Publications

BACKGROUND

Bleeding after pancreaticoduodenectomy most often occurs from the gastro- or duodeno-jejunal anastomosis. Bleeding at the pancreatic surface would be the most difficult to treat because it typically requires surgical resection of the pancreatic remnant-a surgery that has significant morbidity and mortality. Data that describe the role of endoscopy in the management of pancreaticojejunostomy bleeding are limited.

CASE

We present the case of a 69-year-old man who had massive upper gastrointestinal bleeding on postoperative day 2 after a pyloric sparing Whipple procedure for cholangiocarcinoma. We endoscopically approached this massive upper gastrointestinal bleed by understanding the postsurgical anatomy to consider all of the potential bleeding sources: duodenojejunostomy, hepaticojejunstomy, and the pancreaticojejunostomy. Using a pediatric colonoscope with water jet capabilities, active bleeding could be seen originating from the cut pancreatic surface. Complete hemostasis was achieved after placement of two clips. We clipped again two clays later due to a minor rebleeding episode. We repeated endoscopy on postoperative day 6 for surveillance of the site. All clips were in place and there was no evidence of bleeding. The patient did well without recurrent bleeding and was discharged home on postoperative day 7. Six-month follow-up showed no recurrent bleeding episodes or development of fistulas.

CONCLUSION

Endoscopic treatment of a bleeding site on the pancreatic surface of a pancreaticojejunostomy can be successful during the immediate postoperative period. Such an attempt at endoscopic hemostasis may prevent the need for completion pancreatectomy.

BACKGROUND

It is uncertain whether evidence supports routinely estimating a postmenopausal woman's risk of breast cancer and intervening to reduce risk.

METHODS

We systematically reviewed prospective studies about models and sex hormone levels to assess breast cancer risk and used meta-analysis with random effects models to summarize the predictive accuracy of breast density. We also reviewed prospective studies of the effects of exercise, weight management, healthy diet, moderate alcohol consumption, and fruit and vegetable intake on breast cancer risk, and used random effects models for a meta-analyses of tamoxifen and raloxifene for primary prevention of breast cancer. All studies reviewed were published before June 2008, and all statistical tests were two-sided.

RESULTS

Risk models that are based on demographic characteristics and medical history had modest discriminatory accuracy for estimating breast cancer risk (c-statistics range = 0.58-0.63). Breast density was strongly associated with breast cancer (relative risk [RR] = 4.03, 95% confidence interval [CI] = 3.10 to 5.26, for Breast Imaging Reporting and Data System category IV vs category I; RR = 4.20, 95% CI = 3.61 to 4.89, for >75% vs <5% of dense area), and adding breast density to models improved discriminatory accuracy (c-statistics range = 0.63-0.66). Estradiol was also associated with breast cancer (RR range = 2.0-2.9, comparing the highest vs lowest quintile of estradiol, P < .01). Most studies found that exercise, weight reduction, low-fat diet, and reduced alcohol intake were associated with a decreased risk of breast cancer. Tamoxifen and raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer and invasive breast cancer overall.

CONCLUSIONS

Evidence from this study supports screening for breast cancer risk in all postmenopausal women by use of risk factors and breast density and considering chemoprevention for those found to be at high risk. Several lifestyle changes with the potential to prevent breast cancer should be recommended regardless of risk.

BACKGROUND & AIMS

Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost utility of ablation with that of endoscopic surveillance strategies.

METHODS

A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted; and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation, and photodynamic therapy.

RESULTS

Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of <$6,000 compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates >or=28% of LGD or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance.

CONCLUSIONS

Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued after successful ablation. As further postablation data become available, the optimal management strategy will be clarified.

BACKGROUND

Young adults have the highest smoking rate of any age group in the U.S., and new strategies to decrease young adult smoking are needed. The objective of the current study was to identify psychographic and demographic factors associated with current smoking and quitting behaviors among young adults.

METHODS

Attitudes, social groups, and self-descriptors, including supporting action against the tobacco industry, advertising receptivity, depression, alcohol use, and other factors associated with smoking were tested for associations with smoking behaviors in a 2005 cross-sectional survey of 1528 young adults (aged 18-25 years) from a web-enabled panel. Analyses were conducted in 2007.

RESULTS

Being older was associated with current smoking, whereas having some higher education and being African American or Hispanic were negatively associated with smoking. Supporting action against the tobacco industry was negatively associated with smoking (AOR=0.34 [95% CI=0.22, 0.52]). Perceived usefulness of smoking, exposure to smokers, increased perceived smoking prevalence, receptivity to tobacco advertising, binge drinking, and exposure to tobacco advertising in bars and clubs were associated with smoking. Supporting action against the tobacco industry was associated with intentions to quit smoking (AOR=4.43 [95% CI=2.18, 8.60]).

CONCLUSIONS

Young adults are vulnerable to tobacco-industry advertising. Media campaigns that denormalize the tobacco industry and appeal to young adults appear to be a powerful intervention to decrease young adult smoking.

Although combination therapy for HIV infection represents a triumph for modern medicine, chronic suppressive therapy is required to contain persistent infection in reservoirs such as latently infected CD4+ lymphocytes and cells of the macrophage-monocyte lineage. Despite its success, chronic suppressive therapy is limited by its cost, the requirement of lifelong adherence, and the unknown effects of long-term treatment. This review discusses our current understanding of suppressive antiretroviral therapy, the latent viral reservoir, and the needs for and challenges of attacking this reservoir to achieve a cure.

The ability of HIV to establish latent infection in CD4+ lymphocytes represents a major barrier to the eradication of HIV. It is not clear what mechanisms favor latent over productive infection, but prior studies have suggested a role for the viral transcription factor Tat or its RNA target, TAR. Using samples from five individuals who were started on ART within 6 months of infection and achieved a viral load <50 (suppressed), we isolated one- and two-exon tat RNA from HIV propagated ex vivo from baseline plasma and from co-cultures of CD4+ T cells obtained at baseline and suppressed time points. Compared to virus from the baseline plasma (mostly from productively-infected CD4+ T cells), virus from the baseline and suppressed co-cultures (mostly from latently-infected cells) had more Tat variants with impaired transactivation activity. These findings suggest that impaired activity in the Tat-TAR axis may contribute to the establishment of latent infection in CD4+ T cells.