Background: Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imag- ing technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett‘s...Background: Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imag- ing technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett‘s epithelium, but this has not been established in a prospective blinded study. This study evaluated the accuracy of EOCT for the diagnosis and the exclusion of dysplasia in patients with Barrett‘s esophagus. Methods: A 2.4 mm diameter EOCT probe was modified for use with a cap-fitted, two -channel endoscope. Pairs of EOCT image streams and jumbo biopsy specimens were obtained. Endoscopy/EOCT procedures were performed by 4 endoscopists who separa tely reviewed the EOCT digital images for the absence or the presence of dysplas ia (low grade, high grade, or cancer) for each biopsy specimen obtained. The end oscopists were blinded to the interpretation of the pathology. An experienced pa thologist blinded to the endoscopic/EOCT findings evaluated each biopsy for the absence or the presence of dysplasia. The setting of the study was a major acade mic medical center. Adult patients with documented Barrett‘s esophagus greater than 2 cm were included in the study. The main outcome measurement was the accur acy of EOCT in the detection of dysplasia in patients with Barrett‘s esophagus. Results: A total of 314 usable EOCT image stream/biopsy pairs were obtained in 33 patients. By using histology as the standard, the performance of EOCT was sensitivity, 68%; specificity, 82%; positive predictive value, 53%; negative predictive value, 89%; and diagnostic accuracy, 78%. Diagnostic accuracy for the 4 endoscopists ranged from 56%to 98%. Limitations of the study were the variability in endoscopists‘accuracy rates, difficulty in real-time interpretation, and the need for refined criteria of dysplasia by EOCT imaging. Conclusions: The current EOCT system has an accuracy of 78%for the detection of dysplasia in patients with Barrett‘s esophagus. EOCT could be used to target biopsies to areas of Barrett‘s epithelium with a higher probability for the presence of dysplasia. However, further modifications, including increased resolution and identification of further pot ential OCT characteristics of dysplasia, are needed before EOCT can be used clin ically.展开更多
Background: In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Estab...Background: In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for subepithelial lesions are currently lacking. Objective: Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract. Design: A prospective head-to-head comparison was performed. Setting: The study was performed in a tertiary care hospital. Patients: Study patients were 23 adults with subepithelial lesions limited to the submucosa. Intervention: All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy speciments were obtained with large-capacity “jumbo" forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device. Main Outcome Measurement: The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection. Results: Twenty-three patients with lesions limited to the submucosa were identi-fied by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test). Conclusion: In the evaluation of subepithelial lesions limited to the submucosa, ESMR has a significantly higher diagnostic yield than jumbo forceps biopsy with use of the bite-on-bite technique.展开更多
Background: Population based mortality rates from liver cirrhosis, and alcohol consumption, have increased sharply in Britain in the past 35 years. Little is known about the long term trends over time in mortality rat...Background: Population based mortality rates from liver cirrhosis, and alcohol consumption, have increased sharply in Britain in the past 35 years. Little is known about the long term trends over time in mortality rates after hospital admission for liver cirrhosis. Aims: To analyse time trends in mortality in the yea r after admission for liver cirrhosis from 1968 to 1999. Subjects: A total of 8192 people who were admitted to hospital in a defined population of Southern England. Methods: Analysis of hospital discharge statistics linked to death certificate data. The main outcome measures were case fatality rates (CFRs) and standardised mortality ratios (SMRs). Results: At 30 days after admission, CFR was 15.9%and the SMR was 93 (86 in men and 102 in women, compared with 1 in the general population). At one year, the overall CFR was 33.6%and SMR was 16.3. There was no improvement from 1968 to 1999 in mortality rates. SMRs were highest for alco holic cirrhosis of the liver (27.4 at one year) but lower for biliary cirrhosis (11.4) and chronic hepatitis (10.0). Mortality from most of the main causes of d eath, including accidents and suicides, was increased. Conclusions: The high mortality rates after hospital admission, and the fact that they have not fallen in the past 30 years, show that liver cirrhosis remains a disease with a very poor prognosis. Increased mortality from accidents, suicides, and mental disorders, particularly among those with alcoholic cirrhoses, indicates that prognosis is influenced by behavioural as well as by physical pathology.展开更多
Background: Some case series and cohort studies suggest that acute GI bleeding decreases the sensitivity of Helicobacter pylori diagnostic testing. Objective: To assess H pylori biopsy testing in patients with acute u...Background: Some case series and cohort studies suggest that acute GI bleeding decreases the sensitivity of Helicobacter pylori diagnostic testing. Objective: To assess H pylori biopsy testing in patients with acute upper-GI bleeding and 1 month later. Design: Prospective cohort study using patients as their own controls. Setting: Urban county hospital. Patients: Sixty-one patients with acute variceal bleeding. Interventions: Antral and body endoscopic biopsies at admission and 1 month later. Main outcome measurements: CLO test and histologic examinations were performed and bi opsy specimens were coded and mixed for blinded histologic examination for H pyl ori density and inflammation. Results: CLO test results changed from H pylori ne gative at baseline to H pylori positive at 1 month in two patients (3%), from H pylori positive to H pylori negative in 6 patients (10%), and remained the sam e in 53 (87%). Histologic results changed from H pylori negative at baseline to H pylori positive at 1 month in two patients (3%), from H pylori positive to H pylori negative in 5 patients (8%),and remained the same in 54 (89%). Changes occurred only in patients with low H pylori density. No significant increase in H pylori density or change in inflammatory cell infiltration was seen. CLO test sensitivity was 8%higher with bleeding vs. 1 month after bleeding (79%vs. 71% ; 95%CI of difference was 11%to 27%; i.e., maximal potential decrease in sens itivity with bleeding is 11%). Limitations: The population is not one for which H pylori testing is recommended, and biopsy test performance was less consisten t than expected. Conclusions: Acute-GI bleeding did not decrease the sensitivit y of rapid urease testing, unless the effect lastsmore than 1 month. Furthermore , bleeding did not produce falsely negative histologic examinations for H pylori , decrease H pylori density, or alter inflammatory cell infiltration. However, g iven the lower than expected overall CLO test sensitivity and frequent use of pr oton pump inhibitors for GI bleeding, histology may be preferred in this setting .展开更多
Objective: To quantitatively examine the dynamics of molecular alterations in volved in dermal remodeling after carbon dioxide (CO2) laser resurfacing of phot odamaged human skin. Design: Serial in vivo biochemical an...Objective: To quantitatively examine the dynamics of molecular alterations in volved in dermal remodeling after carbon dioxide (CO2) laser resurfacing of phot odamaged human skin. Design: Serial in vivo biochemical analyses after laser therapy. Setting: Academic referral center, Department of Dermatology, University of Mich igan, Ann Arbor. Subjects: Volunteer sample of 28 adults, 48 to 76 years old, wi th clinically evident photodamage of the forearms. Intervention: Focal CO2 laser resurfacing of photodamaged forearms and serial biopsies at baseline and variou s times after treatment. Main Outcome Measures: Reverse transcriptase real-tim e polymerase chain reaction technology and immunohistochemistry were used to ass ess levels of type I and type III procollagens; matrix metalloproteinases (MMPs) 1, 3, 9, and 13; tropoelastin; fibrillin; primary cytokines interleukin 1β an d tumor necrosis factor α ; and profibrotic cytokine transforming growth factor β 1. Results: Production of type I procollagen and type III procollagen messen ger RNA peaked at 7.5 and 8.9 times baseline levels, respectively, 21 days after treatment and remained elevated for at least 6 months. Increases in messenger R NA levels of several cytokines (interleukin 1β , tumor necrosis factor a, and t ransforming growth factor β 1) preceded and/or accompanied changes in collagen levels. Marked increases in messenger RNA levels of MMP- 1 (39 130- fold), MMP - 3 (1041- fold), MMP- 9 (75- fold) , andMMP- 13 (767- fold)were noted. Le vels of fibrillin and tropoelastin rose in a delayed fashion several weeks after treatment. Conclusions: The biochemical changes seen after CO2 laser resurfacin g proceed through a well-organized and highly reproducible wound healing respo nse that results in marked alterations in dermal structure. These quantitative c hanges may serve as a means for comparison as other therapeutic modalitiesmeant to improve the appearance of photodamaged skin are evaluated.展开更多
文摘Background: Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imag- ing technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett‘s epithelium, but this has not been established in a prospective blinded study. This study evaluated the accuracy of EOCT for the diagnosis and the exclusion of dysplasia in patients with Barrett‘s esophagus. Methods: A 2.4 mm diameter EOCT probe was modified for use with a cap-fitted, two -channel endoscope. Pairs of EOCT image streams and jumbo biopsy specimens were obtained. Endoscopy/EOCT procedures were performed by 4 endoscopists who separa tely reviewed the EOCT digital images for the absence or the presence of dysplas ia (low grade, high grade, or cancer) for each biopsy specimen obtained. The end oscopists were blinded to the interpretation of the pathology. An experienced pa thologist blinded to the endoscopic/EOCT findings evaluated each biopsy for the absence or the presence of dysplasia. The setting of the study was a major acade mic medical center. Adult patients with documented Barrett‘s esophagus greater than 2 cm were included in the study. The main outcome measurement was the accur acy of EOCT in the detection of dysplasia in patients with Barrett‘s esophagus. Results: A total of 314 usable EOCT image stream/biopsy pairs were obtained in 33 patients. By using histology as the standard, the performance of EOCT was sensitivity, 68%; specificity, 82%; positive predictive value, 53%; negative predictive value, 89%; and diagnostic accuracy, 78%. Diagnostic accuracy for the 4 endoscopists ranged from 56%to 98%. Limitations of the study were the variability in endoscopists‘accuracy rates, difficulty in real-time interpretation, and the need for refined criteria of dysplasia by EOCT imaging. Conclusions: The current EOCT system has an accuracy of 78%for the detection of dysplasia in patients with Barrett‘s esophagus. EOCT could be used to target biopsies to areas of Barrett‘s epithelium with a higher probability for the presence of dysplasia. However, further modifications, including increased resolution and identification of further pot ential OCT characteristics of dysplasia, are needed before EOCT can be used clin ically.
文摘Background: In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for subepithelial lesions are currently lacking. Objective: Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract. Design: A prospective head-to-head comparison was performed. Setting: The study was performed in a tertiary care hospital. Patients: Study patients were 23 adults with subepithelial lesions limited to the submucosa. Intervention: All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy speciments were obtained with large-capacity “jumbo" forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device. Main Outcome Measurement: The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection. Results: Twenty-three patients with lesions limited to the submucosa were identi-fied by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test). Conclusion: In the evaluation of subepithelial lesions limited to the submucosa, ESMR has a significantly higher diagnostic yield than jumbo forceps biopsy with use of the bite-on-bite technique.
文摘Background: Population based mortality rates from liver cirrhosis, and alcohol consumption, have increased sharply in Britain in the past 35 years. Little is known about the long term trends over time in mortality rates after hospital admission for liver cirrhosis. Aims: To analyse time trends in mortality in the yea r after admission for liver cirrhosis from 1968 to 1999. Subjects: A total of 8192 people who were admitted to hospital in a defined population of Southern England. Methods: Analysis of hospital discharge statistics linked to death certificate data. The main outcome measures were case fatality rates (CFRs) and standardised mortality ratios (SMRs). Results: At 30 days after admission, CFR was 15.9%and the SMR was 93 (86 in men and 102 in women, compared with 1 in the general population). At one year, the overall CFR was 33.6%and SMR was 16.3. There was no improvement from 1968 to 1999 in mortality rates. SMRs were highest for alco holic cirrhosis of the liver (27.4 at one year) but lower for biliary cirrhosis (11.4) and chronic hepatitis (10.0). Mortality from most of the main causes of d eath, including accidents and suicides, was increased. Conclusions: The high mortality rates after hospital admission, and the fact that they have not fallen in the past 30 years, show that liver cirrhosis remains a disease with a very poor prognosis. Increased mortality from accidents, suicides, and mental disorders, particularly among those with alcoholic cirrhoses, indicates that prognosis is influenced by behavioural as well as by physical pathology.
文摘Background: Some case series and cohort studies suggest that acute GI bleeding decreases the sensitivity of Helicobacter pylori diagnostic testing. Objective: To assess H pylori biopsy testing in patients with acute upper-GI bleeding and 1 month later. Design: Prospective cohort study using patients as their own controls. Setting: Urban county hospital. Patients: Sixty-one patients with acute variceal bleeding. Interventions: Antral and body endoscopic biopsies at admission and 1 month later. Main outcome measurements: CLO test and histologic examinations were performed and bi opsy specimens were coded and mixed for blinded histologic examination for H pyl ori density and inflammation. Results: CLO test results changed from H pylori ne gative at baseline to H pylori positive at 1 month in two patients (3%), from H pylori positive to H pylori negative in 6 patients (10%), and remained the sam e in 53 (87%). Histologic results changed from H pylori negative at baseline to H pylori positive at 1 month in two patients (3%), from H pylori positive to H pylori negative in 5 patients (8%),and remained the same in 54 (89%). Changes occurred only in patients with low H pylori density. No significant increase in H pylori density or change in inflammatory cell infiltration was seen. CLO test sensitivity was 8%higher with bleeding vs. 1 month after bleeding (79%vs. 71% ; 95%CI of difference was 11%to 27%; i.e., maximal potential decrease in sens itivity with bleeding is 11%). Limitations: The population is not one for which H pylori testing is recommended, and biopsy test performance was less consisten t than expected. Conclusions: Acute-GI bleeding did not decrease the sensitivit y of rapid urease testing, unless the effect lastsmore than 1 month. Furthermore , bleeding did not produce falsely negative histologic examinations for H pylori , decrease H pylori density, or alter inflammatory cell infiltration. However, g iven the lower than expected overall CLO test sensitivity and frequent use of pr oton pump inhibitors for GI bleeding, histology may be preferred in this setting .
文摘Objective: To quantitatively examine the dynamics of molecular alterations in volved in dermal remodeling after carbon dioxide (CO2) laser resurfacing of phot odamaged human skin. Design: Serial in vivo biochemical analyses after laser therapy. Setting: Academic referral center, Department of Dermatology, University of Mich igan, Ann Arbor. Subjects: Volunteer sample of 28 adults, 48 to 76 years old, wi th clinically evident photodamage of the forearms. Intervention: Focal CO2 laser resurfacing of photodamaged forearms and serial biopsies at baseline and variou s times after treatment. Main Outcome Measures: Reverse transcriptase real-tim e polymerase chain reaction technology and immunohistochemistry were used to ass ess levels of type I and type III procollagens; matrix metalloproteinases (MMPs) 1, 3, 9, and 13; tropoelastin; fibrillin; primary cytokines interleukin 1β an d tumor necrosis factor α ; and profibrotic cytokine transforming growth factor β 1. Results: Production of type I procollagen and type III procollagen messen ger RNA peaked at 7.5 and 8.9 times baseline levels, respectively, 21 days after treatment and remained elevated for at least 6 months. Increases in messenger R NA levels of several cytokines (interleukin 1β , tumor necrosis factor a, and t ransforming growth factor β 1) preceded and/or accompanied changes in collagen levels. Marked increases in messenger RNA levels of MMP- 1 (39 130- fold), MMP - 3 (1041- fold), MMP- 9 (75- fold) , andMMP- 13 (767- fold)were noted. Le vels of fibrillin and tropoelastin rose in a delayed fashion several weeks after treatment. Conclusions: The biochemical changes seen after CO2 laser resurfacin g proceed through a well-organized and highly reproducible wound healing respo nse that results in marked alterations in dermal structure. These quantitative c hanges may serve as a means for comparison as other therapeutic modalitiesmeant to improve the appearance of photodamaged skin are evaluated.
