Acid suppression medications reduce risk of oesophageal adenocarcinoma in Barrett's oesophagus: a nested case-control study in US male veterans

BACKGROUND

Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) may reduce the risk of oesophageal adenocarcinoma (OAC) in Barrett's oesophagus; however, current epidemiologic studies are inconclusive.

AIM

To evaluate the independent effects of PPIs and H2RAs on risk of OAC in patients with Barrett's oesophagus.

METHODS

We conducted a nested case-control study of male veterans diagnosed with Barrett's oesophagus. Cases with incident OAC were matched by incidence density sampling on birth year and Barrett's diagnosis date to controls with Barrett's oesophagus who did not develop OAC. We identified prescription medication usage 1 year prior to Barrett's oesophagus diagnosis to 3 months prior to the OAC diagnosis. Odds ratios (OR) and 95% CI were estimated using conditional logistic regression.

RESULTS

Compared with 798 controls, the 300 cases were less likely to use PPIs (90.0% vs 94.5%, P = 0.01) and H2RAs (19.7% vs 25.7%, P = 0.04). In the multivariable model including the use of statins, H2RAs, aspirin and nonsteroidal anti-inflammatory drugs, PPI use was associated with 41% lower risk of OAC (OR 0.59, 95% CI 0.35-0.99). While risk reduction of OAC was stronger for high-dose PPIs (omeprazole daily dose >40 mg, adjusted OR 0.11, 95% 0.04-0.36), we did not find a dose-response relationship with PPI duration (P trend = 0.45). Likewise, H2RA use was independently associated with 30% lower risk of OAC (OR 0.70, 95% CI 0.50-0.99).

CONCLUSION

Use of PPIs and H2RAs among patients with Barrett's oesophagus are associated with lower risk of OAC. Further clinical trials are needed to confirm this possible chemopreventive effect.

Epidemiology and outcomes of hepatitis C infection in elderly US Veterans

The chronic hepatitis C (CHC) cohort in the United States is getting older. Elderly patients with CHC may be at a high risk of cirrhosis and hepatocellular carcinoma (HCC), but also other nonhepatic comorbidities that negatively impact their likelihood of receiving or responding to antiviral treatment. There is little information on the clinical epidemiology or outcomes of CHC and its treatment in the elderly. We conducted a retrospective cohort study of 1 61 744 patients with a positive Hepatitis C virus RNA in the Veterans Health Administration Hepatitis C Clinical Case Registry to examine the association between age subgroups (20-49, 50-64, 65-85 years) and risk of cirrhosis, HCC or death using Cox proportional hazards models. We also examined the effect of treatment with a sustained viral response (SVR) on these outcomes in each age subgroup. The age distribution was 36.8% 20- to 49-year-olds, 57.6% 50- to 64-year-olds and 5.6% 65- to 85-year-olds (i.e. elderly). Risk of cirrhosis, HCC and death was significantly elevated in elderly patients [HR cirrhosis = 1.14 (1.00-1.29), HR HCC = 2.44 (1.99-2.99); HR death 2.09 (1.98-2.22)] compared with younger patients. The incidence of HCC was than 8.4 per 1000 PY in the elderly compared with 2.6 per 1000 PY and 5.7 per 1000 PY, among the 20-49 and 50-64 age groups, respectively. Elderly patients were significantly less likely to receive antiviral treatment (3.8% vs 14.8% and 19.1%, P < 0.0001), but among those who received treatment SVR was not different among the age groups (33.5% vs 33.2% and 32.1%). In an analysis limited to those who received treatment, SVR compared to treatment receipt with no SVR was associated with a reduction in risk of developing cirrhosis (HR = 0.34; 0.18-0.66) and HCC (HR = 0.60; 0.22-1.61) and all-cause mortality risk (HR = 0.52, 0.33-0.82). Elderly patients with CHC are more likely to develop HCC than younger patients but have traditionally received less antiviral treatment than younger patients. However, receipt of curative treatment is associated with a benefit in reducing cirrhosis, HCC and overall mortality, irrespective of age.

Physical activity and the risk of Barrett's esophagus

Physical activity either directly or through influencing body fat may affect the risk of Barrett's esophagus (BE). However, the effect of physical activity on the risk of developing BE has not been examined. We conducted a case-control study among consecutive eligible patients either scheduled for elective endoscopy or recruited from primary care clinics to undergo a study endoscopy. Study participants completed the International Physical Activity Questionnaire (IPAQ) short form that measures physical activity during the past 7 days. We categorized level of physical activity by low, moderate, or high and estimated metabolic equivalent minutes per week (MET min/week). We calculated odds ratios (ORs) using logistic regression models and adjusted for age, sex, race, gastroesophageal reflux disease symptoms, Helicobacter pylori infection, body mass index, and waist-to-hip ratio. There were 307 cases with BE and 1724 controls (1262 from endoscopy and 462 from the primary care clinic) with IPAQ information. BE cases were more likely to be in the high-category physical activity category than controls (14.3% vs. 11.5% P = 0.08). However, there were no differences in the overall average MET min/week for walking between BE cases and controls (909 vs. 561; P = 0.16), with similar findings among those with moderate activity (1094 vs. 755, P = 0.18) or vigorous activity (784 vs. 826, P = 0.93). In multivariable logistic regression, physical activity level was not significantly associated with BE (OR = 1.19, 95% confidence interval: 0.82-1.73). Recent amount and intensity of physical activity are not associated with a reduction in the risk of BE. Studies are required to examine the long-term effects of physical activity.

Cirrhosis is under-recognised in patients subsequently diagnosed with hepatocellular cancer

BACKGROUND

Most clinical practice guidelines recommend screening for HCC in patients with cirrhosis. However, patients with compensated cirrhosis are often asymptomatic and may remain unrecognised for years.

AIMS

To determine the extent to which cirrhosis is unrecognised in a US Veteran population with HCC, and to evaluate the association between lack of cirrhosis recognition and stage of HCC at diagnosis.

METHODS

We reviewed the electronic medical records of a random sample of HCC cases diagnosed in the national Veterans Affairs system between 2005 and 2011. We conducted multivariable analyses adjusting for patients' demographics, comorbidity, aetiology of underlying disease and healthcare utilisation including HCC surveillance.

RESULTS

Of 1201 patients with HCC and cirrhosis, 24.6% had unrecognised cirrhosis prior to HCC diagnosis. Older patients [>65 years, odds ratio (OR) 2.32], African Americans (OR 1.93), patients with alcoholic or NAFLD liver disease (OR 1.69 and 4.77 respectively), HIV (OR 3.02), and fewer comorbidities (Deyo 0 vs. 3, OR 2.42) had significantly higher odds of having unrecognised cirrhosis than comparison groups. Furthermore, patients with unrecognised cirrhosis were 6.5 times more likely to have advanced stage HCC at diagnosis. The effect of cirrhosis recognition on HCC stage remained significant after adjusting for pre-specified covariates (OR 3.37).

CONCLUSIONS

In one quarter of patients, cirrhosis was unrecognised prior to HCC diagnosis, and this group was significantly more likely to have advanced stage HCC. These findings emphasise the importance of timely evaluation for cirrhosis in at-risk populations as a critical step to improving outcomes for patients with HCC.

Brief report: the length of newly diagnosed Barrett's esophagus may be decreasing

Few studies have examined the temporal trends of length in newly diagnosed Barrett's esophagus (BE) and arrived at conflicting results. The aim of this study was to identify whether there has been a change over time in the length of BE at the time of diagnosis. This is a retrospective, single-center, observational study from Houston, Texas on newly diagnosed BE between 2008 and 2013. All cases were defined by the presence of endoscopically visible BE and histologic confirmation of intestinalized columnar epithelium with goblet cells. The length of BE was measured using the Prague classification. We examined temporal changes in 1-year intervals in the length of BE at the time of diagnosis. Both the frequency and mean length of BE at diagnosis seemed to decrease over time from February 2008 to July 2013. The proportion of patients diagnosed with BE ≥3 cm per year declined during the study period, while the proportion of patients with BE ≥1 and <3 cm increased, and those with <1 cm remained stable. The mean age and the gender of patients diagnosed with BE ≥3 cm did not differ significantly by BE length or year of diagnosis. The mean length of newly diagnosed BE may be decreasing as a result of a decline in BE ≥3 cm. These observations cannot be explained by changes in age and gender.

The impact of hepatitis C burden: an evidence-based approach

BACKGROUND

Infection with the hepatitis C virus (HCV) has been considered a major cause of mortality, morbidity and resource utilisation in the US. In addition, HCV is the main cause of hepatocellular cancer (HCC) in the US. Recent developments in the diagnosis and treatment of HCV, including new recommendations pertaining to screening for HCV by the Centers for Disease Control and Prevention and newer treatment regimens with high efficacy, short duration and the potential for interferon-free therapies, have energised the health care practitioners regarding HCV management.

AIM

To assess the full impact of HCV burden on clinical, economic and patient-reported outcomes.

METHODS

An expert panel was convened to assess the full impact of HCV burden on a number of important outcomes using an evidence-based approach predicated on Grading of Recommendations Assessment, Development and Evaluation methodology. The literature was summarised, graded using an evidence-based approach and presented during the workshop. Workshop presentations were intended to review recent, relevant evidence-based literature and provide graded summary statements pertaining to HCV burden on topics including the relationships between HCV and the development of important outcomes.

RESULTS

The associations of HCV with cirrhosis, HCC, liver-related mortality, type 2 diabetes mellitus, rheumatological diseases and quality of life impairments are supported by strong evidence. Also, there is strong evidence that sustained viral eradication of HCV can improve important outcomes such as mortality and quality of life.

CONCLUSIONS

The current evidence suggests that HCV has been associated with tremendous clinical, economic and quality of life burden.

Human papillomavirus and the risk of Barrett's esophagus

Human papillomavirus (HPV) is strongly associated with squamous esophageal cancer. The potential role of HPV in Barrett's esophagus (BE) has been examined but remains unclear. The aim of the study was to determine the prevalence of HPV in esophageal and gastric tissues obtained from patients with and without BE. We designed a cross-sectional study was conducted with prospective enrollment of eligible patients scheduled for esophagogastroduodenoscopy (EGD). All participants had biopsies of endoscopic BE, squamous-lined esophagus, and stomach. Immunohistochemistry (IHC) on formalin-fixed and paraffin-embedded tissue was conducted using monoclonal antibodies. Polymerase chain reaction (PCR) for HPV was performed on DNA extracted from esophageal biopsies snapped frozen within 30 minutes after endoscopic capture. The Roche HPV Linear Array Assay with PGMY primers that has high sensitivity for detecting 37 types of HPV was used. A total of 127 subjects were included: 39 with definitive BE had IHC done on samples from non-dysplastic BE, squamous esophagus, gastric cardia, and gastric body; and 88 control patients without BE had IHC done on squamous esophageal samples, gastric cardia, and gastric body. HPV was not detected in any of the samples in either group. For confirmation, HPV DNA PCR was performed on randomly selected samples from 66 patients (both esophagus and BE from 13 patients with BE, and 53 esophagus from patients without BE); no sample had HPV DNA detected via PCR in the presence of adequate quality control. HPV infection does not play a role in the formation of non-dysplastic Barrett's esophagus in men in the United States.

Esophageal eosinophilia after radiofrequency ablation for Barrett's esophagus

Radiofrequency ablation (RFA) with HALO system has been developed as a new treatment option for Barrett's esophagus (BE). It had been observed that some patients had esophageal eosinophilia (EE) infiltration after RFA. The incidence and features of EE after RFA were systematically determined. From a prospectively compiled database, data on 148 patients who underwent RFA for BE were analyzed. Biopsies were taken pre- and post-RFA from the BE segment, and histological sections of the biopsy specimens were stained with hematoxylin and eosin, and examined by a gastrointestinal pathologist. The incidence of EE post-RFA was then determined. Of the 148 patients, 120 (81%) were men, 137 (92%) were white, 64 (43%) were overweight and 49 (33%) obese, and 128 (86%) were over 50 years of age or more. Four (2.7%) of the patients developed post-RFA EE, but none had symptoms of eosinophilic esophagitis. All patients except one had a history of seasonal allergies. All four were taking proton pump inhibitor before and after RFA. Two patients with EE drank alcohol, one of which was a smoker. EE is a potential adverse event of RFA for BE. The absence of esophageal dysfunction symptoms suggests a different clinicopathological entity from eosinophilic esophagitis. Further studies should be done to assess its clinical significance, if therapy is needed, or if it may eventually lead to eosinophilic esophagitis.

Sleep duration and incidence of colorectal cancer in postmenopausal women

Background:

Sleep duration is dependent on circadian rhythm that controls a variety of key cellular functions. Circadian disruption has been implicated in colorectal tumorigenesis in experimental studies. We prospectively examined the association between sleep duration and risk of colorectal cancer (CRC).

Methods:

In the Women’s Health Initiative Observational Study, 75 828 postmenopausal women reported habitual sleep duration at baseline 1993–1998. We used Cox proportional hazards regression model to estimate the hazard ratio (HR) of CRC and its associated 95% confidence interval (CI).

Results:

We ascertained 851 incident cases of CRC through 2010, with an average 11.3 years of follow-up. Compared with 7 h of sleep, the HRs were 1.36 (95% CI 1.06–1.74) and 1.47 (95% CI 1.10–1.96) for short (⩽5 h) and long (⩾9 h) sleep duration, respectively, after adjusting for age, ethnicity, fatigue, hormone replacement therapy (HRT), physical activity, and waist to hip ratio. The association was modified by the use of HRT (P-interaction=0.03).

Conclusion:

Both extreme short and long sleep durations were associated with a moderate increase in the risk of CRC in postmenopausal women. Sleep duration may be a novel, independent, and potentially modifiable risk factor for CRC.

Patients' intuitive judgments about surveillance endoscopy in Barrett's esophagus: a review and application to models of decision-making

Adherence to practice guidelines for endoscopic surveillance of Barrett's esophagus is equivocal with evidence of underutilization and overutilization. While physicians report strong agreement with and adherence to recommended surveillance endoscopy (esophagogastroduodenoscopy [EGD]) guidelines, less is known about modifiable barriers and facilitators shaping patients' adherence behaviors. The aim of this study is to conduct a structured literature review of studies exploring patients' perspectives regarding surveillance EGD and to place these results within a conceptual framework. A structured literature review of PubMed, Cochrane, and Google Scholar databases with qualitative thematic analysis was performed. Six studies met eligibility criteria. Analysis of results identified five distinct themes. First, patients' objective cancer risk estimates are consistent with subjective risk perceptions, but neither is associated with EGD surveillance. Second, patients have strong beliefs in the benefits of cancer screening and surveillance and trust in their doctors. Third, anxiety and depression symptoms are related to risk perceptions and outcome expectancies of surveillance. Fourth, endoscopic surveillance itself has affective and physical consequences. Finally, health services and system variables are related to risk perception and EGD surveillance. These themes coherently fit within an integrated model of intuitive decision-making and health behaviors. Studies meeting eligibility criteria were heterogeneous in terms of their study objectives and findings. Quantitative meta-analyses of study findings could not be performed. To improve adherence, endoscopic surveillance programs should consider how patients intuitively frame risks and benefits and patients' emotional reactions to the endoscopy procedure, and focus on how physicians communicate recommendations.

Myelosuppression monitoring after immunomodulator initiation in veterans with inflammatory bowel disease: a national practice audit

BACKGROUND

Immunomodulator medications (IMM) play a vital role in the care of patients with inflammatory bowel disease (IBD). IBD practice guidelines recommend myelosuppression monitoring after initiation of IMM.

AIM

To identify adherence rates and predictors of myelosuppression monitoring after IMM initiation in a large practice setting.

METHODS

We identified a national cohort of VA users with IBD for the fiscal years 2003-2009 using the Veterans Affairs administrative datasets. Subjects with filled prescriptions for IMM were included. The primary endpoint was the proportion of subjects who had a white blood cell (WBC) test completed within 90 days of the IMM index date. Determinants of myelosuppression monitoring were identified by univariate and multivariate analyses.

RESULTS

A total of 6045 unique IBD patients were identified with filled IMM prescriptions. Overall, only 57% of subjects completed a WBC test within 90 days of IMM index date. Monitoring rates increased over time, from 48% in 2003 to 75% in 2009. There was variability of monitoring rates by facility, ranging from 0 to 83%. In multivariate analyses, older age at IMM index date was associated with a lower rate of monitoring. Frequency of VA encounters and IMM index date were associated with increased rates of myelosuppression monitoring.

CONCLUSIONS

Monitoring for myelosuppression among veterans with inflammatory bowel disease after immunomodulator medications initiation is low with wide variability based on facility. This may reflect a low quality of care among veterans with IBD. Provider- and system-wide interventions are needed to improve adherence and reduce variability of immunomodulator medications monitoring across facilities.

Review article: current treatment options and management of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

AIM

To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

RESULTS

The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

CONCLUSIONS

A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

Systematic review: the epidemiology of eosinophilic oesophagitis in adults

BACKGROUND

The epidemiology of eosinophilic oesophagitis (EoE) in adults remains unclear.

AIM

To estimate the prevalence and incidence of EoE through a systematic review of published literature.

METHODS

We conducted systematic literature searches in PubMed in September 2009. Studies were excluded if they contained any participants below 18 years of age, published in languages other than English, or had no exact reporting of prevalence or incidence rates.

RESULTS

Nine studies fulfilled the criteria; one evaluated a population-based sample, one examined patients referred from a defined geographical region and seven studies examined the prevalence in a total of 6018 patients in clinic or hospital settings. The lowest prevalence was reported in population-based studies (4 and 0.23 per 1000), followed by studies of unselected patients (1.0%, 6.5%) and highest in the other five clinic/hospital based studies (2.2-48.2%). Men were more affected in seven of eight studies (64.5-100%). The sample size weighted average prevalence from the population-based studies was 0.03%. For studies evaluating symptomatic patients, it was 2.8%.

CONCLUSIONS

The prevalence of EoE in adults varies considerably based on the study sampling frame: high in dysphagia patients, quite low in population-based studies and intermediate among unselected endoscopy patients.

Trauma history and risk of the irritable bowel syndrome in women veterans

BACKGROUND

Over 1.8 million women in the U.S. are veterans of the armed services. They are at increased risk of occupational traumas, including military sexual trauma.

AIM

To evaluate the association between major traumas and irritable bowel syndrome among women veterans accessing Veteran Affairs (VA) healthcare.

METHODS

We administered questionnaires to assess trauma history as well as IBS, post-traumatic stress disorder (PTSD) and depression symptoms to 337 women veterans seen for primary care at VA Women's Clinic between 2006 and 2007. Logistic regression was used to evaluate the association between individual traumas and IBS risk after adjustment for age, ethnicity, PTSD and depression.

RESULTS

Irritable bowel syndrome prevalence was 33.5%. The most frequently reported trauma was sexual assault (38.9%). Seventeen of eighteen traumas were associated with increased IBS risk after adjusting for age, ethnicity, PTSD and depression, with six statistically significant [range of adjusted odds ratios (OR) between 1.85 (95% CI, 1.08-3.16) and 2.6 (95% CI, 1.28-3.67)]. Depression and PTSD were significantly more common in IBS cases than controls, but neither substantially explained the association between trauma and increased IBS risk.

CONCLUSIONS

Women veterans report high frequency of physical and sexual traumas. A lifetime history of a broad range of traumas is independently associated with an elevated risk of the irritable bowel syndrome.

Irritable bowel syndrome symptoms and health related quality of life in female veterans

BACKGROUND

The status and determinants of health-related quality of life (HRQOL) in female veterans with and without irritable bowel syndrome (IBS) are unknown.

AIM

To compare HRQOL in female veterans with and without IBS symptoms and examine the contribution of post-traumatic stress disorder, depression and anxiety to HRQOL.

METHODS

A cross-sectional study of 339 female veterans. Self-report questionnaires were used to evaluate IBS symptoms, post-traumatic stress disorder, depression, anxiety and HRQOL.

RESULTS

Symptoms consistent with IBS were present in 33.5% of participants. Female veterans with IBS symptoms had significant reductions in physical component score and 5 of 8 Health Related Quality of Life subscales and on 7 of 8 Irritable Bowel Syndrome Quality Of Life subscales than female veterans without IBS symptoms. Compared with the US general female population, female veterans had significantly lower Health Related Quality of Life physical component score and mental component scores (MCS) irrespective of IBS symptom status. Differences in the MCS score were most explained by depression, while those in the physical component score were most explained by anxiety.

CONCLUSIONS

Irritable bowel syndrome symptoms in female veterans are associated with considerable reduction in HRQOL. However, female veterans, regardless of IBS symptom status, have lower HRQOL compared with the general US female population.

Diagnostic yield of oesophagogastroduodenoscopy in children with abdominal pain

BACKGROUND

Abdominal pain is the most common indication for oesophagogastroduodenoscopy (OGD) in children. However, existing studies examining the diagnostic outcomes of OGD in children with abdominal pain are limited.

AIM

To examine the diagnostic yield of OGD with biopsy in the evaluation of abdominal pain and to describe the endoscopic and histological findings in patients undergoing OGD for abdominal pain of unclear aetiology.

METHODS

We performed a retrospective cross-sectional cohort study in children under 18 years of age who had OGD for the primary indication of abdominal pain, at Texas Children's Hospital and Children's Hospital of The King's Daughters from 1 January 2002 to 30 June 2005.

RESULTS

Overall, OGD was diagnostic in 454 (38.1%) of the 1191 procedures, including reflux oesophagitis (23%, n = 271), Helicobacter pylori infections (5%, n = 55), peptic ulcers (3%, n = 32), eosinophilic oesophagitis (2%, n = 25), celiac disease (1%, n = 9) and Crohn's disease (0.5%, n = 7). Male gender, older age, elevated C-reactive protein and vomiting were associated with increased diagnostic yield.

CONCLUSIONS

Our findings suggest that OGD is valuable for the evaluation of chronic abdominal pain in children, with a diagnostic yield of 38%. The majority of alarm symptoms and routine laboratory tests are not significantly associated with diagnostic yield.

Epidemiology, screening, diagnosis and treatment of hepatocellular carcinoma

Globally, over half a million people develop hepatocellular carcinoma (HCC) each year and an almost equal number die of it. Some aspects of HCC remain disappointingly unchanged. For example, hepatitis B infection, for which an effective safe vaccine has been developed, remains responsible for a substantial proportion of cases worldwide. Further, the overall survival of patients with HCC remains very low. Nevertheless, the past few years have witnessed several important advances in our understanding of risk factors, screening, as well as treatment of HCC; these advances may change some of the current realities for HCC. In this paper, we will review the epidemiology, screening, diagnosis, and treatment of HCC with special emphasis on recent developments such the role of fatty liver disease, obesity, and coffee may play in causing HCC, the recent guidelines in screening and diagnosis, and state-of-the-art treatment algorithms.

Systematic review: the global incidence and prevalence of peptic ulcer disease

BACKGROUND

Peptic ulcer disease (PUD) is most commonly associated with Helicobacter pylori infection and the use of acetylsalicylic acid (ASA) and nonsteroidal anti-inflammatory drugs (NSAIDs). The management of H. pylori infection has improved radically in recent years; however, the prescription of ASA and NSAIDs has increased over the same period.

AIM

To evaluate the current global incidence and prevalence of PUD by systematic review of the literature published over the last decade.

METHODS

Systematic searches of PubMed, EMBASE and the Cochrane library.

RESULTS

The annual incidence rates of PUD were 0.10-0.19% for physician-diagnosed PUD and 0.03-0.17% when based on hospitalization data. The 1-year prevalence based on physician diagnosis was 0.12-1.50% and that based on hospitalization data was 0.10-0.19%. The majority of studies reported a decrease in the incidence or prevalence of PUD over time.

CONCLUSIONS

Peptic ulcer disease remains a common condition, although reported incidence and prevalence are decreasing. This decrease may be due to a decrease in H. pylori-associated PUD.

Phase I and II enzyme polymorphisms as risk factors for Barrett's esophagus and esophageal adenocarcinoma: a systematic review and meta-analysis

Although several studies have examined the association between phase I/II enzyme polymorphisms and esophageal adenocarcinoma (EAC) and/or Barrett's esophagus (BE), their overall findings remain unclear. We performed a systematic review and meta-analysis to determine whether phase I/II polymorphisms are independent risk factors for either BE or EAC. We employed keyword searches in multiple databases to identify studies published before October 1, 2007. Single-nucleotide polymorphisms (SNPs) examined in > or =3 studies were meta-analyzed to obtain a pooled estimate of effect. Meta-analysis suggested the minor allele for GSTP1 Val(105) conveys modest excess risk (odds ratio [OR](BE)= 1.50, 95% confidence interval [CI] 1.16-1.95; OR(EAC)= 1.20, 95% CI 0.94-1.54). No excess risk was observed with GSTM1 null (OR(BE)= 0.77, 95% CI: 0.56-1.08; OR(EAC)= 1.08, 95% CI: 0.79-1.48), GSTT1 null (OR(BE)= 1.35, 95% CI: 0.91-2.01; OR(EAC)= 0.84, 95% CI: 0.48-1.49), or CYP1A Val(462) (OR(EAC)= 0.89, 95% CI: 0.40-1.97). Insufficient data existed to meta-analyze remaining SNPs. Our review identified GSTP1(Ile105Val) as a possible risk factor for BE and EAC in Caucasian males. No excess risk was observed for other phase I/II polymorphisms with sufficient data to meta-analyze. Additional studies are needed to determine if GSTP1 conveys excess risk in females or non-Caucasians and to evaluate other phase I/II polymorphisms.

Irritable bowel syndrome and dyspepsia among women veterans: prevalence and association with psychological distress

BACKGROUND

The burden of functional GI disorders and their associations with psychological distress in women veterans is unclear.

AIM

To examine 1-year prevalence of irritable bowel syndrome (IBS) and dyspepsia symptoms and their associations with anxiety, depression and post-traumatic stress disorder (PTSD) among women veterans receiving primary care at a Veteran Affairs Medical Center Women's Clinic.

METHODS

Irritable bowel syndrome, dyspepsia and psychological distress were assessed using the validated self-administered Bowel Disorder Questionnaire, the Beck Depression and Anxiety Inventories, as well as the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorder Questionnaire.

RESULTS

We enrolled 248 women (84% participation rate). Ninety-three (38%) reported IBS and 51 (21%) dyspepsia symptoms. Women with IBS and dyspepsia reported higher mean scores of anxiety (IBS: 24 vs. 12, P < 0.0005 and dyspepsia: 26 vs. 12, P < 0.0005), depression (IBS: 22 vs. 11, P = 0.0005 and dyspepsia: 23 vs. 11, P < 0.0005) and PTSD (IBS: 87 vs. 69, P < 0.001 and dyspepsia: 86 vs. 69, P < 0.0005). Age- and ethnicity-adjusted logistic regression analyses showed a 3- to 46-fold increase in odds of IBS and dyspepsia among women with anxiety, depression or PTSD.

CONCLUSION

Women veterans have high prevalence of IBS and dyspepsia symptoms, both of which are highly associated with presence of depression, anxiety and PTSD.

Hepatitis vaccination in patients with hepatitis C: practice and validation of codes at a large Veterans Administration Medical Centre

BACKGROUND

Hepatitis vaccination is recommended in patients with chronic liver disease.

AIM

To validate Current Procedural Terminology (CPT) codes and drug codes for hepatitis vaccination in administrative databases and determine vaccination rates in hepatitis C virus (HCV)-infected patients in a single large Veterans Administration Medical Center.

METHODS

We calculated predictive values for hepatitis vaccination codes in a validation set of 168 patients. We then conducted a retrospective cohort study of 243 HCV-infected patients to determine rates of hepatitis vaccination and serological testing.

RESULTS

The presence of CPT or drug codes for hepatitis A vaccine yielded a positive predictive value (PPV) and negative predictive value (NPV) of 93.2% and 94.0%. The presence of hepatitis B vaccine codes yielded a PPV of 98.0% and an NPV of 94.0%. Among patients diagnosed with HCV between 2000 and 2005, receipt of hepatitis vaccination was documented in approximately 8% overall and 7% in patients with cirrhosis. Half of the patients without hepatitis vaccinations were either not tested for immunity or had negative serology.

CONCLUSIONS

Current Procedural Terminology or drug codes for hepatitis vaccinations in administrative data are highly predictive of the presence of vaccinations in medical records. Our data suggest that there is significant under-utilization of vaccination in patients with HCV.

The use of acid-decreasing medication in veteran patients with gastro-oesophageal reflux disorder with and without Barrett's oesophagus

AIM

To examine use of acid-decreasing medications, especially proton pump inhibitors (PPIs), in patients with gastro-oesophageal reflux disorder (GERD) with and without Barrett's oesophagus (BO) in a large-scale study.

METHODS

We conducted a retrospective cohort study of patients with newly diagnosed BO (ICD-9 code 5302) and patients with GERD and no BO (ICD-9 53081, 5301) in Department of Veterans Affairs (VA) databases. Filled prescriptions for oral PPI and histamine2-receptor antagonists (H2RA) were identified in the VA Pharmacy Benefit Management database during 365 days following diagnosis. Groups with or without PPI or H2RA were compared in unadjusted and adjusted regression analyses. Chart review was used to validate diagnoses in a subset of patients with and without BO.

RESULTS

We evaluated 7732 patients with BO and 13 457 with GERD and no BO diagnosed between 1/2000 and 12/2002. At least one PPI prescription was filled during the first year following diagnosis in 91.5% of BO and 61.4% of non-BO patients (P < 0.0001), and one H2RA in 31.7% of BO and 59.4% of non-BO patients (P < 0.0001), respectively. However, 6.1% of BO patients were prescribed neither. Median duration for PPI filled prescriptions was twice as long for BO (221.7 vs. 106.9 days) compared with non-BO patients. The ratio of PPI or H2RA filled prescription days to available follow-up days among BO subjects was 0.66 (122.8 days were not covered with prescription for either), and 0.55 in GERD patients with no BO (165.0 days on neither).

CONCLUSIONS

Veterans Affairs patients with BO are 50% more likely to be prescribed a PPI than patients with GERD and no BO. However, on average, PPI prescriptions cover only 60% of follow-up time for BO patients.

The validity of viral hepatitis and chronic liver disease diagnoses in Veterans Affairs administrative databases

BACKGROUND

The validity of International Classification of Diseases-9 codes for liver disease has not been determined.

AIM

To examine the accuracy of International Classification of Diseases-9 codes for cirrhosis with hepatitis C virus or alcoholic liver disease and HIV or hepatitis B virus coinfection with hepatitis C virus in Veterans Affairs data.

METHODS

We conducted a retrospective study comparing the Veterans Affairs administrative data with abstracted data from the Michael E. DeBakey VA Medical Center's medical records. We calculated the positive predictive value, negative predictive value, per cent agreement and kappa.

RESULTS

For cirrhosis codes, the positive predictive value (probability that cirrhosis is present among those with a code) and negative predictive value (probability that cirrhosis is absent among those without a code) were 90% and 87% with 88% agreement and kappa = 0.70. For hepatitis C virus codes, the positive predictive value and negative predictive value were 93% and 92%, yielding 92% agreement and kappa = 0.78. For alcoholic liver disease codes, the positive predictive value and negative predictive value were 71% and 98%, with 89% agreement and kappa = 0.74. All parameters for HIV coinfection with hepatitis C virus were >89%; however, the codes for hepatitis B virus coinfection had a positive predictive value of 43-67%.

CONCLUSION

These diagnostic codes (except hepatitis B virus) in Veterans Affairs administrative data are highly predictive of the presence of these conditions in medical records and can be reliably used for research.

The association between gastro-oesophageal reflux disease and asthma: a systematic review

BACKGROUND AND AIMS

Gastro-oesophageal reflux disease (GORD) has been linked to a number of extra-esophageal symptoms and disorders, primarily in the respiratory tract. This systematic review aimed to provide an estimate of the strength and direction of the association between GORD and asthma.

METHODS

Studies that assessed the prevalence or incidence of GORD in individuals with asthma, or of asthma in individuals with GORD, were identified in Medline and EMBASE via a systematic search strategy.

RESULTS

Twenty-eight studies met the selection criteria. The sample size weighted average prevalence of GORD symptoms in asthma patients was 59.2%, whereas in controls it was 38.1%. In patients with asthma, the average prevalence of abnormal oesophageal pH, oesophagitis and hiatal hernia was 50.9%, 37.3% and 51.2%, respectively. The average prevalence of asthma in individuals with GORD was 4.6%, whereas in controls it was 3.9%. Pooling the odds ratios gave an overall ratio of 5.5 (95% CI 1.9-15.8) for studies reporting the prevalence of GORD symptoms in individuals with asthma, and 2.3 (95% CI 1.8-2.8) for those studies measuring the prevalence of asthma in GORD. One longitudinal study showed a significant association between a diagnosis of asthma and a subsequent diagnosis of GORD (relative risk 1.5; 95% CI 1.2-1.8), whereas the two studies that assessed whether GORD precedes asthma gave inconsistent results. The severity-response relationship was examined in only nine studies, with inconsistent findings.

CONCLUSIONS

This systematic review indicates that there is a significant association between GORD and asthma, but a paucity of data on the direction of causality.

Views of hepatitis C virus patients delayed from treatment for psychiatric reasons

For patients with chronic hepatitis C virus, certain psychiatric disorders are contraindications for antiviral therapy with interferon-alpha (IFN). Although these conditions delay a significant portion of patients from beginning therapy, no one has yet portrayed the views of these patients. A qualitative analysis, drawing upon semi-structured interviews, was developed to generate hypotheses regarding patient views of the treatment disposition process, and to generate strategies for increasing the portion of treatment-eligible patients. Two focus groups were conducted: one for patients delayed from treatment due to current or recent depression, and one for patients delayed due to current or recent alcohol use. A grounded theory analysis of the interview data were conducted. Patients were generally satisfied with the decision-making process, based largely on education from, and trust in, physicians. Upon learning their diagnosis, patients reported making healthy behaviour changes regarding alcohol, diet, exercise and herbal remedies. Some patients reported that requiring a period of alcohol abstinence was excessive, as they believed that they could discontinue alcohol use immediately, if so instructed by a physician. Patients seemed to over-interpret the likelihood of suicide during interferon-alpha (IFN) therapy. Current or recent psychiatric morbidity delays many patients from beginning interferon therapy. Nonetheless, this may be an optimal time for physicians to encourage healthy behaviours including abstinence from alcohol. Also, physicians may need to extensively assess the use of herbal remedies by patients. To help patients make judgments about beginning therapy, physicians should focus upon risk communication regarding the likelihood of suicide on therapy with interferon.

Temporal trends in new and recurrent oesophageal strictures in a Medicare population

BACKGROUND

The widespread use of proton pump inhibitors for gastro-oesophageal reflux disease could result in a decline in new as well as recurrent gastro-oesophageal reflux disease-related oesophageal strictures. The temporal trends of strictures have not been examined in population-based studies.

METHODS

To examine the temporal trends in strictures, we calculated the age-adjusted incidence rates of new oesophageal strictures with or without oesophageal dilation in a sample of Medicare beneficiaries between 1992 and 2000. We also examined recurrent dilations recorded at least 3 months after a new stricture or the preceding recurrent stricture.

RESULTS

The age-adjusted rates for strictures accompanied with dilation declined by approximately 11% from 215 per million to 192 per million. New oesophageal strictures with dilation declined as a proportion of all upper endoscopies procedures (from 2.6% to 1.9%). Recurrent dilation within 1 year declined dramatically from 16% (9.5% CI: 12.5-20.3) in 1992 to 8% (95% CI: 4.43-10.62) in 2000. In multivariable proportional hazards model, there was a 30% risk reduction of recurrent oesophageal strictures.

CONCLUSIONS

This population-based study indicates that the incidence of new as well as recurrent oesophageal strictures has been declining. In the face of rising incidence of other gastro-oesophageal reflux disease-related complications, it is important to understand the explanation of the present observations.

Cyclooxygenase-2 selectivity of non-steroidal anti-inflammatory drugs and the risk of myocardial infarction and cerebrovascular accident

AIM

To assess degree of cyclooxygenase-2 (COX-2) selectivity of a non-steroidal anti-inflammatory drug (NSAID) and risk of myocardial infarction (MI) or cerebrovascular accident (CVA).

METHODS

Prescription fill data were linked to medical records of a merged VA-Medicare dataset. NSAIDs were categorized by Cox-2 selectivity. Incidence of CVA and MI within 180 days of index prescription was assessed using Cox-proportional hazards models adjusted for gender, race, cardiovascular and pharmacological risk factors and propensity for prescription of highly COX-2 selective NSAIDs.

RESULTS

Of 384,322 patients (97.5% men and 85.4% white), 79.4% were prescribed a poorly selective, 16.4% a moderately selective and 4.2% a highly selective NSAID. There were 985 incident cases of MI and 586 cases of CVA in >145 870 person-years. Highly selective agents had the highest rate of MI (12.3 per 1000 person-years; [95% CI: 12.2-12.3]) and CVA (8.1 per 1000 person-years; [95% CI: 8.0-8.2]). Periods without NSAID exposure were associated with lowest risk. In adjusted models, highly selective COX-2 selective NSAIDs were associated with a 61% increase in CVA and a 47% increase in MI, when compared with poorly selective NSAIDs.

CONCLUSIONS

The risk of MI and CVA increases with any NSAID. Highly COX-2 selective NSAIDs confer the greatest risk.

GI Epidemiology: databases for epidemiological studies

BACKGROUND

Large databases are being increasingly used for examining the epidemiology and outcomes of digestive and liver disorders. The complexity and rigor of the methods used to conduct these studies are often underestimated.

AIMS

For the most commonly used databases, we provide a brief description of the contents, highlight strengths and weakness, and provide links for more detailed information. We also present a systematic approach to utilizing large databases for addressing research questions, highlighting commonly encountered study design issues, as well as strategies for resolving these issues.

CONCLUSIONS

1. Research using large databases requires the same essential skills needed to conduct research studies using other data sources. These include a rigorous study design, expertise in analytic methods, and relevant research questions. 2. The completeness and accuracy of information contained in the database must be assessed. Methods for improving the quality and completeness of this information should be considered. 3. Despite similarities among large databases, gaining insight and experience into the structure and content of each database is essential. Key points *Large databases can be a powerful source of information to examine the clinical epidemiology and outcomes of digestive and liver disorders. * Research using large databases requires the same essential skills needed to conduct research studies using other data sources. These include a rigorous study design, expertise in analytic methods, and relevant research questions. * The completeness and accuracy of information contained in the database must be assessed. Methods for improving the quality and completeness of this information should be considered. * Despite similarities among large databases, gaining insight and experience into the structure and content of each database is essential. * Examples of commonly used large databases are presented with a synopsis of information contained in the database, as well as strengths and limitations of using the database for research.

Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies

BACKGROUND

Over-the-counter histamine-2 receptor antagonists, antacids and alginate/antacids are commonly used for gastro-oesophageal reflux disease.

AIM

To conduct a systematic review and meta-analysis of related treatment trials.

METHODS

We performed a systematic search and abstraction of randomized, placebo-controlled trials conducted during 1972-2005. Study quality was measured by the Jadad score (0-5). Results were pooled using random effects model.

RESULTS

Ten trials (n = 3442, placebo = 2940; Jadad score 3.5) showed a higher response with histamine-2 receptor antagonists in regard to complete relief of heartburn, symptomatic improvement, and episodes requiring rescue antacids. The absolute benefit increase was 10-12% and relative benefit increase was 19-41%. Four trials (n = 578, placebo = 577; Jadad score 3.5) showed a trend in favour of antacids in symptomatic improvement (absolute benefit increase 8%, 95% CI: 0-16%; relative benefit increase 0.11) and requirement of rescue antacids (OR 0.70, 95% CI: 0.59-0.84). Four trials (n = 146, placebo = 138; Jadad score 3.8) found alginate/antacid combination superior to placebo in symptomatic improvement (absolute benefit increase 26%, 95% CI: 12%-41%, relative benefit increase 0.60).

CONCLUSIONS

Over-the-counter medications are effective in treating symptomatic gastro-oesophageal reflux disease. Compared with the placebo response, which ranged between 37% and 64%, the relative benefit increase was up to 41% with histamine-2 receptor antagonists, 60% with alginate/antacid combinations, and 11% with antacids.

The epidemiology of pancreatic cancer in the United States: changes below the surface

BACKGROUND

Pancreatic cancer is the fourth leading cause of cancer death in the United States.

AIM

To examine temporal changes in the incidence and survival of patients with pancreatic adenocarcinoma.

METHODS

Using data from nine registries of the Surveillance, Epidemiology and End Results programme, age-adjusted incidence rates per 100 000 and survival rates were calculated for pancreatic cancer between 1977 and 2001.

RESULTS

We identified 58 655 cases of pancreatic cancer. The age-adjusted incidence rate remained stable during the study period (11.3 in 1977-1981 and 10.9 in 1997-2001). Overall, men were 30% more affected than women (age-adjusted incidence rate of 13.0 in men and 9.8 in women). The age-adjusted incidence rates were almost 50% higher among Blacks (16.4) than Whites (10.8) and people of other races (9.8). Over time the proportions of patients with localized disease decreased from 12.3% to 7.4% and those with regional disease increased from 18.6% to 25.8%, while metastatic disease remained stable (52.5% vs. 49.8%). The 1-year relative survival increased from 15.2% in 1977-1981 to 21.6% in 1997-2001.

CONCLUSIONS

The incidence of pancreatic cancer is stable. A shift from localized to regional disease was observed over time. The overall survival remains poor despite important improvements among patients with early stage disease.

The association of body mass index with Barrett's oesophagus

BACKGROUND

Obesity has been linked to gastro-oesophageal reflux disease symptoms and oesophageal adenocarcinoma; however, there is no published evidence for an association with Barrett's oesophagus.

AIM

To investigate the association between obesity and Barrett's oesophagus.

METHODS

We conducted a retrospective cross-sectional study of patients who underwent upper endoscopy at the Southern Arizona Veteran's Affairs Healthcare System between 1998 and 2004. We examined male patients without malignancy, with available information on weight and height. Based on endoscopic and histological findings, patients were classified as cases with Barrett's oesophagus or non-cases without Barrett's oesophagus. Multivariable logistic regression analysis was conducted to examine the association of body mass index and obesity with Barrett's oesophagus and Barrett's oesophagus length while adjusting for age and race.

RESULTS

There were 65 cases with Barrett's oesophagus and 385 non-cases without Barrett's oesophagus. The mean body mass index was significantly higher in cases than in non-cases (29.8 vs. 28.0, P = 0.03). Cases had significantly greater mean weight than controls (206 lb vs. 190,P = 0.005). The proportions of cases with body mass index 25-30 and body mass index > or =30 were greater than those in non-cases (44.6% vs. 37.7%) and (40.0% vs. 33.5%), respectively (P = 0.08). In the multivariable logistic regression model adjusting for race and age, when compared with body mass index < 25, the odds ratio was 2.43 (95% confidence interval: 1.12-5.31) for body mass index 25-30 and 2.46 (1.11-5.44) for body mass index > or =30. When examined as a continuous variable the adjusted odd ratio for each five-point increase in body mass index was 1.35 (95% confidence interval: 1.06-1.71, P = 0.01). The association between weight and Barrett's oesophagus was also statistically significant (adjusted odd ratio for each 10 pound increase = 1.10, 1.03-1.17, P =0.002). Among the 65 cases of Barrett's oesophagus, there was no correlation between the length of Barrett's oesophagus at the time of diagnosis and the body mass index (correlation coefficient = 0.03, P = 0.79).

CONCLUSION

This retrospective cross-sectional study in male veterans shows that overweight is associated with a two-and-half-fold increased risk of Barrett's oesophagus. Larger studies of the underlying mechanism are warranted to better understand how and why obese patients are at greater risk for Barrett's oesophagus.

Epidemiology of gastro-oesophageal reflux disease: a systematic review

A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence of GORD was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period. Data on factors associated with GORD were also evaluated. An approximate prevalence of 10-20% was identified for GORD, defined by at least weekly heartburn and/or acid regurgitation in the Western world while in Asia this was lower, at less than 5%. The incidence in the Western world was approximately 5 per 1000 person years. A number of potential risk factors (for example, an immediate family history and obesity) and comorbidities (for example, respiratory diseases and chest pain) associated with GORD were identified. Data reported in this systematic review can be interpreted with confidence as reflecting the epidemiology of "true" GORD. The disease is more common in the Western world than in Asia, and the low rate of incidence relative to prevalence reflects its chronicity. The small number of studies eligible for inclusion in this review highlights the need for global consensus on a symptom based definition of GORD.

Epidemiology of gastro-oesophageal reflux disease: a systematic review

A systematic review of the epidemiology of gastro-oesophageal reflux disease (GORD) has been performed, applying strict criteria for quality of studies and the disease definition used. The prevalence and incidence of GORD was estimated from 15 studies which defined GORD as at least weekly heartburn and/or acid regurgitation and met criteria concerning sample size, response rate, and recall period. Data on factors associated with GORD were also evaluated. An approximate prevalence of 10-20% was identified for GORD, defined by at least weekly heartburn and/or acid regurgitation in the Western world while in Asia this was lower, at less than 5%. The incidence in the Western world was approximately 5 per 1000 person years. A number of potential risk factors (for example, an immediate family history and obesity) and comorbidities (for example, respiratory diseases and chest pain) associated with GORD were identified. Data reported in this systematic review can be interpreted with confidence as reflecting the epidemiology of "true" GORD. The disease is more common in the Western world than in Asia, and the low rate of incidence relative to prevalence reflects its chronicity. The small number of studies eligible for inclusion in this review highlights the need for global consensus on a symptom based definition of GORD.

Diabetes increases the risk of hepatocellular carcinoma in the United States: a population based case control study

BACKGROUND

Diabetes has been associated with an increased risk of hepatocellular carcinoma (HCC) in studies of referred patients. This is the first population based case control study in the USA to examine this association while adjusting for other major risk factors related to HCC.

METHODS

We used the Surveillance Epidemiology and End-Results Program (SEER)-Medicare linked database to identify patients aged 65 years and older diagnosed with HCC and randomly selected non-cancer controls between 1994 and 1999. Only cases and controls with continuous Medicare enrollment for three years prior to the index date were examined. Inpatient and outpatient claims files were searched for diagnostic codes indicative of diabetes, hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholic liver disease, and haemochromatosis. HCC patients without these conditions were categorised as idiopathic. Unadjusted and adjusted odds ratios were calculated in logistic regression analyses.

RESULTS

We identified 2061 HCC patients and 6183 non-cancer controls. Compared with non-cancer controls, patients with HCC were male (66% v 36%) and non-White (34% v 18%). The proportion of HCC patients with diabetes (43%) was significantly greater than non-cancer controls (19%). In multiple logistic regression analyses that adjusted for demographics features and other HCC risk factors (HCV, HBV, alcoholic liver disease, and haemochromatosis), diabetes was associated with a threefold increase in the risk of HCC. In a subset of patients without these major risk factors, the adjusted odds ratio for diabetes declined but remained significant (adjusted odds ratio 2.87 (95% confidence interval 2.49-3.30)). A significant positive interaction between HCV and diabetes was detected (p<0.0001). Similar findings persisted in analyses restricted to diabetes recorded between two and three years prior to HCC diagnosis.

CONCLUSIONS

Diabetes is associated with a 2-3-fold increase in the risk of HCC, regardless of the presence of other major HCC risk factors. Findings from this population based study suggest that diabetes is an independent risk factor for HCC.

Utility of a depression score to predict candidacy for hepatitis C virus therapy in veterans: a prospective longitudinal study

BACKGROUND

The frequency and determinants of receipt of antiviral therapy once a diagnosis of a mood disorder is established in hepatitis C virus (HCV)-infected patients remains unknown.

AIM

To examine the incidence and determinants of receiving antiviral therapy in HCV-infected veterans with abnormal scores of Zung Self-Rating Depression Scale (SDS).

METHODS

We systematically evaluated the presence of psychiatric disorders among HCV-infected patients with initial referral between September 2000 and May 2002. We reviewed medical records, obtained history, and administered Zung SDS to evaluate for depressive symptoms. Patients with psychiatric disorders were referred for psychiatric evaluation. The primary outcome was the receipt of antiviral therapy during and after the initial evaluation up to December 1, 2003. The association between SDS scores and receipt of antiviral therapy was examined in a multivariate Cox proportional hazards regression.

RESULTS

A total of 424 patients completed a Zung SDS. The scores were normal in only 43% of all patients, and were impaired mildly in 25%, moderately in 23%, and severely in 9%. Zung SDS scores were significantly higher in patients who served during the Vietnam War era, participated in combat, or had lower albumin levels. At the end of the first visit, 180 (42%) had psychiatric disorders. An abnormal Zung score (>55) was the only reason for referral to psychiatry in 83 of 180 patients; and in those 78 (94%) a formal psychiatric evaluation confirmed depressive disorder. Psychiatric disorders were the sole contraindication to therapy in 145 (34%) patients in whom eligibility for antiviral therapy was achieved in 42 (29%) during a mean follow-up duration of 27 months.

CONCLUSIONS

Approximately one-quarter of patients with psychiatric disorders may become eligible for antiviral therapy following subsequent management of these disorders. The Zung self-screening test is an easy, valid method for detecting mood disorders in HCV-infected veterans.

Increased use of low anterior resection for veterans with rectal cancer

BACKGROUND

Two surgical procedures with curative intent are available to patients with rectal cancer: lower anterior resection and abdominoperineal resection; however, lower anterior resection may improve quality of life and functional status.

AIM

To examine temporal changes in after lower anterior resection and abdominoperineal resection between 1989 and 2000. Potential factors associated with the use of lower anterior resection were evaluated.

METHODS

Using national administrative data, we identified patients who received lower anterior resection or abdominoperineal resection. Logistic regression models examined the association between use of lower anterior resection and time period of surgical resection.

RESULTS

A total of 5201 rectal cancer patients underwent resection. The use of lower anterior resection increased from 40.0% (1989-91) to 50.1% (1998-2000) paralleled by a corresponding decline in abdominoperineal resection (60.1 to 49.9%; P < 0.001). Patients who received surgery during 1992-94, 1995-97 and 1998-2000 were 6, 7 and 28% more likely to receive lower anterior resection, when compared with 1989-1991 after adjusting for demographic characteristics, co-morbidity and hospital surgical volume. Older age, lower co-morbidity score and lower hospital surgical volume were predictive of lower anterior resection.

CONCLUSIONS

An increase in the use of lower anterior resection for rectal cancer was observed over time. This observed increase in use is not confined to high-volume hospitals.

Dietary intake and the risk of gastro-oesophageal reflux disease: a cross sectional study in volunteers

BACKGROUND

Although diet has been associated with gastro-oesophageal reflux disease (GORD), the role of dietary components (total energy, macro and micronutrients) is unknown. We examined associations of GORD symptoms with intakes of specific dietary components.

METHODS

We conducted a cross sectional study in a sample of employees (non-patients) at the Houston VAMC. The Gastro Esophageal Reflux Questionnaire was used to identify the onset, frequency, and severity of GORD symptoms. Dietary intake (usual frequency of consumption of various foods and portion sizes) over the preceding year was assessed using the Block 98 food frequency questionnaire. Upper endoscopy was offered to all participants and oesophageal erosions recorded according to the LA classification. We compared the dietary intake (macronutrients, micronutrients, food groups) of participants with or without GORD symptoms, or erosive oesophagitis. Stepwise multiple logistic regression analyses were used to examine associations between nutrients and GORD symptoms or oesophageal erosions, adjusting for demographic characteristics, body mass index (BMI), and total energy intake.

RESULTS

A total of 371 of 915 respondents (41%) had complete and interpretable answers to both heartburn and regurgitation questions and met validity criteria for the Block 98 FFQ. Mean age was 43 years, 260 (70%) were women, and 103 (28%) reported at least weekly occurrences of heartburn or regurgitation. Of the 164 respondents on whom endoscopies were performed, erosive oesophagitis was detected in 40 (24%). Compared to participants without GORD symptoms, daily intakes of total fat, saturated fat, cholesterol, percentage of energy from dietary fat, and average fat servings were significantly higher in participants with GORD symptoms. In addition, there was a dose-response relationship between GORD and saturated fat and cholesterol. The effect of dietary fat became non-significant when adjusted for BMI. However, high saturated fat, cholesterol, or fat servings were associated with GORD symptoms only in participants with a BMI >25 kg/m2 (effect modification). Fibre intake remained inversely associated with the risk of GORD symptoms in adjusted full models. Participants with erosive oesophagitis had significantly higher daily intakes of total fat and protein than those without it (p<0.05).

CONCLUSIONS

In this cross sectional study, high dietary fat intake was associated with an increased risk of GORD symptoms and erosive oesophagitis while high fibre intake correlated with a reduced risk of GORD symptoms. It is unclear if the effects of dietary fat are independent of obesity.

Outcomes in elderly patients following surgery for colorectal cancer in the veterans affairs health care system

AIM

To compare 30-day and 5-year mortality in elderly vs. younger patients following surgical resection for colorectal cancer.

METHODS

A cohort study of patients admitted to VA hospitals with a new diagnosis of colorectal cancer who underwent surgical resection between October 1990 and September 2000. Cumulative survival rates (30-day and 5-year) were calculated from Kaplan-Meier estimates and adjusted risks of death were estimated using Cox proportional hazards models.

RESULTS

We identified 34,888 individuals with a new diagnosis of colorectal cancer between October 1990 and September 2000, of whom 22 633 (65%) underwent surgical resection. The 30-day mortality following resection for rectal and colon cancer, respectively, for patients <65 years was 2.1 and 2.8% compared with 4.9 and 5.6% for those > or =65 years. The 5-year cumulative survival for rectal and colon cancer for patients <65 years was 54.0 and 57.6% compared with 44.5 and 46.6% for those > or =65 years. In patients > or =65 years with rectal or colon cancer, after adjustment, 30-day mortality was 2 times greater and 5-year mortality was 1 times greater than in younger patients.

CONCLUSIONS

Older age is an independent predictor of increased short-term and long-term mortality following surgery in patients with rectal and colon cancer.

The length of newly diagnosed Barrett's oesophagus and prior use of acid suppressive therapy

BACKGROUND

The length of Barrett's oesophagus seems to correlate well with indicators of severe gastro-oesophageal reflux disease. However, it remains unknown whether prior acid suppressive therapy affects the length of newly diagnosed Barrett's oesophagus.

METHODS

A retrospective analysis of a well-characterized large cohort of patients with Barrett's oesophagus diagnosed between 1981 and 2000.

AIM

To compare the length of Barrett's oesophagus between patients who received acid suppressive therapy prior to their diagnosis to those who did not receive such therapy. Pharmacy records were obtained from Department of the Veterans Affairs computerized records and prospectively collected research records. We further examined the association between prior use of acid suppressive therapy and the length of Barrett's oesophagus in correlation analyses, as well as multivariate linear regression analyses while adjusting for differences in year of diagnosis, age, gender, ethnicity, and the presence of intestinal metaplasia of the gastric cardia. Results : There were 340 patients with Barrett's oesophagus first diagnosed between 1981 and 2000. The average length of Barrett's oesophagus at the time of first diagnosis was 4.4 cm (range: 0.5-16). Of all patients, 139 (41%) had prior use of histamine-2 receptor antagonists, or proton-pump inhibitors (41 used both), and 201 (59%) used neither prior to the diagnosis of Barrett's oesophagus. The mean length of Barrett's oesophagus was significantly shorter in patients with prior use of proton-pump inhibitors (3.4 cm) or proton-pump inhibitors and histamine-2 receptor antagonists (3.1 cm) when compared to those with none of these medications (4.8 cm). In the multivariate linear regression model, the prior use of proton-pump inhibitors or either proton-pump inhibitors or histamine-2 receptor antagonists was an independent predictor of shorter length of Barrett's oesophagus (P = 0.0396).

CONCLUSIONS

The use of acid suppressive therapy among patients is associated with a reduction in the eventual length of newly diagnosed Barrett's oesophagus with gastro-oesophageal reflux disease. This finding is independent of the year of diagnosis or demographic features of patients. Further studies are required to confirm this finding.

Systemic review: Natural history of irritable bowel syndrome

BACKGROUND

The natural history of irritable bowel syndrome is unclear, including the likelihood that these patients will be diagnosed with an alternative organic or functional gastrointestinal disorder. Understanding the stability of an irritable bowel syndrome diagnosis may limit repeated diagnostic evaluation among these patients.

METHODS

The inclusion criteria included observational longitudinal studies of clinic-based samples of adult patients with irritable bowel syndrome. Only studies published in the English language in full manuscript form were included. Literature searches, selection and review of eligible articles, and data abstraction were performed in a duplicate, independent manner.

RESULTS

Fourteen studies met study selection criteria. In six studies with relevant information, 2-5% of irritable bowel syndrome patients were diagnosed with an alternative organic GI disorder after 6 months to 6 years of follow-up. Long-term follow-up indicated that 2-18% of patients developed worse irritable bowel syndrome symptoms, approximately 30-50% of patients had unchanged symptoms, and the rest either improved or had symptoms disappear. Prior surgery (one study), higher somatic scores (one study), higher baseline anxiety (two studies), depression scores (one study) were predictive of worsening of symptoms during long-term follow-up.

CONCLUSIONS

Irritable bowel syndrome, a chronic disorder, is a stable diagnosis. Once initial investigations are negative, fewer than 5% are diagnosed with an alternative organic GI disorder. Repeated diagnostic evaluations of patients with recurrent or persistent symptoms similar to their baseline symptoms are not warranted.

Systemic review: the prevalence and clinical course of functional dyspepsia

AIM

To examine the prevalence of functional dyspepsia in the general population, and to evaluate the natural history/clinical course of patients with functional dyspepsia.

METHODS

Full-length published manuscripts during 1980-2002 were included if: (i) participants had uninvestigated or functional dyspepsia; (ii) dyspepsia was defined; (iii) for prevalence, population-based samples were evaluated; (iv) for prognosis, the total number of the inception cohort and the total number of individuals available at the end of follow-up were reported.

RESULTS

Twenty-two studies (1976-2002) that examined the prevalence of dyspepsia fulfilled the inclusion and exclusion criteria; 17 studies examined more than 1000 participants, but only two studies provided information sufficient to calculate the prevalence of functional dyspepsia (11.5-14.7%). The prevalence of uninvestigated dyspepsia was in the range 10-40%. When the definition of dyspepsia was restricted to participants with upper abdominal pain, irrespective of the presence of heartburn or acid regurgitation, the prevalence rate estimate was 5-12%. Thirteen studies examined the clinical course of functional dyspepsia (seven retrospective and six prospective). Sample sizes were small (n = 35-209). A follow-up ascertainment of symptoms amongst individuals in the original cohorts was obtained in 92.5-98.2% of prospective studies and in 67.7-82.2% of retrospective studies. The follow-up duration was in the range 1.5-10 years for prospective studies and 5-27 years for retrospective studies; the median follow-up duration for all studies was approximately 5 years. A variable prognosis was reported. An outcome of symptom improvement or becoming asymptomatic was reported in at least one-half of patients in 10 of the 13 studies, and in at least two-thirds of patients in six of the 13 studies. Prognostic factors were inconsistent and, in general, poorly described.

CONCLUSIONS

Functional dyspepsia is prevalent world-wide, but the prognosis remains poorly defined. There is a need for population-based studies to examine the prevalence and clinical course of documented functional dyspepsia.

Health-related quality of life in functional dyspepsia

BACKGROUND

We performed a systematic review of the literature to compare the health-related quality of life (HRQOL) of patients with functional dyspepsia with either healthy controls or those with other diseases.

METHODS

Full-length published manuscripts during 1980-2002 were included if (a) patients had functional dyspepsia, but not uninvestigated dyspepsia; and (b) HRQOL was measured using a validated generic or dyspepsia-specific instruments, but not global assessment alone.

RESULTS

Twelve studies were reviewed; six fulfilled the selection criteria. None examined HRQOL among samples of the general population. None used dyspepsia-specific HRQOL instruments. Three studies contained four comparisons of HRQOL between functional dyspepsia patients and controls; two studies examined HRQOL changes in response to therapy. Two studies demonstrated a significant reduction at least in some domains of HRQOL among patients with functional dyspepsia compared to controls, while one study was negative. In general, studies that reported a decline in HRQOL Short Form-36 (SF-36) showed that changes in the physical domain were similar to those on mental domain of the SF-36.

CONCLUSIONS

There is some evidence for a decrease in HRQOL in patients with moderate to severe functional dyspepsia who seek care for their symptoms; however, more studies are needed. A therapeutic response in functional dyspepsia-related pain or discomfort might result in a corresponding improvement in HRQOL.

Meta-analysis: proton pump inhibitor or H2-receptor antagonist for Helicobacter pylori eradication

AIM

To compare H2-receptor antagonists and proton pump inhibitors as adjuvants to triple therapy for Helicobacter pylori eradication.

METHODS

H. pylori-infected patients with peptic ulcer were randomized to receive either 300 mg nizatidine or 30 mg lansoprazole plus 1 g amoxicillin and 500 mg clarithromycin taken b.d. for 7 days. H. pylori eradication was assessed 4 weeks after therapy. Using meta-analytical techniques, we combined the results of this study with other randomized controlled comparisons of H2-receptor antagonists and proton pump inhibitors as adjuvants to triple therapy.

RESULTS

One hundred and one patients were randomized. H. pylori eradication was 94% (47/50) [95% confidence interval (CI), 83-99%] (intention-to-treat) in the H2-receptor antagonist group vs. 86% (44/51) (95% CI, 74-94%) in the proton pump inhibitor group (P = 0.3). There has been a total of 12 similar studies (1415 patients). The overall efficacy was similar in intention-to-treat analysis: 78% (549/701) with H2-receptor antagonists vs. 81% (575/714) with proton pump inhibitors (odds ratio, 0.86; 95% CI, 0.66-1.12). A non-significant trend favouring H2-receptor antagonist (79% vs. 69%; odds ratio, 1.14; 95% CI, 0.76-1.71; P = 0.5) was seen in the comparison of clarithromycin-containing regimens. In contrast, in non-clarithromycin-containing trials, there was a slight, but significant, advantage with proton pump inhibitors (85% vs. 78%; odds ratio, 0.64; 95% CI, 0.45-0.92; P = 0.02).

CONCLUSION

Overall, proton pump inhibitor and H2-receptor antagonist antisecretory agents appear to be similarly effective as adjuvants for H. pylori triple therapy. It is unlikely that the direct anti-H. pylori effect of proton pump inhibitors is responsible for their ability to enhance anti-H. pylori therapy.

Risk factors for the severity of erosive esophagitis in Helicobacter pylori-negative patients with gastroesophageal reflux disease

BACKGROUND

The risk factors for the varying grades of erosive esophagitis (EE) severity could be better understood. For that reason. we evaluated the risk factors associated with EE in patients with gastroesophageal reflux disease.

METHOD

We determined the presence and severity of EE (using the Los Angeles Classification) in patients with negative serology Helicobacterpylori who underwent esophagogastroduodenoscopy as part of screening in four prospective, multicenter, randomized, double-blind comparative trials of once-daily esomeprazole and omeprazole for the acute healing of erosive esophagitis. We also examined the baseline characteristics of enrolled patients, and identified risk factors for severe disease using a multivariable logistic regression model.

RESULTS

Erosive esophagitis was documented in 6709 patients of a total of 10,294 patients who underwent endoscopy: of these. 34% had grade A. 39% had grade B. 20% had grade C. and 7% had grade D disease. The majority of patients were male (61%) and Caucasian (93%) with a mean age of 46 years. In the regression model, the following were significant independent risk factors for severe (grades C and D) versus mild erosive esophagitis (grades A and B): severe heartburn (adjusted odds ratio 1.79); prolonged heartburn > 5 years in duration (1.16); obesity (1.21); the presence of hiatus hernia (2.13); male gender (1.97); and Caucasian ethnicity (1.53).

CONCLUSION

In this large sample of patients with predominantly H. pylori-negative gastroesophageal reflux disease, risk factors for severe erosive esophagitis were the duration and severity of heartburn, and obesity.

Health-related quality of life among persons with irritable bowel syndrome: a systematic review

AIM

To perform a systematic review of the literature with three objectives: (1) to compare the health related quality of life (HRQoL) of patients with irritable bowel syndrome with that of healthy controls; (2) to compare the HRQoL of irritable bowel syndrome patients to those with other diseases; and (3) to examine therapy-associated changes in HRQoL of irritable bowel syndrome patients.

METHODS

Searches of all English and non-English articles from 1980 to 2001 were performed in Medline and Embase, and two investigators performed independent data abstraction.

RESULTS

Seventeen articles met our selection criteria. 13 studies addressed objective no. 1; 11 showed a significant reduction in HRQoL among irritable bowel syndrome patients. Of these, only one study was considered of high quality. Four studies addressed objective no. 2, none of which was considered to be high quality in addressing this objective. Four trials (three of high quality) addressed objective no. 3. One showed that symptomatic improvement with Leupron compared to placebo was accompanied an improvement only in the comparative health domain of the HRQoL. The second study reported significant positive changes in HRQoL after 12 weeks of cognitive behavioural therapy. The third report of two placebo-controlled studies indicated significant improvement with alosetron on most domains of Irritable Bowel Syndrome Quality of Life Questionnaire.

CONCLUSIONS

(i) There is reasonable evidence for a decrease in HRQoL in patients with moderate to severe irritable bowel syndrome; however, the data are conflicting regarding the impact of irritable bowel syndrome on HRQoL in population-based studies of nonconsulters. (ii) HRQoL in irritable bowel syndrome patients is impaired to a degree comparable to other chronic disorders such as GERD and depression. (iii) A therapeutic response in irritable bowel syndrome-related pain has a corresponding improvement in HRQoL. (iv) Limitations of the literature include focusing on moderate-severe irritable bowel syndrome in referral centres, and lack of appropriate controls

Epidemiological differences between adenocarcinoma of the oesophagus and adenocarcinoma of the gastric cardia in the USA

BACKGROUND AND AIMS

It has been suggested that gastric cardia adenocarcinoma (GCA) is a distinct entity from oesophageal adenocarcinoma (OA). We examined several epidemiological features of GCA and OA in the USA to elucidate differences/similarities between these malignancies.

METHODS

Using the database of Surveillance, Epidemiology, and End Results (SEER) program, we examined incidence rates for temporal changes, and ethnic and age distributions, and performed birth cohort analyses for cases with morphologically and histologically confirmed OA or GCA.

RESULTS

The age adjusted incidence rates of OA rose progressively, reaching 1.8 per 100 000 (95% confidence interval 1.7-1.9) during 1987-1991 and 2.5 per 100 000 (2.3-2.6) during 1992-1996. In 1992-1996, Whites were affected five times more than Blacks, and men eight times more than women. A significant increase in incidence occurred among younger persons aged 45-65 years. Irrespective of age, OA was characterised by higher incidence rates among more recent birth cohorts: a 40% increase in incidence for each five year increase in the date of birth--a "birth cohort effect". On the other hand, the incidence rates of GCA reached their highest level of 3.3 per 100 000 (3.2-3.4) in 1987-1991 and subsequently declined during 1992-1996 to 3.1 per 100 000 (3.0-3.3). Whites were affected twice more than blacks and men five times more than women. Most patients with GCA were older than 60 years with no increase among younger persons and no birth cohort effect (p=0.99).

CONCLUSION

Several significant epidemiological differences exist between OA and GCA. These differences suggest that these two malignancies are separate entities with different risk factors.