Protective Propensity of Race or Environmental Features in the Development of Barrett's Esophagus in African Americans - A Single Center Pilot Study.

BACKGROUND AND STUDY AIMS: Barrett's Esophagus (BE) is a well-recognized pre-malignant condition. Previous data indicate histologically confirmed BE frequency varies by ethnicity in the United States. However, clinical factor assessment to explain this has only occurred in a veteran population to date. The study aim was to determine which clinical factors may be associated with the ethnic variation seen in histologically confirmed BE among a general population. PATIENTS AND METHODS: The University of Florida-Jacksonville endoscopy database was searched for all cases of endoscopic BE from September 2002 to October 2012. Histologic BE was diagnosed only if salmon colored, columnar-appearing esophageal mucosa was seen at endoscopy and biopsy revealed intestinal metaplasia with Alcian blue-stained goblet cells. Data collected included: age/BMI at diagnosis, ethnicity, sex, GERD history, atypical manifestations, endoscopic BE length, presence of esophageal stricture/ulcer/hiatal hernia, presence/absence of dysplasia and medication use (aspirin/NSAIDs/statin/PPI). RESULTS: Salmon colored esophageal mucosa was observed in 1105 of 15,564 patients (7.1%) with BE histologically confirmed in 249 of 1105 patients (23%). Ethnic distribution of histologic BE patients: 83% non-Hispanic white (nHw), 13% African American (AA) and 4% other. No difference was seen between groups with regard to BMI, GERD symptom/complications, BE length, and cigarette, alcohol or medication use. CONCLUSION: BE occurs primarily in nHw in north Florida. This occurs despite similarities in GERD history, cigarette/alcohol use, medications prescribed and BMI. Molecular level investigation is necessary to explain this observed disparity between nHw and AA.

Stent type used does not impact complication rate or placement time but can decrease treatment cost for benign and malignant esophageal lesions.

AIM: To evaluate if differences exist between self-expanding esophageal metal stents (SEMS) and self-expanding esophageal plastic stents (SEPS) when used for benign or malignant esophageal disorders with regard to safety, efficacy, clinical outcomes, placement ease and cost. METHODS: A retrospective analysis was performed to evaluate outcome in patients having SEPS/SEMS placed for malignant or benign esophageal conditions from January 2005 to April 2012. Inclusion criteria was completed SEMS/SEPS placement. Outcomes assessed included technical success of and time required for stent placement, procedure-related complications, need for repeat intervention, hospital stay, mortality and costs. RESULTS: Forty-three patients underwent stent placement for either benign/malignant esophageal disease during the study period. Thirty patients had SEMS (25 male, mean age 59.6 years old) and 13 patients had SEPS (10 male, mean age 61.7 years old). Placement outcome as well as complication rate (SEPS 23.1%, SEMS 25.2%) and in-hospital mortality (SEPS 7.7%, SEMS 6.7%) after placement did not differ between stent types. Migration was the most frequent complication reported occurring equally between types (SEPS 66.7%, SEMS 57.1%). SEPS was less costly than SEMS, decreasing institutional cost by $255/stent. CONCLUSION: SEPS and SEMS have similar outcomes when used for benign or malignant esophageal conditions. However, SEPS use results in decreased costs without impacting care.

Proton radiotherapy dose perturbations caused by esophageal stents of varying material composition are negligible in an experimental model.

BACKGROUND: Self-expanding metal and plastic esophageal stents (SEMS and SEPS, respectively) are used in conjunction with chemoradiation for palliation of malignant dysphagia. To date, the dosimetric effects of stents undergoing proton radiotherapy are not known. STUDY AIM: To investigate the proton radiotherapy dose perturbations caused by esophageal stents of varying designs and materials undergoing external beam treatment for esophageal cancer. PATIENTS AND METHODS: Simulated clinical protocol. Solid acrylic phantom was used to mimic the esophageal tissue environment. Stents made of nitinol, stainless steel and polyester were tested. Proton beam dose of 2 Gy-E was delivered to each stent in a single anterior to posterior field. Film and image based evidence of dose perturbation were main outcomes measured. RESULTS: Only the stainless steel and plastic stents demonstrated slight overall dose attenuations (- 0.5 % and - 0.4 %, respectively). All the nitinol-based stents demonstrated minimal overall dose perturbations ranging from 0.0 % to 1.2 %. Negligible dose perturbations were observed on each of the stent surfaces proximal to the radiation source, ranging from - 0.8 % (stainless steel stent) to 1.0 % (nitinol stent). Negligible dose effects were also observed on the distal surfaces of each stent ranging from - 0.5 % (plastic and stainless steel stents) to 1.0 % (nitinol stent). CONCLUSION: Proton radiotherapy dose perturbations caused by stents of varying designs and material composition are negligible. Negligible dose perturbation is in keeping with the inherent advantage of proton therapy over traditional radiotherapy composed of photons - given its relative large mass, protons have little side scatter.

African American ethnicity is not associated with development of Barrett's oesophagus after erosive oesophagitis.

BACKGROUND: Barrett's oesophagus is the primary risk factor for oesophageal adenocarcinoma; erosive oesophagitis is considered an intermediate step with Barrett's oesophagus development potential upon healing. Barrett's oesophagus occurs in 9-19% following erosive oesophagitis but minimal data exists in African Americans. The study aim was to determine if ethnicity is associated with Barrett's oesophagus formation following erosive oesophagitis. METHODS: Retrospective review of endoscopies from September 2007 to December 2012 was performed. Inclusion criteria were erosive oesophagitis on index endoscopy, repeat endoscopy ≥6 weeks later and non-Hispanic white or African American ethnicity. Barrett's oesophagus frequency following erosive oesophagitis by ethnicity was compared. RESULTS: A total of 14,303 patients underwent endoscopy during the study period; 1636 had erosive oesophagitis. Repeat endoscopy was performed on 125 non-Hispanic white or African American patients ≥6 weeks from the index procedure. Barrett's oesophagus occurred in 8% of non-Hispanic whites while no African American developed it on repeat endoscopy following erosive oesophagitis (p=0.029). No significant difference was seen between ethnic groups in any clinical parameter assessed. CONCLUSIONS: African American ethnicity appears to result in decreased Barrett's oesophagus formation following erosive oesophagitis. Further investigation to demonstrate factors resulting in decreased Barrett's oesophagus formation among African Americans should be performed.

Direct-acting antiviral therapy for hepatitis C: attitudes regarding future use.

INTRODUCTION: Response to current therapy of hepatitis C virus (HCV) is suboptimal. Direct-acting antiviral therapies (DAA) are expected to improve treatment outcomes. Additional treatments for HCV will invariably make therapeutic choices and patient management more complex. We hypothesize that current perceptions regarding the complexity of DAA therapy will influence attitudes towards future use by practitioners who are currently treating HCV. METHODS: An Internet-based survey was sent to 10,082 AASLD and AGA members to determine if they treat HCV infection, their knowledge of DAA therapies, attitudes towards current and future HCV treatments, and if they participated in clinical trials using DAA agents. RESULTS: Out of a total of 1,757 individuals responding to the survey, 75% treat HCV; 79% were MDs, 67% were Gastroenterologists, and 24% were Hepatologists. Of the respondents, 77% indicated they were "very aware" or "aware" of DAA therapies, 20% participated in clinical trials, and 3% had minimal knowledge of DAA agents. Comparing treatment "today" versus in the future when DAAs were available, 85 vs. 81% would treat (p = 0.0054), 6 vs. 10% would refer to an "HCV expert" (p = 0.016), and 1% would refer to an ID specialist. Of respondents with "minimal knowledge" of DAA, 52% stated that they would use them in the future. CONCLUSIONS: Although the majority of respondents appear ready to utilize DAA agents in the future, referrals to "hepatitis C experts" will increase. More than half of respondents with "minimal knowledge" of DAA therapies also appear to be willing to utilize these compounds, raising concerns regarding their inappropriate use. Broad education of healthcare providers to prevent inappropriate use of these agents will be critical.