The corrugated esophagus, a sign of severe reflux disease: radiographic and endoscopic appearance.

PURPOSE: To present the appearance of esophageal scarring resulting in a corrugated configuration seen on barium radiographs and through the endoscope. MATERIALS AND METHODS: Barium radiographs and endoscopic images obtained in 8 patients with a fixed deformity of the esophagus which resulted in a corrugated pattern were retrospectively reviewed. All patients (6 males, 2 females) presented long histories of gastroesophageal reflux disease; they were aged 29-84 (mean 46.0) years. Six patients complained of obstructive symptoms (dysphagia or recurrent food impactions). RESULTS: All of the lesions occurred in the mid or distal esophagus, with an average length of 11.1 (range 4-22) cm, and an average diameter of 15.4 (range 9-22) mm. Additional findings included hiatal hernia (n = 6), distal esophageal scarring (n = 3), esophageal fold thickening (n = 1) and intramural pseudodiverticula (n = 1). CONCLUSION: The finding of a corrugated pattern of the esophagus is suggestive of chronic severe gastroesophageal reflux disease. The reduction in esophageal caliber as a consequence often leads to symptomatic dysphagia.

Esophageal dysmotility in an adult with chronic granulomatous disease.

Chronic granulomatous disease (CGD) is a group of hereditary disorders of impaired intracellular destruction of phagocytosed bacteria. Gastrointestinal manifestations are present, with hepatic abscess being the most common. In this case report, we present an adult with CGD with esophageal involvement, which has been described in only one other adult. The clinical history, modalities of diagnosis (including endoscopy, barium radiography, and esophageal manometry), and therapeutic strategies pertaining to the esophageal manifestations of CGD are discussed. A review of the pertinent available literature is provided.

A cost-minimization analysis of alternative treatment strategies for achalasia.

OBJECTIVE: The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. METHODS: A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. RESULTS: Respective reference case costs per cure of PD, Botox, and LHM strategies were $3,111, $3,723, and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were > or = 70% and < 9.5%, respectively, and cost of a Botox session was > or = $450. The results were not sensitive to the probabilities of short- and long-term response to Botox, recurrence after PD, LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD. CONCLUSIONS: For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains < 10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient ference for each strategy.

Use of the Web for medical information by a gastroenterology clinic population.

CONTEXT: Surveys have shown that 60 million persons in the United States searched for health information online in 1998. However, lack of sampling from a clinic population limits the generalizability of these surveys to clinical practice. OBJECTIVES: To determine gastroenterology patients' access to and use of the Web as a medical information resource, to identify for what information patients search, and to determine how often physicians recommend that patients search the Web. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of 1006 gastroenterology outpatients in Durham, NC, and Rockford, Ill, conducted in August 1999. MAIN OUTCOME MEASURES: Patient characteristics and education level, access to the Web, use of the Web as a medical information resource, search methods, and plans for future Web use. RESULTS: A total of 924 patients (92%) completed the questionnaire. Median age was 53 years, 41% were men, and the median education level was having completed some college. Fifty percent (462/924) reported having access to the Web. Of the 462 with access, 235 (51%) had searched the Web for medical information within the previous 12 months. Therefore, 25.5% of all patients surveyed had searched the Web for medical information within the previous year. Sixty percent of patients intended to use the Web as a medical information resource in the future. Only 35 (4%) of 825 had ever been referred to the Web by a physician. CONCLUSIONS: In this clinic setting, more than one quarter of gastroenterology outpatients reported having obtained medical information from the Web within the previous year. More than two thirds of patients stated they would use the Web as a medical information resource in the future. JAMA. 2000;284:1962-1964.

Downstream ribosomal entry for translation of coronavirus TGEV gene 3b.

Gene 3b (ORF 3b) in porcine transmissible gastroenteritis coronavirus (TGEV) encodes a putative nonstructural polypeptide of 27.7 kDa with unknown function that during translation in vitro is capable of becoming a glycosylated integral membrane protein of 31 kDa. In the virulent Miller strain of TGEV, ORF 3b is 5'-terminal on mRNA 3-1 and is presumably translated following 5' cap-dependent ribosomal entry. For three other strains of TGEV, the virulent British FS772/70 and Taiwanese TFI and avirulent Purdue-116, mRNA species 3-1 is not made and ORF 3b is present as a non-overlapping second ORF on mRNA 3. ORF 3b begins at base 432 on mRNA 3 in Purdue strain. In vitro expression of ORF 3b from Purdue mRNA 3-like transcripts did not fully conform to a predicted leaky scanning pattern, suggesting ribosomes might also be entering internally. With mRNA 3-like transcripts modified to carry large ORFs upstream of ORF 3a, it was demonstrated that ribosomes can reach ORF 3b by entering at a distant downstream site in a manner resembling ribosomal shunting. Deletion analysis failed to identify a postulated internal ribosomal entry structure (IRES) within ORF 3a. The results indicate that an internal entry mechanism, possibly in conjunction with leaky scanning, is used for the expression of ORF 3b from TGEV mRNA 3. One possible consequence of this feature is that ORF 3b might also be expressed from mRNAs 1 and 2.

Economic considerations in the treatment of gastroesophageal reflux disease: a review.

Gastroesophageal reflux disease is a common problem. Most patients with erosive GERD require long-term treatment, without which relapse is common. The cost of ongoing medical care for GERD is substantial, and patients with symptomatic GERD have impaired quality of life. Treatment strategies for GERD should aim to improve patient outcome at a reasonable cost. Cost-effectiveness methodology facilitates the integration of costs and patient outcomes, enabling the clinician to choose the most cost-effective therapy in a variety of clinical circumstances. The published studies reviewed in this paper show that proton pump inhibitors are the most cost-effective initial and maintenance medical therapy for GERD under most circumstances. However, variations in drug acquisition costs, such as may occur in managed care practice settings, may lead to H2-receptor antagonists being preferred under some circumstances. In the long-term management of GERD, laparoscopic surgery is effective, but its high initial cost makes it less cost-effective than proton pump inhibitors in the early treatment years. Also, recent data suggest that the long-term morbidity is higher than previously suspected. Finally, appropriate application of cost-effectiveness analyses to clinical practice requires critical appraisal of model design and the perspective adopted. The purpose of this article is to describe the interpretation and application of the results of cost-effectiveness analyses in clinical practice, and to examine the published literature on the cost-effectiveness of treatment options for GERD.

Cost-effectiveness analysis of hepatitis A vaccination strategies for adults.

Our objective in this study was to determine the cost-effectiveness of hepatitis A vaccination strategies in healthy adults in the United States. We constructed a decision model simulating costs and health consequences for otherwise healthy adults with respect to hepatitis A prevention. Three strategies were compared: (1) no intervention, (2) vaccination against hepatitis A, and (3) testing for antibodies to hepatitis A and vaccinating those without antibodies. Costs and probabilities were obtained from the published literature. One- and two- way sensitivity analyses were performed. Under baseline conditions, the "test" strategy cost $230,100 per life-year saved compared with the "no intervention" strategy. The incremental cost-effectiveness of the "vaccination" strategy compared with the "test" strategy was $20.1 million per life-year saved. The "test" strategy was cost-effective when the hepatitis A case fatality rate exceeded 17% (baseline 2.7%). The "vaccination" strategy was cost-effective when 1 dose of vaccine cost $7 or less (baseline $57). Under baseline conditions, neither the "test" nor the "vaccination" strategies are considered cost-effective according to current standards. Large changes in hepatitis A incidence, mortality rates, or vaccine cost are required for either of the intervention strategies to approach potentially cost-effectiveness. Such conditions may occur in areas in which hepatitis A is endemic, and/or under mass-vaccination scenarios.

The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: report on the Cleveland Clinic Barrett's Esophagus Registry.

OBJECTIVE: The reported incidence of adenocarcinoma in Barrett's esophagus is variable. The aim of this study was to determine the incidence of dysplasia and adenocarcinoma in a population of patients with Barrett's esophagus followed prospectively and to compare these findings with other series. METHODS: All patients enrolled in the Cleveland Clinic Foundation's Barrett's esophagus registry from 1979 to 1995 were followed. Barrett's esophagus was defined as intestinal metaplasia anywhere in the tubular esophagus. The incidence of dysplasia and adenocarcinoma in these patients was recorded systematically. RESULTS: A total of 136 patients (91 male, 45 female) were followed in an endoscopic surveillance program for a mean of 4.2 yr and a total of 570 patient-years of follow-up. Thirty patients (22%) had short segment Barrett's esophagus. Two adenocarcinomas developed during follow-up, yielding an incidence of one per 285 patient-years of follow-up. Low grade dysplasia developed in 24 patients, whereas high grade dysplasia developed in four patients. CONCLUSIONS: Our study suggests that the incidence of adenocarcinoma in Barrett's esophagus is lower than initially thought. However, large multicenter studies are required to clarify the epidemiological and clinical factors related to the development of dysplasia and adenocarcinoma in Barrett's esophagus.

A continuous quality improvement initiative reduces inappropriate prescribing of prophylactic antibiotics for endoscopic procedures.

OBJECTIVE: Despite the availability of guidelines, most gastroenterologists do not administer prophylactic antibiotics appropriately to patients having endoscopic procedures. In 1994 we recognized that in our endoscopy unit, many patients were receiving antibiotics without proper indication. We devised a continuous quality improvement initiative to analyze and improve this problem. METHODS: Divisional guidelines for the appropriate administration of prophylactic antibiotics for endoscopy were drawn up in 1995. By retrospective analysis of our comprehensive endoscopy database we compared the rate of prophylactic antibiotic administration, and the proportion of antibiotics that were indicated before and after adoption of the divisional guidelines. RESULTS: A total of 1427 endoscopic procedures were done during a 6-month period in 1994 (before adoption of guidelines). Of these, 55 (3.85%) received antibiotics. In a 6-month period in 1996 after adoption of guidelines, 1452 procedures were performed and 29 of these (1.99%) received antibiotics. The odds ratio for receiving antibiotics appropriately in 1996, compared with 1994, was 3.4 (chi2 p = 0.016). Given an annual volume of 2900 procedures in our endoscopy unit, approximately 54 patients will avoid unnecessary antibiotics, yielding a cost saving of $1128 per year. CONCLUSIONS: A divisional continuous quality improvement initiative on antibiotic prophylaxis for endoscopy significantly reduced the proportion of patients receiving antibiotics unnecessarily. This quality improvement initiative enhanced the quality of care for patients having endoscopy and yielded a small cost saving. These improvements were achieved with minimal effort and cost to the division.

The major product of porcine transmissible gastroenteritis coronavirus gene 3b is an integral membrane glycoprotein of 31 kDa.

The open reading frame potentially encoding a polypeptide of 27.7 kDa and located as the second of three ORFs (gene 3b) between the S and M genes in the genome of the Purdue strain of porcine transmissible gastroenteritis coronavirus (TGEV) was cloned and expressed in vitro to examine properties of the protein. Gene 3b has a postulated role in pathogenesis, but its truncated form in some laboratory-passaged strains of TGEV has led to the suggestion that it is not essential for virus replication. During synthesis in vitro in the presence of microsomes, the 27.7-kDa polypeptide became an integral membrane protein, retained its postulated hydrophobic N-terminal signal sequence, and underwent glycosylation on apparently two asparagine linkage sites to attain a final molecular mass of 31 kDa. A 20-kDa N-terminally truncated, nonglycosylated, nonanchored form of the protein was also made via an unknown mechanism. The existence of both transmembrane and soluble forms of the gene 3 product in the cell is suggested by immunofluorescence patterns showing both a punctuated perinuclear and diffuse intracytoplasmic distribution. No gene 3b product was found on gradient-purified Purdue TGEV by a Western blotting procedure that would have detected as few as 4 molecules/virion, indicating the protein probably is not a structural component of the virion.

Pretreatment with methylprednisolone to prevent ERCP-induced pancreatitis: a randomized, multicenter, placebo-controlled clinical trial.

OBJECTIVE: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP). Uncontrolled data suggest a lower incidence of pancreatitis in patients with a history of iodine sensitivity when given pretreatment with corticosteroids. We conducted a clinical trial to assess the efficacy of a commonly prescribed corticosteroid, methylprednisolone, to prevent ERCP-induced pancreatitis. METHODS: Patients were entered into a randomized, multicenter, double-blind, placebo-controlled study of intravenous methylprednisolone (125 mg) versus a saline placebo immediately before the ERCP. All patients were evaluated for early and late complications. RESULTS: Two hundred eighty-six patients were randomized. Thirty-one randomized patients were excluded for technical reasons at the time of ERCP. Overall, the incidence of pancreatitis was 16 of 129 (12.4%, 95% CI: 6.7-18.1%) in the methylprednisolone group and 11 of 126 (8.7%, 95% CI: 4.4-15.1%) in the placebo group, which was not significantly different (p = 0.34). Although there was a higher rate of sphincterotomy performed in the methylprednisolone group compared to the control group (31.8% vs 16.8%, p = 0.005), the incidence of pancreatitis was not different when patients undergoing sphincterotomy were analyzed separately (13.6% in the methylprednisolone group and 9.6% in the placebo group,p = 0.50). There was no significant difference between the two groups for those with ERCP-induced pancreatitis in hospital length of stay (p = 0.22), days of parenteral analgesia (p = 0.09), or days of parenteral nutrition (p = 0.15). CONCLUSION: Intravenous methylprednisolone is not beneficial in preventing ERCP-induced pancreatitis.

Traumatic rupture of the ascending aorta and aortic valve.

A case of traumatic rupture of the ascending aorta and aortic valve is described. An account of the successful management of this condition is given and the relevant literature is reviewed.

Axillofemoral bypass: a critical reappraisal of its role in the management of aortoiliac occlusive disease.

Two hundred twenty-four consecutive patients (361 graft limbs) who underwent bypass grafting with the USCI Sauvage filamentous velour Dacron arterial prosthesis for aortoiliac occlusive disease over the 9 year period 1970 to 1979 are reviewed. Eighty-four axillofemoral (23 percent of patients), 210 aortofemoral (47 percent of patients), and 67 femorofemoral grafts (30 percent of patients) had cumulative patency rates of 72.1, 91.1, and 86.4 percent, respectively. Experimental and clinical factors influencing the patency of axillofemoral grafts are discussed, and the concept of an improved porous Dacron prosthesis specific for the axillofemoral site is presented.