Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.     

Hirschsprung-associated inflammatory bowel disease: A multicenter study from the APSA Hirschsprung disease interest group

Background/PurposeA small number of Hirschsprung disease (HD) patients develop inflammatory bowel disease (IBD)-like symptoms after pullthrough surgery. The etiology and pathophysiology of Hirschsprung-associated IBD (HD-IBD) remains unknown. This study aims to further characterize HD-IBD, to identify potential risk factors and to evaluate response to treatment in a large group of patients.MethodsRetrospective study of patients diagnosed with IBD after pullthrough surgery between 2000 and 2021 at 17 institutions. Data regarding clinical presentation and course of HD and IBD were reviewed. Effectiveness of medical therapy for IBD was recorded using a Likert scale.ResultsThere were 55 patients (78% male). 50% (n = 28) had long segment disease. Hirschsprung-associated enterocolitis (HAEC) was reported in 68% (n = 36). Ten patients (18%) had Trisomy 21. IBD was diagnosed after age 5 in 63% (n = 34). IBD presentation consisted of colonic or small bowel inflammation resembling IBD in 69% (n = 38), unexplained or persistent fistula in 18% (n = 10) and unexplained HAEC >5 years old or unresponsive to standard treatment in 13% (n = 7). Biological agents were the most effective (80%) medications. A third of patients required a surgical procedure for IBD.ConclusionMore than half of the patients were diagnosed with HD-IBD after 5 years old. Long segment disease, HAEC after pull through operation and trisomy 21 may represent risk factors for this condition. Investigation for possible IBD should be considered in children with unexplained fistulae, HAEC beyond the age of 5 or unresponsive to standard therapy, and symptoms suggestive of IBD. Biological agents were the most effective medical treatment.Level of EvidenceLevel 4     

Family Physician Clinical Inertia in Managing Hypoglycemia

AimsClinical inertia behaviour affects family physicians managing chronic disease such as diabetes. Literature addressing clinical inertia in the management of hypoglycemia is scarce. The objectives of this study were to create a measurement for physician clinical inertia in managing hypoglycemia (ClinInert_InHypoDM), and to determine physicians’ characteristics associated with clinical inertia.MethodsThe study was a secondary analysis of data provided by family physicians from the InHypo-DM Study, applying exploratory factor analysis. Principal axis factoring with an Oblimin rotation was employed to detect underlying factors associated with physician behaviors. Multiple linear regression was used to determine association between the ClinInert_InHypoDM scores and physician characteristics.ResultsFactor analysis identified a statistically sound 12-item one-factor scale for clinical inertia behavior. No statistically significant differences in clinical inertia score for the studied independent variables were found.ConclusionsThis study provides a scale for assessing clinical inertia in the management of hypoglycemia. Further testing this scale in other family physician populations will provide deeper understanding about the characteristics and factors that influence clinical inertia. The knowledge derived from better understanding clinical inertia in primary care has potential to improve outcomes for patients with diabetes.     

Les répercussions psychiques du cancer chez l’adolescent et le jeune adulte – AJA – et la famille : revue de la littérature narrative

Adolescent and young adult cancer – AYA – enters a period of life during which a dynamic developmental process takes place, particularly with the existential issues of separation-individualization and empowerment at stake. The experience of cancer is in fact a major ordeal, a major upheaval not only for the young person but also for his entire family. This review of the narrative literature aims to take stock of current knowledge on the psychological repercussions of serious illness on the AYA and his family. After presenting results, we will propose recommendations for the clinic and avenues for future research.     

«¿Para qué auscultarle si le voy a pedir una TAC?» y otras perversiones en la práctica clínica diaria del siglo XXI. Defensa de la historia clínica para aspirar a la excelencia profesional

A presentation is made of 12 cases that have a full and detailed clinical history and physical examination, which are essential for obtaining optimal diagnostic-therapeutic planning for quality care. Furthermoe, education in values focused on the patient is considered as another of the essential objectives to be transmitted in university faculties and hospitals. This article, based on anonymised real cases, aims to provide small brushstrokes in this regard, hoping that they will be useful.     

Family-centered Care for Sick Newborns: A Thumbnail View

Family-centered care (FCC) for sick newborns is emerging as a paradigmatic shift in the practice of facility-based newborn care. It seeks to transforming a provider-centered model into a client-centered one and thus build a new therapeutic alliance. FCC is the cornerstone of continuum of care, imparting caregiving competencies to parents/caregivers both within institutions as well as after the discharge. This has potential gains for the newborn, family members, and facility-level staff. The initial model piloted in tertiary-care settings is now undergoing translation at five sites across the country; the outcomes are keenly awaited.     

中国精神分裂症患者不同家庭干预措施效果比较的meta分析

目的对中国精神分裂症患者采取家庭干预的研究文献进行综合回顾和系统评价, 比较不同条件下家庭干预效果的差异。方法在中国知网、维普、万方、中国生物医学文献数据库四大中文数据库及OVID Medline、Science Direct、Web of Science、EBSCO四大英文数据库中, 检索各数据库建库至2015年1月为止使用社会功能缺陷筛选量表(SDSS)、简明精神病(科)量表(BPRS)、阳性与阴性症状量表(PANSS)研究中国精神分裂症患者家庭干预效果的文献, 以标准化加权均数差( SMD)作为效应量, 采用meta分析比较不同干预时间、不同干预类型、对不同病程和不同严重程度的精神分裂症患者的家庭干预效果差异。 结果共纳入57篇符合标准的文献。SDSS、PANSS分析结果显示:① 干预时间越长干预效果越好( P < 0.0001、 P=0.0025);② 单独家庭干预比多个家庭合并单独家庭干预的效果更明显( P < 0.0001、 P=0.0131);③ 干预对于病情较重患者效果较好( P < 0.0001、 P=0.0280)。SDSS量表还显示家庭干预对于病程短的患者效果更好( P < 0.0001)。 结论家庭干预更适合病程较短的精神分裂症患者, 干预应实施较长时间; 单独家庭干预更有利于患者阴性症状的改善和社会功能的康复, 且对于病情较轻患者的阴性症状改善效果更好。