216a as a molecular component involved in the loss of autophagic function during endothelial aging. The inverse correlation between miR-216a and autophagic genes was conserved during human umbilical vein endothelial cells (HUVECs) aging and in vivo models of human atherosclerosis and heart failure. Luciferase experiments indicated BECN1, but not ATG5 as a direct target of miR-216a. HUVECs were transfected in order to modulate miR-216a expression and stimulated with 100 µg/ml oxidized low-density lipoprotein (ox-LDL) to induce a stress repairing autophagic process. We found that in young HUVECs, miR-216a overexpression repressed BECN1 and ATG5 expression and the ox-LDL induced autophagy, as evaluated by microtubule-associated protein 1 light chain 3 (LC3B) analysis and cytofluorimetric assay. Moreover, miR-216a stimulated ox-LDL accumulation and monocyte adhesion in HUVECs. Conversely, inhibition of miR-216a in old HUVECs rescued the ability to induce a protective autophagy in response to ox-LDL stimulus. In conclusion, mir-216a controls ox-LDL induced autophagy in HUVECs by regulating intracellular levels of BECN1 and may have a relevant role in the pathogenesis of cardiovascular disorders and atherosclerosis.

Endovascular treatment of aorto-iliac aneurysms: four-year results of iliac branch endograft.

INTRODUCTION: The aim of this report was to analyse early and mid-term outcomes of endovascular treatment (endovascular aneurysm repair, EVAR) for aorto-iliac aneurysms with the use of an iliac branch device (IBD). REPORT: A total of 85 EVAR procedures with IBD were electively carried out in 81 patients between September 2007 and August 2012. Technical success was obtained in 98.7% of the cases. The mean follow-up duration was 20.4 months (SD ± 15.4). There was one IBD occlusion (1.2%). Estimated 48 months' survival, freedom from re-intervention and branch occlusion were 76.7%, 88.3% and 98%, respectively. CONCLUSIONS: EVAR for aorto-iliac aneurysms using IBD is an effective procedure with low complication and re-intervention rates at mid-term follow-up.

Conventional carotid endarterectomy versus stenting: comparison of restenosis rates in arteries with identical predisposing factors.

AIM: The aim of the study was to investigate the possible role of individual predisposition in the pathogenesis of carotid restenosis. METHODS:Over 1700 patients have undergone carotid endarterectomy (CEA) in our institute over the past 15 years. We retrospectively reviewed the charts of those who also had contralateral carotid stenting (CAS) for primary atherosclerotic stenosis and recorded the rates of post-CEA and post-CAS restenosis ≥50%. RESULTS: In the 29 cases analyzed (21 men/8 women), CEA was performed with conventional technique and direct suturing in most cases. Mean ages at the time of CEA and CAS were 69.2±6.6 and 73±6.7 yrs, respectively, and risk profiles at the 2 time points were similar: hypertension (96.5%), dyslipidemia (55.2%), smoking (51.7%), diabetes (31%), coronary artery disease (48.3%), chronic obstructive pulmonary disease (37.9%), and chronic renal failure (13.8%). Antiplatelet therapy protocols were identical for the two procedures. During follow-up (mean: 67.25±51.6 months after CEA, 24.6±16.9 months after CAS), Duplex scans revealed restenosis in 12 patients (9 arteries treated with CEA, 6 managed with CAS). In three patients, restenosis was bilateral. Restenosis-free survival rates at five years were 85% after CEA and 66% after CAS (P=NS). CONCLUSION: In this selected group of patients, CEA and CAS were associated with a similar incidence of restenosis. Only 25% of the patients who developed restenosis did so after both procedures. These preliminary findings indicate that individual predisposition does not play a crucial role in the pathogenesis of restenosis. To confirm this conclusion, an analysis of a much larger, multicenter cohort is essential.

Linkage of Crohn's disease-related serological phenotypes: NFKB1 haplotypes are associated with anti-CBir1 and ASCA, and show reduced NF-kappaB activation.

BACKGROUND AND AIMS: Genetics studies of the serum expression of antibodies to microbial antigens may yield important clues to the pathogenesis of Crohn's disease. Our aim was to conduct a linkage study using expression of anti-CBir1, anti-I2, anti-OmpC and ASCA as quantitative traits. METHODS: Expression of antibodies to microbial antigens was measured by enzyme-linked immunosorbant assay (ELISA) and a standard approximately 10 cM whole genome microsatellite study was conducted. Single nucleotide polymorphism genotyping was performed using either Illumina or TaqMan MGB technology. Nuclear factor Kappa B (NF-kappaB) activation in cells from Epstein-Barr virus (EBV)-transformed cell lines was assessed using an electrophoretic mobility shift assay and protein was measured using ELISA and western blotting. RESULTS: Evidence for linkage to anti-CBir1 expression was detected on human chromosome 4 (logarithm of odds (LOD) 1.82 at 91 cM). We therefore directly proceeded to test the association of haplotypes in NFKB1, a candidate gene. One haplotype, H1, was associated with anti-CBir1 (p = 0.003) and another, H3, was associated with ASCA (p = 0.023). Using cell lines from Crohn's disease patients with either H1 or H3, NF-kappaB activation and NF-kappaB p105 and p50 production were significantly lower for patients with H1 compared to patients with H3. CONCLUSIONS: These results suggest that NFKB1 haplotypes induce dysregulation of innate immune responses by altering NF-kappaB expression. The results also show the use of EBV-transformed lymphoblastoid cell lines to conduct phenotypic studies of genetic variation.

Diagnostic yield of capsule endoscopy in ulcerative colitis and inflammatory bowel disease of unclassified type (IBDU).

BACKGROUND AND STUDY AIMS: Capsule endoscopy is increasingly reported as an important diagnostic procedure in patients with known or suspected Crohn's disease, but its clinical utility in patients with ulcerative colitis or unclassified type inflammatory bowel disease (IBDU) is unclear. The aim of our study was to determine the diagnostic yield of capsule endoscopy for small-bowel disease in patients with ulcerative colitis and IBDU. PATIENTS AND METHODS: All data from patients with a history of ulcerative colitis or IBDU who underwent capsule endoscopy between October 2001 and August 2005 were analyzed for procedure indications and findings. Images were reviewed by an experienced capsule endoscopist. The finding of multiple ulcerations (three or more) on capsule endoscopy was classified as diagnostic of small-bowel Crohn's disease. RESULTS: 120 patients had undergone 122 capsule endoscopy procedures. Overall, 19 of 120 patients (15.8 %) had capsule endoscopy findings consistent with the diagnosis of Crohn's disease. The proportion of patients with small-bowel disease was significantly higher among patients with a history of colectomy (7 of 21 patients, 33 %) compared with those without colectomy (12/99, 12 %) ( P = 0.04). Among patients with positive findings on capsule endoscopy, 18 had also previously undergone a small-bowel follow-through study and only one showed findings consistent with Crohn's disease. CONCLUSIONS: Many patients with a diagnosis of ulcerative colitis and atypical features or IBDU may have small-bowel findings on capsule endoscopy that are consistent with Crohn's disease. Capsule endoscopy should be considered in ulcerative colitis patients with atypical clinical features particularly after colectomy.

Acute pancreatitis as a possible consequence of metronidazole during a relapse of ulcerative colitis.

We present the first case of metronidazole-related acute pancreatitis during a relapse of ulcerative colitis. A 31-year-old male patient, with inflammatory bowel disease on mesalamine treatment for the last 5 months, suffered from a 48-h abdominal pain and nausea. He was also administered metronidazole during a relapse 5 days before. Laboratory and imaging investigation revealed acute pancreatitis. Conservative measures and metronidazole as well as mesalamine withdrawal resulted in complete recovery. Clinical remission of ulcerative colitis was obtained by prednisolone administration. Mesalamine was reintroduced and no recurrence was noticed for a year. Acute pancreatitis was mainly attributed to metronidazole owing to the absence of recurrence after mesalamine readministration, the time of onset after the initiation of metronidazole and the lower typical range between its onset and mesalamine exposure. Identifying acute pancreatitis as a possible consequence of a certain medication in inflammatory bowel disease patients may be particularly important to determine further treatment of their disease.

The endovascular management of open aortic surgery complications with emergency stent-graft repair in high-risk patients.

The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications.

Open surgery of infrarenal aortic aneurysms with iliac involvement: repair should be entirely intra-abdominal.

AIM: A review of the literature on the surgical treatment of abdominal aortic aneurysms (AAAs) reveals that aortofemoral bypass (AFB) is used frequently in some centers. The latter series are characterized by higher rates of graft-related complications than in those in which AFB is used less frequently. The aim of our study was to evaluate the relative frequency and outcome of different types of bypass grafts in the surgical treatment of AAAs with iliac involvement, in our center and in others. METHODS: Between 1994 and 2004, 190 AAA patients with involvement of the iliac axes underwent elective repair in our department. Surgery was performed via median transperitoneal access. RESULTS: The AAAs extended to the common iliac artery (CIA) in 90.5% of patients. The remaining 9.5% extended to the external iliac artery (EIA). Aorto bi-iliac grafts were used in 159 cases, straight tube grafts in 13, aorto EIA grafts in 15, and AFBs in 3. Overall 30-day morbidity and mortality rates were 12.1% and 2.6%, respectively. At follow-up (mean: 5.6 years), one distal limb infection of an AFB and 4 CIA/EIA aneurysmal enlargements occurred and were repaired accordingly. Secondary patency and 5-year cumulative survival rate were 100% and 80%, respectively. CONCLUSIONS: In this series of AAAs extending to the iliac axes, AFB was used selectively (1.6%), even when the AAA extended to the EIA. This allowed us to maintain direct vascularization of the hypogastric arteries and eliminate the risk of complications associated with inguinal access. We feel, therefore, that for the repair of aortoiliac aneurysms, AFB is rarely indicated.

Popliteal artery aneurysms. Factors associated with thromboembolism and graft failure.

AIM: The purpose of this study was to review our experience with popliteal artery aneurysms (PAAS) and to identify the major factors associated with thromboembolism of PAAS and failure of grafts after surgical repair. METHODS: The medical records of 38 patients with 42 PAA, who presented in a university medical center between March 1985 and September 2000, were retrospectively reviewed. Data were collected on clinical presentation, risk factors, type of reconstructions, early and late morbidity, limb loss and mortality. Duplex scan, as well as computed tomography, was performed in 33 (78.6%) cases, and preoperative angiography in 38 (90.5%). Thrombolysis was performed prior to surgical reconstruction (16.07+/-21.97 months) in 4 cases presented with acute ischemia. All patients underwent synthetic (23, 54.8%) or autogenous (19, 45.2%), below-the-knee (39, 92.9%) or above-the-knee (3, 7.1%) femoropopliteal bypass graft. The proximal and distal anastomoses were end-to-end both in both cases in 30 bypasses (71.4%). Thirty-six (86%) aneurysms were surgically treated by one vascular surgeon. Postoperative anticoagulants were given in 8 cases (19%). Long-term follow-up (mean: 57.59+/-37.77 months) was available for 35 patients (92.1%). Multivariate analysis was used to assess association between risk factors and outcome. RESULTS: Thirty-five patients were males, 3 were females; mean age was 68.31+/-8.66 years. Risk factors were arterial hypertension (25, 69%), smoking (19, 50%), dyslipidemia (7, 18.4%) and diabetes (5, 13.2%). Thirty PAAS (71.4%) were symptomatic for acute (11, 26.2%) or chronic (7, 16.7%) ischemia, distal embolization (8, 19%), compression of the popliteal fossa (3, 7.1%) and rupture (2, 4.8%, one of which presented with acute ischemia); 12 were asymptomatic. Bilateral PAAS were present in 18 patients (47.4%); 14 (36.8%) also had an abdominal aortic aneurysm (AAA); associated AAAS were twice as common in patients with bilateral PAAS (9/18, 50%) compared to those with unilateral PAAS (5/20, 25%; p=NS). The mean diameter of the PAAS was 3.4 cm; no significant difference was found in the mean diameter of symptomatic and asymptomatic aneurysms. Complete thrombosis of the aneurysmal sac was found in 15 cases (35.7%), severe atherosclerotic femoro-popliteal lesions in 17 (40.5%), arteriomegaly in 11 (26.2%), occlusion of the superficial femoral artery (SFA) in 7 (16.7%). Three leg arteries were present in 17 limbs (40.5%), 2 in 6 (14.3%), 1 in 7 (16.7%), no leg vessels in 12 (28.6%). Occlusion of the SFA and the absence of major leg arteries were independently associated with thrombosis of the aneurysmal sac (p=0.005). Two-thirds of patients with thrombosed PAA (10, 66.7%) presented with acute ischemia, while 1/3 (5, 33.3%; p=NS) had some degree of claudication. Optimal runoff (score=1) was estimated in 23 limbs, while score was between 2-7 in 19 limbs. Thrombolysis was successful in all 4 cases, with no complications. Primary graft patency was 66.1% at 4 years; the only variables independently associated with loss of bypass patency were smoking (p=0.04) and poor leg runoff (p=0.02). Postoperative bypass occlusion occurred in 2 cases presented respectively with acute and chronic ischemia, and in 2 asymptomatic patients; all 4 bypasses were polytetrafluoroethylene grafts. A total of 8 thrombosed, polytetrafluoroethylene, below-the-knee bypass grafts required secondary reconstructions (2 redo + 6 restorative procedures). The secondary patency rate at 3 years was 77.9%. Lower limb amputation had to be performed 2 months after primary reconstruction in 1 case (2.4%) presented with acute ischemia. The estimated limb salvage rate at 10 years was 96%. Mortality was 4.8%. Survival at 6 years was 82.6%. CONCLUSION: Our experience indicates that SFA occlusion and poor runoff vessels were independent factors associated with PAA thrombosis. The diameter of asymptomatic PAAs was not significantly different than that of asymptomatic ones. Use of tobacco and poor runoff vessels were independent factors associated with primary bypass patency. In PAAs complicated with acute ischemia, thrombolysis allowed us to regain a good runoff and to perform subsequent bypass procedure, with no amputation. The use of autogenous graft material, when possible, is recommended.

Effective and safe endoscopic reversal of nondysplastic Barrett's esophagus with thermal electrocoagulation combined with high-dose acid inhibition: a multicenter study.

BACKGROUND: Barrett's esophagus is a metaplastic change in the esophageal lining with an increased risk for adenocarcinoma. Multiple endoscopic techniques have been applied in an effort to reverse Barrett's. This is a multicenter trial defining the efficacy and safety of multipolar electrocoagulation combined with high-dose acid inhibition. METHODS: Patients with a 2- to 6-cm segment of Barrett's esophagus without dysplasia were enrolled at 3 centers. They were treated with omeprazole 40 mg twice daily and then with up to 6 sessions with electrocoagulation aimed at eliminating all the endoscopically apparent Barrett's. Four quadrant large-capacity biopsies every 2 cm were centrally assessed for residual intestinal metaplasia. RESULTS: Fifty-eight patients reached the endpoint of failure of visual reversal of Barrett's after 6 treatment sessions or a 6-month follow-up after the last session. Eighty-five percent had visual reversal and 78% both visual and histologic reversal. Four patients had histologic evidence of residual intestinal metaplasia. Transient esophageal symptoms were common. One patient developed a stricture requiring dilation and one required overnight hospitalization for chest pain. CONCLUSIONS: The majority of patients with 2 to 6 cm of nondysplastic Barrett's esophagus can be safely reversed with this combination therapy. Long-term follow-up will be necessary to document the durability of the new squamous epithelium.

The economic impact of the diagnosis of dysplasia in Barrett's esophagus.

OBJECTIVE: Cost-effective strategies for identifying patients with Barrett's esophagus who are most likely to develop cancer have not been developed. Surveillance endoscopy is currently used, and we hypothesized that more frequent surveillance intervals would identify patients with "transient positive" diagnoses of dysplasia--dysplasia found on one examination but not on subsequent ones. Our aim was to explore the potential economic impact of transient positive diagnoses of dysplasia on alternative surveillance strategies over a 10-yr period. METHODS: Data were derived from a 2-yr randomized, prospective study comparing omeprazole to ranitidine in 95 patients with Barrett's esophagus. A transient positive diagnosis of dysplasia was defined as a patient who was diagnosed with dysplasia during the study period but whose 24-month biopsies revealed no dysplasia. We calculated the number of transient positive diagnoses of dysplasia and modeled the potential economic impact of a diagnosis of dysplasia over a 10-yr period. RESULTS: Thirty patients (31%) had at least one reading of dysplasia during the study period. Nineteen patients (20%) had a transient positive diagnosis of dysplasia. During the study period, no cancers were found. A surveillance strategy of every other year and every 6 months for dysplasia would result in 1072 endoscopies over a 10-yr period at a discounted cost of $1,587,184. A total of 61% of endoscopies would be because of transient positive diagnoses of dysplasia. A strategy of yearly surveillance and every 6 months for dysplasia would result in 1404 endoscopies at a discounted cost of $2,096,733, of which 28% would result from transient positive diagnoses of dysplasia. The discounted incremental costs of more frequent surveillance in this cohort of patients over 10 yr is $509,549. CONCLUSIONS: Based on current practice strategies, transient positive diagnoses of dysplasia account for 28-61% of endoscopies in Barrett's surveillance programs. This analysis suggests that the endoscopy workload and costs associated with surveillance could be substantially reduced if patients with transient positive diagnoses of dysplasia reverted to usual surveillance after two negative examinations.

Esophageal biopsy.

Esophageal biopsy is a natural extension of the endoscopic evaluation of many patients. It has a high likelihood of diagnostic accuracy in malignant and infectious esophageal disease. With careful attention to landmarks and good communication between the gastroenterologist and the pathologist BE should be readily diagnosed. With proper attention to the recommended biopsy protocols dysplasia should be detected accurately. Future research will determine the value of biopsy in the patient with gastroesophageal reflux and a normal endoscopy.

Hyperfibrinogenemia is associated with specific histocytological composition and complications of atherosclerotic carotid plaques in patients affected by transient ischemic attacks.

BACKGROUND: Epidemiological studies have demonstrated that hyperfibrinogenemia is an independent risk factor for cerebrovascular atherosclerosis. However, the underlying mechanisms are poorly understood. We studied whether hyperfibrinogenemia could modify the histological composition of atherosclerotic plaque and precipitate carotid thrombosis resulting from rupture of the plaque. METHODS AND RESULTS: We studied the histological composition of 71 carotid atherosclerotic plaques from patients who had undergone surgical endarterectomy after a first episode of transient ischemic attack. Patients were divided into 3 groups corresponding to the tertiles of plasma fibrinogen values. Hypercholesterolemia, hypertriglyceridemia, hypertension, diabetes, and smoking habit were also assessed. At the histological analysis, plaques of patients in the highest tertile of fibrinogen (>407 mg/dL) were characterized by a high incidence of thrombosis (66.7% of cases) compared with plaques of subjects in the lower (21.7%) (P=0.002) and middle (29. 2%) (P=0.009) tertiles. Plaque rupture was significantly associated with high fibrinogen levels (54.2%, P=0.003). Multivariate logistic regression indicated that hyperfibrinogenemia was an independent risk factor for a decrease in cap thickness (P=0.0005), macrophage foam cell infiltration of the cap (P=0.003), and thrombosis (P=0. 003). When the presence of other risk factors was accounted for, hyperfibrinogenemia remained an independent predictor of carotid thrombosis with an odds ratio of 5.83, compared with other risk factors. CONCLUSIONS: The results of the present study add to the evidence that hyperfibrinogenemia, independently of other risk factors, is associated with a specific histological composition of carotid atherosclerotic plaques that predisposes them to rupture and thrombosis.