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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: Endoscopic submucosal dissection (ESD) in Asia has been shown to be superior to endoscopic mucosal resection (EMR) and surgery for the management of selected early gastrointestinal cancers. We aimed to evaluate technical outcomes of ESD in North America. METHODS: We conducted a multicenter prospective study on ESD across 10 centers in the United States and Canada between April 2016 and April 2020. End points included rates of en bloc resection, R0 resection, curative resection, adverse events, factors associated with failed resection, and recurrence post-R0 resection. RESULTS: Six hundred and ninety-two patients (median age, 66 years; 57.8% were men) underwent ESD (median lesion size, 40 mm; interquartile range, 25-52 mm) for lesions in the esophagus (n = 181), stomach (n = 101), duodenum (n = 11), colon (n = 211) and rectum (n = 188). En bloc, R0, and curative resection rates were 91.5%, 84.2%, and 78.3%, respectively. Bleeding and perforation were reported in 2.3% and 2.9% of the cases, respectively. Only 1 patient (0.14%) required surgery for adverse events. On multivariable analysis, severe submucosal fibrosis was associated with failed en bloc, R0, and curative resection and higher risk for adverse events. Overall recurrence was 5.8% (31 of 532) at a mean follow-up of 13.3 months (range, 1-60 months). CONCLUSIONS: In this large multicenter prospective North American experience, we demonstrate that ESD can be performed safely, effectively, and is associated with a low recurrence rate. The technical resection outcomes achieved in this study are in line with the current established consensus quality parameters and further support the implementation of ESD for the treatment of select gastrointestinal neoplasms; ClinicalTrials.gov, Number: NCT02989818.
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Ressecção Endoscópica de Mucosa/estatística & dados numéricos , Neoplasias Gastrointestinais/cirurgia , Trato Gastrointestinal/cirurgia , Idoso , Canadá/epidemiologia , Ressecção Endoscópica de Mucosa/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Período Pós-Operatório , Estudos Prospectivos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND AND AIMS: Data are limited on the role of endoscopic submucosal dissection (ESD) as a potential diagnostic and staging tool in Barrett's esophagus (BE) neoplasia. We aimed to evaluate the frequency and factors associated with change of histologic diagnosis by ESD compared with pre-ESD histology. METHODS: This was a multicenter, prospective cohort study of patients who underwent ESD for BE visible neoplasia. A change in histologic diagnosis was defined as "upstaged" or "downstaged" if the ESD specimen had a higher or lower degree, respectively, of dysplasia or neoplasia when compared with pre-ESD specimens. RESULTS: Two hundred five patients (median age, 69 years; 81% men) with BE visible neoplasia underwent ESD from 2016 to 2021. Baseline histology was obtained using forceps (n = 182) or EMR (n = 23). ESD changed the histologic diagnosis in 55.1% of cases (113/205), of which 68.1% were upstaged and 31.9% downstaged. The frequency of change in diagnosis after ESD was similar whether baseline histology was obtained using forceps (55.5%) or EMR (52.2%) (P = .83). In aggregate, 23.9% of cases (49/205) were upstaged to invasive cancer on ESD histopathology. On multivariate analysis, lesions in the distal esophagus and gastroesophageal junction (odds ratio, 2.1; 95 confidence interval, 1.1-3.9; P = .02) and prior radiofrequency ablation (odds ratio, 2.5; 95% confidence interval, 1.2-5.5; P = .02) were predictors of change in histologic diagnosis. CONCLUSIONS: ESD led to a change of diagnosis in more than half of patients with BE visible neoplasia. Selective ESD can serve as a potential diagnostic and staging tool, particularly in those with suspected invasive disease. (Clinical trial registration number: NCT02989818.).
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Adenocarcinoma , Esôfago de Barrett , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/patologia , Esôfago de Barrett/cirurgia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Masculino , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Progress in rectal cancer therapy has been hindered by the lack of effective disease-specific preclinical models that account for the unique molecular profile and biology of rectal cancer. Thus, we developed complementary patient-derived xenograft (PDX) and subsequent in vitro tumor organoid (PDTO) platforms established from preneoadjuvant therapy rectal cancer specimens to advance personalized care for rectal cancer patients. Multiple endoscopic samples were obtained from 26 Stages 2 and 3 rectal cancer patients prior to receiving 5FU/RT and implanted subcutaneously into NSG mice to generate 15 subcutaneous PDXs. Second passaged xenografts demonstrated 100% correlation with the corresponding human cancer histology with maintained mutational profiles. Individual rectal cancer PDXs reproduced the 5FU/RT response observed in the corresponding human cancers. Similarly, rectal cancer PDTOs reproduced significant heterogeneity in cellular morphology and architecture. PDTO in vitro 5FU/RT treatment response replicated the clinical 5FU/RT neoadjuvant therapy pathologic response observed in the corresponding patient tumors (p < 0.05). The addition of cetuximab to the 5FU/RT regiment was significantly more sensitive in the rectal cancer PDX and PDTOs with wild-type KRAS compared to mutated KRAS (p < 0.05). Considering the close relationship between the patient's cancer and the corresponding PDX/PDTO, rectal cancer patient-derived research platforms represent powerful translational research resources as population-based tools for biomarker discovery and experimental therapy testing. In addition, our findings suggest that cetuximab may enhance RT effectiveness by improved patient selection based on mutational profile in addition to KRAS or by developing a protocol using PDTOs to identify sensitive patients.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Modelos Biológicos , Medicina de Precisão/métodos , Neoplasias Retais/tratamento farmacológico , Animais , Cetuximab/farmacologia , Cetuximab/uso terapêutico , Fluoruracila/farmacologia , Fluoruracila/uso terapêutico , Xenoenxertos/efeitos dos fármacos , Xenoenxertos/crescimento & desenvolvimento , Xenoenxertos/patologia , Humanos , Camundongos , Mutação , Terapia Neoadjuvante , Organoides/efeitos dos fármacos , Organoides/crescimento & desenvolvimento , Organoides/patologia , Proteínas Proto-Oncogênicas p21(ras)/genética , Neoplasias Retais/patologia , Neoplasias Retais/radioterapia , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
With an increasingly aging population and improved mortality in individuals with end-stage kidney disease, more surgeries are being performed on patients with all stages of chronic kidney disease (CKD). This high-risk population carries unique risk factors that have been associated with increased adverse perioperative outcomes, including acute kidney injury, cardiovascular events, and mortality. In this article, we review the literature describing absolute risks associated with common surgeries performed in patients with CKD and patients receiving maintenance dialysis. We also review perioperative optimization with special risk assessment including evaluation of cardiovascular and bleeding risk evaluation, hypertension management, and timing of dialysis. Predictive model scores are reviewed as a method to stratify risk for acute kidney injury, major adverse cardiac events, or other serious complications with elective surgeries. A multidisciplinary approach with individualized counseling is necessary to counsel the patient with advanced CKD or patients treated with maintenance dialysis considering elective surgery.
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Artroplastia do Joelho , Osteoartrite do Joelho/cirurgia , Cuidados Pré-Operatórios/métodos , Diálise Renal/métodos , Insuficiência Renal Crônica/terapia , Medição de Risco/métodos , Progressão da Doença , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/complicações , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
While patients with sickle cell disease currently constitute a very small minority of the US dialysis population (0.1%), there is anticipated growth of this group as the life expectancy of those with sickle cell disease (SCD) increases. SCD patients suffer a high burden of morbidity, which is enhanced by the presence of end-stage renal disease (ESRD). In this review, we discuss the pathophysiology of SCD and the basic tenets of its management with focus on the dialysis patient with SCD. Anemia in dialysis patients with SCD is a unique challenge. The hemoglobin target in SCD dialysis patients with ESRD should not exceed 10 g/dl. SCD patients, and particularly those on dialysis, are likely to be poorly responsive to erythropoietin-stimulating agent (ESA) therapy and might be at increased risk for vaso-occlusive crisis (VOC) with ESA. Iron chelation and hydroyxurea therapy require special considerations and modifications in dialysis patients with SCD. There are theoretical advantages to both hemodialysis (HD) and peritoneal dialysis (PD) in SCD patients. With HD, there is a secure vascular access available for both standard and exchange blood transfusion in patients who need them. With PD, the absence of an acute rise in hematocrit with ultrafiltration (UF) might offer lower risk of VOC. During VOC, reduction in UF goals should be considered but administration of intravenous fluids should be reserved only for clear cases of volume depletion. Finally, renal transplantation appears to confer a survival advantage to dialysis in SCD patients and should be pursued when possible.
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Anemia Falciforme/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Diálise Renal , HumanosRESUMO
BACKGROUND: Compared to whites, blacks have higher colorectal cancer incidence and mortality rates and are at greater risk for early-onset disease. The reasons for this racial disparity are poorly understood, but one contributing factor could be differences in access to high-quality screening and medical care. AIMS: The present study was carried out to assess whether a racial difference in prevalence of large bowel polyps persists within a poor and uninsured population (n = 233, 124 blacks, 91 whites, 18 other) undergoing screening colonoscopy. METHODS: Eligible patients were uninsured, asymptomatic, had no personal history of colorectal neoplasia, and were between the ages 45-64 years (blacks) or 50-64 years (whites, other). We examined the prevalence of any adenoma (conventional, serrated) and then difference in adenoma/polyp type by race and age categories. RESULTS: Prevalence for ≥1 adenoma was 37 % (95 % CI 31-43 %) for all races combined and 36 % in blacks <50 years, 38 % in blacks ≥50 years, and 35 % in whites. When stratified by race, blacks had a higher prevalence of large conventional proximal neoplasia (8 %) compared to whites (2 %) (p value = 0.06) but a lower prevalence of any serrated-like (blacks 18 %, whites 32 %; p value = 0.02) and sessile serrated adenomas/polyps (blacks 2 %, whites 8 % Chi-square p value; p = 0.05). CONCLUSIONS: Within this uninsured population, the overall prevalence of adenomas was high and nearly equal by race, but the racial differences observed between serrated and conventional polyp types emphasize the importance of taking polyp type into account in future research on this topic.
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Pólipos Adenomatosos/etnologia , Negro ou Afro-Americano , Neoplasias do Colo/etnologia , Pólipos do Colo/etnologia , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Pobreza/etnologia , População Branca , Pólipos Adenomatosos/diagnóstico , Pólipos Adenomatosos/economia , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/economia , Pólipos do Colo/diagnóstico , Pólipos do Colo/economia , Colonoscopia , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza/economia , Valor Preditivo dos Testes , Prevalência , Fatores de Risco , South Carolina/epidemiologiaAssuntos
Diálise Renal , Insuficiência Renal Crônica , Adulto , Comunicação , Humanos , Manutenção , Medição de RiscoRESUMO
BACKGROUND: Most patients presenting with symptoms of esophageal cancer (EC) have advanced disease. Even with resection, the cure rate is extremely low due to local recurrence and metastatic disease. Early detection and effective therapeutic intervention are essential to improve survival. AIMS: This study tested the hypothesis that the presence of EC modulates concentrations of specific plasma proteins and peptides, potentially allowing discrimination between EC and controls based on mass spectrometric analysis of the respective plasma proteomes. METHODS: Blood samples from 79 esophageal cancer patients and 40 age-matched normal subjects were processed to plasma, and protein/peptide sub-fractions were isolated using HIC8 or WAX-derivatized superparamagnetic beads. Triplicate matrix-assisted laser desorption time-of-flight mass spectra were acquired for specific plasma fractions from each subject. RESULTS: HIC8 and WAX-derivatized plasma eluates yielded 79 and 77 candidate features, respectively, and a Random Forest algorithm identified a subset of features whose peak intensities allowed discrimination between cancer patients and controls. Areas under the curve in receiver operating characteristic curves for HIC8 spectra were 0.88 and 0.83 for WAX spectra. The combined feature set discriminated EC from control plasma with 79 % sensitivity and 79 % specificity, with positive and negative test likelihood ratios of >14 and 0.17, respectively. CONCLUSIONS: These data lay the foundation for the development of a clinically useful test for esophageal cancer based on statistical analysis of proteomic spectra of patient plasma samples. This approach will be validated by analysis of larger patient cohorts, development of cancer-specific classifiers, and assessment of racial origin imbalances.
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Adenocarcinoma/sangue , Biomarcadores Tumorais/sangue , Carcinoma de Células Escamosas/sangue , Neoplasias Esofágicas/sangue , Proteômica/métodos , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: White light endoscopy with random biopsies is the standard for detection of intestinal metaplasia (IM) and neoplasia in patients with Barrett's oesophagus (BO). Narrow band imaging (NBI) highlights surface patterns that correlate with IM and neoplasia in BO. OBJECTIVE: To compare high-definition white light (HD-WLE) and NBI for detection of IM and neoplasia in BO. DESIGN: International, randomised, crossover trial comparing HD-WLE and NBI. Patients referred for BO screening/surveillance at three tertiary referral centres were prospectively enrolled and randomised to HD-WLE or NBI followed by other procedures in 3-8 weeks. During HD-WLE, four quadrant biopsies every 2 cm, together with targeted biopsies of visible lesions (Seattle protocol), were obtained. During NBI examination, mucosal and vascular patterns were noted and targeted biopsies were obtained. All biopsies were read by a single expert gastrointestinal pathologist in a blinded fashion. RESULTS: 123 patients with BO (mean age 61; 93% male; 97% Caucasian) with mean circumferential and maximal extents of 1.8 and 3.6 cm, respectively, were enrolled. Both HD-WLE and NBI detected 104/113 (92%) patients with IM, but NBI required fewer biopsies per patient (3.6 vs 7.6, p<0.0001). NBI detected a higher proportion of areas with dysplasia (30% vs 21%, p=0.01). During examination with NBI, all areas of high-grade dysplasia and cancer had an irregular mucosal or vascular pattern. CONCLUSIONS: NBI targeted biopsies can have the same IM detection rate as an HD-WLE examination with the Seattle protocol while requiring fewer biopsies. In addition, NBI targeted biopsies can detect more areas with dysplasia. Regular appearing NBI surface patterns did not harbour high-grade dysplasia/cancer, suggesting that biopsies could be avoided in these areas.
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Esôfago de Barrett/patologia , Neoplasias Esofágicas/patologia , Esofagoscopia/métodos , Esôfago/patologia , Imagem de Banda Estreita , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Cross-Over , Feminino , Humanos , Biópsia Guiada por Imagem/métodos , Masculino , Metaplasia , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Método Simples-CegoRESUMO
OBJECTIVES: Telemedicine has become a widely accepted alternative to face-to-face patient encounters. Although there have been several peer-reviewed journal articles on incorporating telemedicine into the medical school curriculum, particularly during the COVID-19 pandemic, assessments of the effectiveness of remote supervision of medical students have not been reported. This prospective cohort study of student subjects using observational survey data evaluated the efficacy of telemedicine as an educational resource by comparing learning outcomes between osteopathic medical students receiving direct (physically present) supervision with a group who received remote (telemedicine) supervision by clinical faculty within a post-acute/long-term care (PA/LTC) setting. Learning outcomes in the domains of patient rapport, attitudes, knowledge, and behavior were measured using standardized survey instruments. DESIGN: Prospective cohort study of student subjects using observational survey data. SETTING AND PARTICIPANTS: A total of 167 fourth-year osteopathic medical students at a teaching nursing home (TNH). METHODS: A total of 167 fourth-year osteopathic medical students (OMS-4s) were randomly assigned face-to-face PA/LTC patient encounters at the TNH. The encounters were follow-up visits to residents of the TNH that were supervised by faculty geriatricians. Half were accompanied by the physician and the other half were supervised by the physician through telemedicine. Evaluation using validated survey instruments measured patient rapport, verbal communication, and physical examination skills as well as attitudes, knowledge, and behaviors of the student/subjects. RESULTS: A nonparametric statistical analysis of 4 dependent variables measuring patient rapport, attitudes, knowledge and behavior showed no significant difference between the 2 teaching modalities. CONCLUSIONS AND IMPLICATIONS: The results of this prospective cohort study indicate that telemedicine supervision is comparable (noninferior) to direct supervision of medical student trainees in a PA/LTC setting.
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OBJECTIVES: Patients' memories of personal polyp characteristics have been shown to be inadequate when compared with the medical record. An accurate polyp history is necessary to adhere to guidelines. We sought to determine whether systematically informing patients of the results of their colonoscopy and pathology in a multifaceted manner could increase their knowledge of their personal polyp history. METHODS: We conducted a prospective pilot study of 240 consecutive patients undergoing screening colonoscopy with polypectomy by a single endoscopist (B.J.H.) at a tertiary care center. All of the patients were provided with a verbal report of findings immediately after the procedure, an endoscopy report specifying polyp size and number, and a mailed letter specifying the pathology results of their polyps. Telephone contact was attempted for all of the patients. Patients were asked to recall the size, number, and histology of their polyps. RESULTS: One hundred (42%) of the patients completed the telephone survey. Forty patients remembered the polyp number; five remembered their polyp histology, and one recalled the polyp size. None of the patients recalled all three factors, although patients who recalled telling a family member the results of the colonoscopy were more likely to recall at least one polyp descriptor (relative risk 2.62 [95% confidence interval 1.01-6.83]). No other variables were associated with polyp recall. CONCLUSIONS: Patients' knowledge of personal polyp characteristics, even after systematic notification, does not seem adequate for determining the best guideline-based colonoscopy surveillance interval. Discussing results with family members may help.
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Pólipos do Colo/cirurgia , Colonoscopia , Rememoração Mental , Adulto , Idoso , Idoso de 80 Anos ou mais , Pólipos do Colo/patologia , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Distribuição de Poisson , Estudos Prospectivos , South Carolina , Inquéritos e Questionários , TelefoneRESUMO
BACKGROUND: Barrett's esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barrett's esophagus and decrease the rate of neoplastic progression. METHODS: In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barrett's esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barrett's esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia. RESULTS: In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with high-grade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P=0.03) and fewer cancers (1.2% vs. 9.3%, P=0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture. CONCLUSIONS: In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)
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Esôfago de Barrett/cirurgia , Ablação por Cateter , Esôfago/patologia , Idoso , Idoso de 80 Anos ou mais , Esôfago de Barrett/patologia , Ablação por Cateter/efeitos adversos , Progressão da Doença , Esôfago/cirurgia , Feminino , Humanos , Modelos Logísticos , Masculino , Metaplasia/cirurgia , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett's esophagus (BE), and reduce rates of esophageal adenocarcinoma. We assessed long-term rates of eradication, durability of neosquamous epithelium, disease progression, and safety of RFA in patients with dysplastic BE. METHODS: We performed a randomized trial of 127 subjects with dysplastic BE; after cross-over subjects were included, 119 received RFA. Subjects were followed for a mean time of 3.05 years; the study was extended to 5 years for patients with eradication of intestinal metaplasia at 2 years. Outcomes included eradication of dysplasia or intestinal metaplasia after 2 and 3 years, durability of response, disease progression, and adverse events. RESULTS: After 2 years, 101 of 106 patients had complete eradication of all dysplasia (95%) and 99 of 106 had eradication of intestinal metaplasia (93%). After 2 years, among subjects with initial low-grade dysplasia, all dysplasia was eradicated in 51 of 52 (98%) and intestinal metaplasia was eradicated in 51 of 52 (98%); among subjects with initial high-grade dysplasia, all dysplasia was eradicated in 50 of 54 (93%) and intestinal metaplasia was eradicated in 48 of 54 (89%). After 3 years, dysplasia was eradicated in 55 of 56 of subjects (98%) and intestinal metaplasia was eradicated in 51 of 56 (91%). Kaplan-Meier analysis showed that dysplasia remained eradicated in >85% of patients and intestinal metaplasia in >75%, without maintenance RFA. Serious adverse events occurred in 4 of 119 subjects (3.4%); the rate of stricture was 7.6%. The rate of esophageal adenocarcinoma was 1 per 181 patient-years (0.55%/patient-years); there was no cancer-related morbidity or mortality. The annual rate of any neoplastic progression was 1 per 73 patient-years (1.37%/patient-years). CONCLUSIONS: In subjects with dysplastic BE, RFA therapy has an acceptable safety profile, is durable, and is associated with a low rate of disease progression, for up to 3 years.
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Adenocarcinoma/patologia , Esôfago de Barrett/patologia , Esôfago de Barrett/cirurgia , Ablação por Cateter/métodos , Neoplasias Esofágicas/patologia , Esôfago/patologia , Lesões Pré-Cancerosas/patologia , Lesões Pré-Cancerosas/cirurgia , Conduta Expectante , Idoso , Ablação por Cateter/efeitos adversos , Progressão da Doença , Epitélio/patologia , Esofagoscopia , Feminino , Humanos , Estimativa de Kaplan-Meier , Estudos Longitudinais , Masculino , Metaplasia , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: In 2008, the American College of Gastroenterology (ACG) modified its colorectal screening guidelines regarding patients with family histories of colorectal polyps, specifically highlighting the importance of obtaining detailed history that includes the number, type, and size of adenomas found in a patient's relative. This information is then used to guide screening recommendations for these patients. OBJECTIVE: To assess the proportion of patients undergoing screening colonscopy for a family history of polyps who have knowledge of their family members' colonoscopy findings. DESIGN: Retrospective, single-center cohort pilot study. SETTING: Tertiary care medical center. PATIENTS: Patients who presented for screening colonoscopy between 2008 and 2010 with an indication of family history of polyps. INTERVENTIONS: Obtain detailed history regarding patient's family history of polyps, including which family member, age of family member at diagnosis, size, type and number of polyps found. MAIN OUTCOME MEASUREMENTS: Knowledge of family history. RESULTS: Seventy-three patients were included in the study. Their knowledge of their family histories of polyps showed the following: 23.2% (17/73; 95% CI, 14%-35%) did not know which family member had polyps, 42.5% (31/73; 95% CI, 31%-55%) did not know the age at diagnosis, 71.2% (52/73; 95% CI, 59%-81%) did not know the polyp type, 90.4% (66/73; 95% CI, 81%-96%) did not know the number of polyps found, and 97.3% (71/73; 95% CI, 90%-100%) did not know the polyp size. LIMITATIONS: Retrospective study at a single tertiary referral center. CONCLUSIONS: Patients' knowledge regarding the details of their family histories of polyp data appears often unknown or incomplete. Thus, at present, it may not appear feasible or practical to incorporate this level of information in colon cancer screening guidelines.
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Pólipos do Colo/diagnóstico , Pólipos do Colo/genética , Colonoscopia , Conhecimentos, Atitudes e Prática em Saúde , Adulto , Idoso , Estudos de Coortes , Saúde da Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos RetrospectivosRESUMO
Nurses often function as capsule endoscopy "pre-readers" to save physicians' time and potentially increase diagnostic yield. Training pre-readers is time consuming, not standardized, and may not be feasible during regular business hours. A way to evaluate the progress and accuracy of pre-readers is needed to ensure competency. The aim of this study was to introduce a feedback and progress assessment tool for training novice capsule endoscopy pre-readers. We created a 1-page form with listings of potential findings for each segment of the examination. Findings could be circled or written in. The trainee reviewed capsule studies and filled out the form on each of 220 patients. The physician reviewers subsequently critiqued the data forms, providing feedback regarding missed lesions, overcalls, and overall agreement. Our trainee achieved consistent agreement with the physician reviewers, after reading 80 studies. In conclusion, a simple, 1-page standardized data sheet can be used to facilitate training of novice capsule pre-readers without significant time commitment from the supervising physician. Future studies may validate this resource-efficient instrument as a training and assessment tool for nurses, physicians, and other practitioners learning capsule endoscopy.