Performance value of high risk factors in colorectal cancer screening in China

AIM:To analyze the performance value of high risk factors in population-based colorectal cancer(CRC) screening in China.METHODS:We compared the performance value of the immunochemical fecal occult blood test(iFOBT) and other high risk factors questionnaire in a population sample of 13 214 community residents who completed both the iFOBT and questionnaire investigation.Patients with either a positive iFOBT and/or questionnaire were regarded as a high risk population and those eligible were asked to undergo colonoscopy.RESULTS:The iFOBT had the highest positive predictive value and negative predictive value in screening for advanced neoplasia.The iFOBT had the highest sensitivity,lowest number of extra false positive results associated with the detection of one extra abnormality for screening advanced neoplasias and adenomas.A history of chronic cholecystitis or cholecystectomy,chronic appendicitis or appendectomy,and chronic diarrhea also had a higher sensitivity than a history of adenomatous polyps in screening for advanced neoplasias and adenomas.The sensitivity of a history of chronic cholecystitis or cholecystectomy was highest among the 10 high risk factors in screening for nonadenomatous polyps.A history of chronic appendicitis or appendectomy,chronic constipation,chronic diarrhea,mucous and bloody stool,CRC in first degree relatives,malignant tumor and a positive iFOBT also had higher sensitivities than a history of adenomas polyps in screening for non-adenomatous polyps.Except for a history of malignant tumor in screening for non-adenomatous polyps,the gain in sensitivity was associated with an increase in extra false positive results associated with the detection of one extra abnormality.CONCLUSION:The iFOBT may be the best marker for screening for advanced neoplasias and adenomas.Some unique high risk factors may play an important role in CRC screening in China.

Contrast-enhanced ultrasonography assessment of gastric cancer response to neoadjuvant chemotherapy

AIM:To quantitatively assess the ability of double contrast-enhanced ultrasound(DCUS) to detect tumor early response to pre-operative chemotherapy.METHODS:Forty-three patients with gastric cancer treated with neoadjuvant chemotherapy followed by curative resection between September 2011 and February 2012 were analyzed.Pre-operative chemotherapy regimens of fluorouracil + oxaliplatin or S-1 + oxaliplatin were administered in 2-4 cycles over 6-12 wk periods.All patients underwent contrast-enhanced computed tomography(CT) scan and DCUS before and after two courses of pre-operative chemotherapy.The therapeutic response was assessed by CT using the response evaluation criteria in solid tumors(RECIST 1.1) criteria.Tumor area was assessed by DCUS as enhanced appearance of gastric carcinoma due to tumor vascularity during the contrast phase as compared to the normal gastric wall.Histopathologic analysis was carried out according to the Mandard tumor regression grade criteria and used as the reference standard.Receiver operating characteristic(ROC) analysis was used to evaluate the efficacy of DCUS parameters in differentiating histopathological responders from non-responders.RESULTS:The study population consisted of 32 men and 11 women,with mean age of 59.7 ± 11.4 years.Neither age,sex,histologic type,tumor site,T stage,nor N stage was associated with pathological response.The responders had significantly smaller mean tumor size than the non-responders(15.7 ± 7.4 cm vs 33.3 ± 14.1 cm,P < 0.01).According to Mandard's criteria,27 patients were classified as responders,with 11(40.7%) showing decreased tumor size by DCUS.In contrast,only three(18.8%) of the 16 non-responders showed decreased tumor size by DCUS(P < 0.01).The area under the ROC curve was 0.64,with a 95%CI of 0.46-0.81.The effects of several cut-off points on diagnostic parameters were calculated in the ROC curve analysis.By maximizing Youden's index(sensitivity + specificity-1),the best cut-off point for distinguishing responders from non-responders was determined,which had optimal sensitivity of 62.9% and specificity of 56.3%.Using this cut-off point,the positive and negative predictive values of DCUS for distinguishing responders from non-responders were 70.8% and 47.4%,respectively.The overall accuracy of DCUS for therapeutic response assessment was 60.5%,slightly higher than the 53.5% for CT response assessment with RECIST criteria(P = 0.663).Although the advantage was not statistically significant,likely due to the small number of cases assessed.DCUS was able to identify decreased perfusion in responders who showed no morphological change by CT imaging,which can be occluded by such treatment effects as fibrosis and edema.CONCLUSION:DCUS may represent an innovative tool for more accurately predicting histopathological response to neoadjuvant chemotherapy before surgical resection in patients with locally-advanced gastric cancer.

Prediction of recurrence and prognosis in patients with hepatocellular carcinoma after resection by use of CLIP score

AIM: The survival time of patients with hepatocellular carcinoma (HCC) after resection is hard to predict. Both residual liver function and tumor extension factors should be considered. A new scoring system has recently been proposed by the Cancer of the Liver Italian Program (CLIP). CLIP score was confirmed to be one of the best ways to stage patients with HCC. To our knowledge, however, the literature concerning the correlation between CLIP score and prognosis for patients with HCC after resection was not published. The aim of this study is to evaluate the recurrence and prognostic value of CLIP score for the patients with HCC after resection. METHODS: A retrospective survey was carried out in 174 patients undergoing resection of HCC from January 1986 to June 1998. Six patients who died in the hospital after operation and 11 patients with the recurrence of the disease were excluded at 1 month after hepatectomy. By the end of June 2001, 4 patients were lost and 153 patients with curative resection have been followed up for at least three years. Among 153 patients, 115 developed intrahepatic recurrence and 10 developed extrahepatic recurrence, whereas the other 28 remained free of recurrence. Recurrences were classified into early (【 or =3 year) and late (】3 year) recurrence. The CLIP score included the parameters involved in the Child-Pugh stage (0-2), plus macroscopic tumor morphology (0-2), AFP levels (0-1), and the presence or absence of portal thrombosis (0-1). By contrast, portal vein thrombosis was defined as the presence of tumor emboli within vascular channel analyzed by microscopic examination in this study. Risk factors for recurrence and prognostic factors for survival in each group were analyzed by the chi-square test, the Kaplan-Meier estimation and the COX proportional hazards model respectively. RESULTS: The 1-, 3-, 5-, 7-,and 10-year disease-free survival rates after curative resection of HCC were 57.2%, 28.3%, 23.5%, 18.8%, and 17.8%, respectively. Median survival time was 28, 10, 4, and 5 mo for CLIP score 0, 1, 2, 3, and 4 to 5, respectively. Early and late recurrence developed in 109 patients and 16 patients respectively. By the chi-square test, tumor size, microsatellite, venous invasion, tumor type (uninodular, multinodular, massive), tumor extension (【 or = or 】50% of liver parenchyma replaced by tumor), TNM stage, CLIP score, and resection margin were the risk factors for early recurrence, whereas CLIP score and Child-Pugh stage were significant risk factors for late recurrence. In univariate survival analysis, Child-Pugh stages, resection margin, tumor size, microsatellite, venous invasion, tumor type, tumor extension, TNM stages, and CLIP score were associated with prognosis. The multivariate analysis by COX proportional hazards model showed that the independent predictive factors of survival were resection margins and TNM stages. CONCLUSION: CLIP score has displayed a unique superiority in predicting the tumor early and late recurrence and prognosis in the patients with HCC after resection.

Alterations in metastatic properties of hepatocellular carcinoma cell following H-ras oncogene transfection

AIM: To demonstrate the relationship between H-ras oncogene and hepatocellular carcinoma (HCC) metastasis. METHODS: Activated H-ras oncogene was transfected into SMMC 7721, a cell line derived from human HCC, by calcium phosphate transfection method. Some metastasis-related parameters were detected in vitro, including adhesion assay, migration assay, expression of collagenase IV(c IV ase) and epidermal growth factor receptor (EGFR). RESULTS: The abilities of H-ras-transfected cell clones in adhesion to laminin (LN) or fibronectin (FN), migration, c IV ase secretion increased markedly, and the expression of EGFR elevated moderately. More importantly, these alterations were consistent positively with the expression of p21, the protein product of H-ras oncogene. CONCLUSION: H-ras oncogene could induce the metastatic phenotype of HCC cell in vitro to raise its metastatic potential.

Role of oxygen free radicals in patients with acute pancreatitis

AIM:The generation of oxygen free radicals has been implicated in the pathogenesis of experimental pancreatitis. The aim of this study was to determine the role of oxygen free radicals in patients with acute pancreatitis. METHODS:The plasma levels of C-reactive protein(CRP), lipid peroxide(LPO),myeloperoxidase(MPO)and superoxide dismutase(SOD)were measured in 13 patients with acute pancreatitis and 14 healthy volunteers. RESULTS:Among the patients with acute pancreatitis,there were higher plasma levels of LPO and MPO and lower SOD activity in patients with severe pancreatitis than in those with mild pancreatitis.However,there was no significant difference in the serum marker of oxidative stress no matter what the etiology was.The LPO level was especially correlated with the concentration of serum CRP and CT severity index. CONCLUSION:The oxygen free radicals may be closely associated with inflammatory process and the severity of acute pancreatitis.Especially,the concentration of plasma LPO is a meaningful index for determining the severity of the disease.

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones:Results of a retrospective,single center study between 1996-2002

AIM: The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP).METHODS: Patients undergoing preoperative ERCP (≤90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1^st of January 1996 to the 31^st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (≥8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCRRESULTS: Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%,for three 72.5%, for four or more 91.4%.CONCLUSION: Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients).Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g.skill of the endoscopist, other diagnostic tools).

Effect of in vitro interferon-beta administration on hepatitis C virus in peripheral blood mononuclear cells as a predictive marker of clinical response to interferon treatment for chronic hepatitis C

AIM:To test whether in vitro incubation of peripheral blood mononuclear cells (PBMC) with interferon (IFN) could efficiently decrease hepatitis C virus-RNA (HCV-RNA) amount and to analyze whether this effect was associated with clinical response to IFN.METHODS:Twenty-seven patients with histologically proven chronic hepatitis C were given intravenous administration of 6 million units (MU) IFN-β daily for 6 weeks followed by three times weekly for 20 weeks. PBMC collected before IFN therapy were incubated with IFN-β and HCV-RNA in PMBC was semi-quantitatively determined.RESULTS: Twenty-five patients completed IFN therapy.Eight patients (32%) had sustained loss of serum HCV-RNA with normal serum ALT levels after IFN therapy (complete responders).HCV-RNA in PBMC was detected in all patients,whereas it was not detected in PBMC from healthy subjects.In vitro administration of IFN-β decreased the amount of HCV-RNA in PMBC in 18 patients (72%). Eight of these patients obtained complete response. On the other hand,none of the patients whose HCV-RNA in PBMC did not decrease by IFN-β was complete responders. Multiple logistic regression analysis revealed that the decrease of HCV-RNA amount in PBMC by IFN-β was the only independent predictor for complete response (P<0.05).CONCLUSION:The effect of in vitro IFN-β on HCV in PBMC reflects clinical response and would be taken into account as a predictive marker of IFN therapy for chronic hepatitis C.

External validation of the Prostate Cancer Prevention Trial and the European Randomized Study of Screening for Prostate Cancer risk calculators in a Chinese cohort

Several prediction models have been developed to estimate the outcomes of prostate biopsies. Most of these tools were designed for use with Western populations and have not been validated across different ethnic groups. Therefore, we evaluated the predictive value of the Prostate Cancer Prevention Trial （PCPT） and the European Randomized Study of Screening for Prostate Cancer （ERSPC） risk calculators in a Chinese cohort. Clinicopathological information was obtained from 495 Chinese men who had undergone extended prostate biopsies between January 2009 and March 2011. The estimated probabilities of prostate cancer and high-grade disease （Gleason 〉6） were calculated using the PCPT and ERSPC risk calculators. Overall measures, discrimination, calibration and clinical usefulness were assessed for the model evaluation. Of these patients, 28.7% were diagnosed with prostate cancer and 19.4% had high-grade disease. Compared to the PCPT model and the prostate-specific antigen （PSA） threshold of 4 ng m1-1, the ERSPC risk calculator exhibited better discriminative ability for predicting positive biopsies and high-grade disease （the area under the curve was 0.831 and 0.852, respectively, P〈O.01 for both）. Decision curve analysis also suggested the favourable clinical utility of the ERSPC calculator in the validation dataset. Both prediction models demonstrated miscalibration： the risk of prostate cancer and high-grade disease was overestimated by approximately 20% for a wide range of predicted probabilities. In conclusion, the ERSPC risk calculator outperformed both the PCPT model and the PSA threshold of 4 ng ml- z in predicting prostate cancer and high-grade disease in Chinese patients. However, the prediction tools derived from Western men significantly overestimated the probability of prostate cancer and high-grade disease compared to the outcomes of biopsies in a Chinese cohort.

Relationship between serum calcium and CA 19-9 levels in colorectal cancer

AIM:To examine the calcium metabolism of colorectal cancer (CRC)in patients with colorectal cancer and control patients. METHODS:Seventy newly diagnosed CRC patients were included.The healthy control group was age and gender matched(n=32).Particular attention was devoted to the relationship between serum calcium of patients,and levels of AFP,CEA,carbohydrate antigen 19-9(CA 19-9)(that could be considered as prognostic factors).Furthermore,the Ca-sensing receptor(CaSR)gene A986S polymorphism was investigated in these patients,as well as the relationship between different CaSR genotypes and the data stated above. RESULTS:A lower level of ionized calcium(also corrected for albumin)was found in the serum of CRC patients with normal 25(OH)vitamin D levels.The ionized calcium concentration was inversely correlated with the serum level of CA.19-9.There was no difference in the distribution of CaSR genotypes,between CRC patients and general population.The genotypes did not correlate with other data examined. CONCLUSION:Based on these results,lower levels of serum calcium might be a pathogenic and prognostic factor in colorectal cancer.

Biliary carcinoembryonic antigen levels in diagnosis of occult hepatic metastases from colorectal carcinoma

AIM:To prospectively explore the role of carcinoembryonic antigen (CEA) in gallbladder bile in patients with colorectal carcinoma and the morphological and clinical features of neoplasia and the occurrence of hepatic metastases. METHODS:CEA levels in the gallbladder and peripheral blood were studied in 44 patients with colorectal carcinoma and 10 patients with uncomplicated cholelithiasis.CEA samples were collected from the gallbladder bile and peripheral blood during the operation,immediately before extirpating the colorectal neoplasia or cholecystectomy. Values of up to 5 ng/ml were considered normal for bile and serum CEA. RESULTS:In the 44 patients with colorectal carcinoma who underwent operation with curative intent,the average level of serum CEA was 8.5 ng/ml (range:0.1 to 111.0 ng/ ml) and for bile CEA it was 74.5 ng/ml (range:0.2 to 571.0 ng/ml).In the patients with uncomplicated cholelithiasis who underwent cholecystectomy,the average level of serum CEA was 2.9 ng/ml (range:1.0 to 3.5 ng/ml) and for bile CEA it was 1.2 ng/ml (range:0.3 to 2.9 ng/ml). The average duration of follow-up time was 16.5 months (range:6 to 48 months).Four patients who underwent extirpation of the colorectal carcinoma without evidence of hepatic metastasis and with an average bile CEA value of 213.2 ng/ml presented hepatic metastases between three and seventeen months after removal of the primary colorectal neoplasia.Three of them successfully underwent extirpation of the hepatic lesions. CONCLUSION:High CEA levels in gallbladders of patients undergoing curative operation for colorectal carcinoma may indicate the presence of hepatic metastases.Such patients must be followed up with special attention to the diagnosis of such lesions.

A review of phosphorus nutrition in irrigated cotton farming systems of Australia

Australian cotton production predominantly occurs on Vertisols.The average lint yield of cotton grown in Australia is 2260–2700 kg·hm^(−2),which is 2.5 to 3 times the world average.This high productivity per unit of land area requires efficient use of resources such as water and nutrients.However,high yields accelerate the export of nutrients such as phosphorus(P)in seed,depleting the soil reserves of P more than in other countries with lower cotton yields.Recent surveys of cotton industry indicate that P application rates should match seed P export(30~40 kg·hm−2),but historical depletion within subsoil is still evident and is continuing.Depletion of soil P is typically more pronounced in the subsoil than in the topsoil(0~20 cm)where P fertiliser is applied,as cotton roots rely on these layers as important sources of plant available water and available P.This mismatch between zones of P uptake and resupply may increase stratification of available P in the soil profile.Recent studies showed that cotton responded poorly to banded applications of fertiliser P,while dispersal of fertiliser throughout the plant beds was more successful.Researchers have also observed sporadic cotton responses to applied P fertiliser in soils where available P concentrations were well above the previously determined critical concentrations indicative of fertiliser P responses in Australia.To sustain highyielding cotton production in Australia,a greater understanding of cotton root acquisition of applied P,as well as a re-examination of critical soil P concentrations for each production region are required.

Association of CagA and VacA presence with ulcer and non-ulcer dyspepsia in a Turkish population

AIM:The mostly known genotypic virulence features,of H.pylori are cytotoxin associated gene A (cagA) and Vacuolating cytotoxin gene A (VacA).We investigated the association of these major virulence factors with ulcer and non-ulcer dyspepsia in our region. METHODS:One hundred and forty two dyspeptic patients were studied (average age 44.8±15.9 years,range 15-87 years,64 males and 78 females).Antral and corpus biopsies were taken for detecting and genotyping of H.pylori.107 patients who were H.pylori positive by histological assessment were divided into three groups according to endoscopic findings:Duodenal ulcer (DU),gastric ulcer (GU) and non-ulcer dyspepsia (NUD).The polymerase chain reaction (PCR) was used to detect CagA and VacA genes of H.pylori using specific primers. RESULTS:H.pyloriwas isolated from 75.4% (107/142) of the patients.Of the 107 patients,66 (61.7%) were cagA- positive and 82 (76.6%) were VacA-positive.CagA gene was positively associated with DU and GU (P<0.01,P<0.02), but not with NUD (P>0.05).Although VacA positivity in ulcer patients was higher than that in NUD group,the difference was not statistically significant (P>0.05). CONCLUSION:There is a significantly positive association between CagA genes and DU and GU.The presence of VacA is not a predictive marker for DU,GU,and NUD in our patients.

Expressions of ICAM-1 and its mRNA in sera and tissues of patients with hepatocellular carcinoma

INTRODUCTIONThe increased expression of ICAM-1 on a widerange of cells and in the sera of patients withmalignancies, chronic liver diseases andinflammation diseases has been described since thelate 1980s[1-22]. Recently rapid progress in studieson expression of ICAM-1 in patients withhepatocellular carcinoma ( HCC ) have beenachieved, including clinical and experimentalresearches[23-31].

Levels of v5 and v6 CD44 splice variants in serum of patients with colorectal cancer are not correlated with pT stage,histopathological grade of malignancy and clinical features

AIM:This study was designed to compare the levels of v5 and v6 splice variants of CD44 evaluated using EITSA test in the serum of patients with colorectal cancer in different stages of progression of the disease estimated in pT stage according to WHO score,histopathological grade of malignancy and some clinicopathological features. METHODS:The serum obtained from 114 persons with colorectal adenocarcinomas was examined using ELISA method,pT stage and grade of malignancy of the tumour were examined in formalin fixed and paraffin embedded materials obtained during operation. RESULTS:Only the level of CD44 v5 in the serum of patients before operation with G2 pT4 tumour was lower than that in other probes and the difference was statistically significant. We did not find any other correlations between the level of v5 and v6 CD44 variants and other evaluated parameters. CONCLUSION:The level of CD44 v5 and v6 estimated by ELISA test in the serum can not be used as a prognostic factor in colorectal cancer.

Mechanical property of single-bolted composite laminates

In order to investigate the effects of different geometrical parameters and pretightening loads on failure mode and bearing strength,a large number of single-bolted T300/QY8911 composite laminates were tested under static tension load.Box-plot was used to extract the singular testing values of bearing strength and effective statistical values were obtained.T-test method of independent samples was used to study how much pretightening loads influence bearing strength.The results show that the geometrical parameters,such as ratios of width to hole diameter(w/d) and edge distance to hole diameter(e/d),remarkably influence failure mode and bearing strength.Net-section failure will occur when w/d is smaller than 4,and shear-out failure will occur when e/d is smaller than 2.Bearing failure or bearing and shear-out combined failure will occur when w/d is greater than 4 and e/d is greater than 2.There is an optimal combination of geometrical parameters to achieve the highest bearing strength.For most of specimens,pretightening loads do not explicitly influence bearing strength.

Identification of the epitopes on HCV core protein recognized by HLA-A2 restricted cytotoxic T lymphocytes

AIM: To identify hepatitis C virus(HCV) core protein epitopes recognized by HLA-A2 restricted cytotoxic T lymphocyte (CTL). METHODS: Utilizing the method of computer prediction followed by a 4h(51)Cr release assay confirmation. RESULTS: The results showed that peripheral blood mononuclear cells (PBMC) obtained from two HLA-A2 positive donors who were infected with HCV could lyse autologous target cells labeled with peptide &quot;ALAHGVRAL (core 150-158)&quot;. The rates of specific lysis of the cells from the two donors were 37.5% and 15.8%, respectively. Blocking of the CTL response with anti-CD4 mAb caused no significant decrease of the specific lysis. But blocking of CTL response with anti-CD8 mAb could abolish the lysis. CONCLUSION: The peptide (core 150-158) is the candidate epitope recognized by HLAA2 restricted CTL.

Comments on the release Laboratory Manual for the Human Semen of the 5th edition of the WHO Examination and Processing of

The authors of the World Health Organization Semen Analysis Manual are to be congratulated on producing a new edition; it is an essential tool to disseminate good practice in andrology. However, the tests described have poor prognostic power to predict a man＇s fertility and show little about the underlying causes of sub-fertility. This commentary urges a revival of research into the diagnosis of male fertility. It suggests that fertility should be regarded as a continuum and that the artificial binary division between fertile and infertile should be abandoned. Models to predict a sub-fertile couple＇s chance of conception in a year should be developed on the basis of prospective data. These models would allow for sophisticated decision making about management. The future lies in the identification of tests to detect underlying pathologies open to specific treatment. Leads such as oxidative stress, defects in the intracellular regulation and the developing field ofproteomics should be explored.

Severity of gastroesophageal reflux disease influences daytime somnolence: A clinical study of 134 patients underwent upper panendoscopy

AIM: To asses the relationship between severity of gastroesophageal refluxe disease and Epworth sleepiness scale as an indicator of daytime somnolence. METHODS: One hundred and thirty-four patients underwent an upper panendoscopy as indicated by the typical reflux symptoms and were also investigated with regard to somnolence. Sleepiness was evaluated by Epworth Sleepiness Scale, which was compared to the severity of endoscopic findings (Savary-Miller/modified by Siewert). Patients with psychiatric disorders or being on sedato-hypnotics as well as shift workers were excluded from the study. The relationship between the severity of the reflux disease and daytime somnolence was analyzed with the help of multivariate regression analysis. RESULTS: A positive tendency was found between the severity of the reflux disease and the corresponding Epworth Sleepiness Scale. In the case of the more severe type-Savary-Miller Ⅲ- at least a mild hypersomnia was found. For this group daytime somnolence was significantly higher than in the case of the non-erosive type of Gastroesophageal Reflux Disease representing the mildest stage of reflux disease. CONCLUSION: The severity of Gastroesophageal Reflux Disease influences daytime somnolence.

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.

Predictive value of symptoms and demographics in diagnosing malignancy or peptic stricture

AIM:To determine which features of history and demographics predict a diagnosis of malignancy or peptic stricture in patients presenting with dysphagia.METHODS:A prospective case-control study of 2000 consecutive referrals(1031 female,age range:17-103 years) to a rapid access service for dysphagia,based in a teaching hospital within the United Kingdom,over 7 years.The service consists of a nurse-led telephone triage followed by investigation(barium swallow or gastroscopy),if appropriate,within 2 wk.Logistic regression analysis of demographic and clinical variables was performed.This includes age,sex,duration of dysphagia,whether to liquids or solids,and whether there are associated features(reflux,odynophagia,weight loss,regurgitation).We determined odds ratio(OR) for these variables for the diagnoses of malignancy and peptic stricture.We determined the value of the Edinburgh Dysphagia Score(EDS) in predicting cancer in our cohort.Multivariate logistic regression was performed and P < 0.05 considered significant.The local ethics committee confirmed ethics approval was not required(audit).RESULTS:The commonest diagnosis is gastro-esophageal reflux disease(41.3%).Malignancy(11.0%) and peptic stricture(10.0%) were also relatively common.Malignancies were diagnosed by histology(97%) or on radiological criteria,either sequential barium swallows showing progression of disease or unequivocal evidence of malignancy on computed tomography.The majority of malignancies were esophago-gastric in origin but ear,nose and throat tumors,pancreatic cancer and extrinsic compression from lung or mediastinal metastatic cancer were also found.Malignancy was statistically more frequent in older patients(aged >73 years,OR 1.1-3.3,age < 60 years 6.5%,60-73 years 11.2%,> 73 years 11.8%,P < 0.05),males(OR 2.2-4.8,males 14.5%,females 5.6%,P < 0.0005),short duration of dysphagia(≤ 8 wk,OR 4.5-20.7,16.6%,8-26 wk 14.5%,> 26 wk 2.5%,P < 0.0005),progressive symptoms(OR 1.3-2.6:progressive 14.8%,intermittent 9.3%,P < 0.001),with weight loss of ≥ 2 kg(OR 2.5-5.1,weight loss 22.1%,without weight loss 6.4%,P < 0.0005) and without reflux(OR 1.2-2.5,reflux 7.2%,no reflux 15.5%,P < 0.0005).The likelihood of malignancy was greater in those who described true dysphagia(food or drink sticking within 5 s of swallowing than those who did not(15.1%vs 5.2% respectively,P < 0.001).The sensitivity,specificity,positive predictive value and negative predictive value of the EDS were 98.4%,9.3%,11.8% and 98.0% respectively.Three patients with an EDS of 3(high risk EDS ≥ 3.5) had malignancy.Unlike the original validation cohort,there was no difference in likelihood of malignancy based on level of dysphagia(pharyngeal level dysphagia 11.9% vs mid sternal or lower sternal dysphagia 12.4%).Peptic stricture was statistically more frequent in those with longer duration of symptoms(> 6 mo,OR 1.2-2.9,≤ 8 wk 9.8%,8-26 wk 10.6%,> 26 wk 15.7%,P < 0.05) and over 60 s(OR 1.2-3.0,age < 60 years 6.2%,60-73 years 10.2%,> 73 years 10.6%,P < 0.05).CONCLUSION:Malignancy and peptic stricture are frequent findings in those referred with dysphagia.The predictive value for associated features could help determine need for fast track investigation whilst reducing service pressures.