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Biomedical subjects

C Mel Wilcox

Publications and source records attributed to C Mel Wilcox.

At least 19 recordsLinked to original sources
PubMed2006

Gastrointestinal Considerations in Patients with Cardiovascular Disease Using Nonopioid Analgesics for Mild-to-Moderate Pain or Cardioprotection.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of medications worldwide, available both through prescription and over the counter (OTC). Although these drugs are highly effective for pain, gastrointestinal (GI) complications may occur. Risk factors for GI complications from NSAIDs have been well studied, and the highest risk exists among the elderly and patients with a history of GI bleeding or complications. The increasingly widespread use of aspirin for both primary and secondary cardiovascular prophylaxis has also drawn attention to the potential increase in GI complications. Several strategies may minimize NSAID-mediated GI complications, including the use of drugs that do not injure the gut, such as acetaminophen or a low-dose opiate. The cyclooxygenase-2 (COX-2) inhibitors, which cause approximately 50% fewer GI complications than traditional NSAIDs, may also be used, although their cardiovascular safety has recently come into question. Antacid therapy with proton pump inhibitors (PPIs) may also be used to reduce NSAID-related dyspepsia and upper GI complications. Misoprostol is also effective in preventing NSAID-related complications, but is not as well tolerated. In any patient, the risk-benefit ratio must be assessed to determine the appropriate therapies to minimize GI complications resulting from daily aspirin therapy.

Acetaminophen↗
PubMed2006

Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: wait and see or surgery?

BACKGROUND: Common bile duct stones (CBDS) are especially prevalent in the elderly population. Although the standard of care for stone removal is endoscopic retrograde cholangiography with sphincterotomy (ERC-S), the clinician's decision to refer a patient for cholecystectomy after ERC-S depends on several factors including potential for future biliary symptoms and complications, morbidity and mortality related to cholecystectomy, and costs associated with referral for cholecystectomy versus conservative approach. Using decision analysis, we explored the economic implications of cholecystectomy versus expectant management following ERC-S in elderly patients with CBDS. MATERIALS AND METHOD: A decision tree was constructed with DATA 3.5 (Williamstown, MA) to estimate the costs and outcomes associated with two treatment strategies following ERC-S for CBDS in patients age 60 yr and older: (1) elective cholecystectomy, and (2) expectant management. Probabilities for potential complications and outcomes were derived from the medical literature and cost reflected Medicare reimbursement rates at our institution. The time horizon of the analysis was 2 yr. RESULTS: Elective cholecystectomy was associated with total costs of 5,259 dollars with 94.3% of the cohort alive (1.886 life-years) at 2 yr, whereas expectant management was associated with total costs of 1,173 dollars with 94.7% of the cohort alive (1.894 life-years). The results were sensitive to the probability of recurrent biliary symptoms in patients treated conservatively. Compared to elective cholecystectomy, expectant management became less effective and more expensive at a yearly probability of recurrent symptoms greater than 40% and 90%, respectively. CONCLUSIONS: In patients aged 60 and older, expectant management after ERC-S for CBDS is a reasonable approach, but the economic attractiveness of this strategy is highly dependent on the probability of recurrent symptoms.

Aged↗
PubMed2006

Endoscopic therapy for chronic pancreatitis: an evidence-based review.

In the setting of chronic pancreatitis, pancreatic ductal obstruction, and ductal leak, pseudocyst formation and biliary obstruction present many challenges for endoscopists. Although chronic pancreatitis has a variety of clinical manifestations, most commonly patients present with intermittent or chronic abdominal pain. Recent studies suggest stenting of pancreatic ductal strictures has a significant impact on reducing chronic pain. The removal of ductal calculi, presumably from relieving obstruction, also improves abdominal pain. When the site of leak is bypassed, ductal leaks may be cured by endoscopic stenting. Multiple plastic bile duct stents to treat chronic pancreatitis-associated bile duct stricture can delay the need for surgery. Although these endoscopic techniques have been beneficial for many patients, further study is warranted to better define their role in chronic pancreatitis compared with well-established surgical techniques.

Common Bile Duct Diseases↗
PubMed2006

Prognostic factors for survival in pancreatic cancer: a population-based study.

BACKGROUND: We performed a population-based study of patients from the deep South of the United States (with >25% black residents) to evaluate the survival rate of patients with pancreatic cancer. Our aims were to analyze prognostic factors influencing pancreatic cancer survival using the population-based Alabama Statewide Cancer Registry and to determine whether race/ethnicity is an independent determinant of outcomes in patients with pancreatic cancer. METHODS: Eligible participants included all persons diagnosed with pancreatic cancer from 1996 to 2000 and reported to the Alabama Statewide Cancer Registry. Survival time was calculated from time of diagnosis to death for pancreatic cancer deaths or to date of last contact or death from other causes for censored participants. Risk factors associated with survival were assessed with the Kaplan-Meier survival method and the log-rank test. Demographic, tumor, and treatment variables were assessed using the Cox proportional hazards model. RESULTS: Of 2230 patients, the median age at diagnosis was 71 years and the male to female ratio was approximately 1:1. Seventy-three percent of patients were white, and 27% of patients were black. The distribution by stage was 12.5% localized disease, 29.6% regional, 35.3% distant, and 22.6% unstaged. The median survival time for all patients was .39+/-.01 years. Patients who underwent surgical treatment were less likely to die of pancreatic cancer (hazard ratio, .48; 95% confidence interval, .41-.56). Similarly, patients who underwent either chemotherapy or radiation therapy had improved survival rates (hazard ratio, .62; 95% confidence interval, .53-.73). Across all stages, black patients were significantly less likely to receive chemotherapy compared with white patients (26.7% vs 32.3%, P=.02), and were less likely to receive surgical intervention (14.02% vs 17.0%, P=.09). When examining patients who were offered their therapy of choice but refused, we found across all stages that a greater proportion of black patients refused therapies versus whites: 5.6% versus 2.9% (P=.02) for chemotherapy, 3.8% versus 1.6% (P=.04) for radiation, and 9.0% versus 3.3% (P=.001 for surgery). The Cox proportional hazard model showed no effect of race on overall survival time while controlling for stage at presentation, type of therapy received, age at diagnosis, and site of primary tumor. CONCLUSIONS: Survival in patients with pancreatic cancer remains dismal. Tumor characteristics and treatment factors are related directly to survival time in patients with pancreatic cancer. Black patients were less likely to receive therapy but also were more likely to refuse the indicated therapy. Factors leading to racial disparity in the treatment of pancreatic cancer warrant further investigation.

Adult↗
PubMed2006

Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis.

Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84-22.5) and conversion rate (OR = 3.45; 95% CI, 1.56-7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.

Alkaline Phosphatase↗
PubMed2006

Frequency of major complications after EUS-guided FNA of solid pancreatic masses: a prospective evaluation.

BACKGROUND: EUS-guided FNA is effective for establishing tissue diagnosis in suspected pancreatic cancer. However, data on the frequency of major complications following EUS-FNA are limited. OBJECTIVE: To evaluate the frequency of major complications after EUS-FNA of solid pancreatic masses. DESIGN: Prospective cohort study. SETTING: Tertiary University based referral center for pancreatico-biliary disorder. PATIENTS: Consecutive patients who underwent EUS-FNA of a solid pancreatic over a 42-month period. All immediate complications were recorded by the endosonographer. Late complications were assessed at 72 hours and at 30-days after the procedure. MAIN OUTCOMES MEASUREMENTS: Major complications were defined as acute pancreatitis, bleeding, infection, perforation, use of reversal medication, hospitalization or death. RESULTS: A total of 355 consecutive patients with a solid pancreatic mass underwent EUS FNA. Major complications were encountered in 9 patients (2.54%, 95% CI 1.17-4.76). Acute pancreatitis occurred in 3 of 355 (0.85 %, 95% CI 0.17-2.45); 2 patients were hospitalized, and 1 patient recovered with outpatient analgesics. Three patients were admitted for severe pain after the procedure; all were treated with analgesics and subsequently discharged with no sequela. Two patients (0.56%, 95% CI 0.07-2.02) developed fever and were admitted for intravenous antibiotics; 1 patient recovered with intravenous antibiotics and the other required surgical debridement for necrosis. One patient required the use of reversal medication. Overall, 1.97% (95% CI 0.80-4.02) of the patients were hospitalized for complications (range 1-16 days). None of the patients experienced clinically significant hemorrhage, perforation, or death. No clear predisposing risk factors were identified. LIMITATIONS: Lack of surgical gold standard and referral to a tertiary center. CONCLUSIONS: EUS-FNA of solid pancreatic masses infrequently leads to major complications. Our results can be used by endosonographers to counsel patients before EUS-FNA of solid pancreatic masses.

Adult↗
PubMed2006

Role of endoscopic evaluation in idiopathic pancreatitis: a systematic review.

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing, and abdominal imaging. For those with a single unexplained attack, the role of invasive evaluation with endoscopic retrograde cholangiopancreatography is unsettled but has been generally limited to those patients with suspected bile duct stones or malignancy. Recent studies suggest that microlithiasis is causative in up to 75% of patients with an unexplained attack and gallbladder in situ, whereas sphincter of Oddi dysfunction is most prevalent in those with recurrent attacks who have previously undergone cholecystectomy. EUS has been shown to be highly accurate for the identification of gallbladder sludge, common bile duct stones, and pancreatic diseases. Given this apparent diagnostic utility, an EUS-based strategy may be a reasonable approach to evaluate patients with a single idiopathic attack. ERCP and sphincter of Oddi manometry should generally be reserved for patients with multiple unexplained attacks and negative EUS results, especially for those patients who have previously undergone cholecystectomy.

Bile↗
PubMed2006

Randomized trial comparing needle-knife and pull-sphincterotome techniques for pancreatic sphincterotomy in high-risk patients.

BACKGROUND: Accepted techniques for pancreatic sphincterotomy include use of a needle knife or a pull sphincterotome to ablate the sphincter. There are no prospective studies comparing outcomes between both techniques. AIM: Compare post-ERCP pancreatitis rates among high-risk patients undergoing pancreatic sphincterotomy with the pull-sphincterotome versus needle-knife technique. STUDY DESIGN: Prospective, randomized trial. METHODS: Patients diagnosed with pancreatic sphincter hypertension at sphincter of Oddi manometry were randomized to undergo pancreatic sphincterotomy with a pull sphincterotome (followed by pancreatic stenting) or a needle knife over a pancreatic stent. MAIN OUTCOME MEASUREMENTS: To compare post-ERCP pancreatitis rates between the pull-sphincterotome and needle-knife groups. RESULTS: Forty-eight patients were randomized. Patient demographics and the incidence of patient and procedure risk factors for pancreatitis were similar in both treatment groups. The trial was stopped early after an interim analysis showed that post-ERCP pancreatitis was significantly higher among patients undergoing sphincterotomy with a pull sphincterotome than a needle knife (7/24 = 29% [95% CI 13-51] vs 0/24 = 0% [95% CI 0-12]; P = .01). No other complications were encountered. At a mean follow-up of 12 months (range 6-18 months), 60% of patients had complete symptom relief, 15% partial symptom relief, and 25% recurrent symptoms. Reintervention rates and clinical outcomes were not significantly different between the 2 groups. LIMITATIONS: Short duration of follow-up. CONCLUSIONS: Pancreatic sphincterotomy is safer in high-risk patients when performed with a needle knife over a pancreatic stent.

Adolescent↗
PubMed2006

Endoscopic management of sphincter of Oddi dysfunction in children.

BACKGROUND: Data on sphincter of Oddi dysfunction (SOD) in children are scant. Most children diagnosed with SOD are treated by biliary sphincterotomy with suboptimal results. The efficacy and safety of pancreatic and dual sphincterotomy in children with SOD has not been previously reported. OBJECTIVE: To evaluate the efficacy and safety of pancreatic and dual sphincterotomy in children with SOD. MATERIALS AND METHODS: Prospective evaluation of all children who underwent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincter of Oddi manometry for evaluation of suspected SOD over a 3-year period. Children diagnosed with SOD underwent pancreatic or dual sphincterotomy with prophylactic pancreatic stenting. RESULTS: SOD was diagnosed by sphincter of Oddi manometry in 6 of 11 children who underwent ERCP for suspected SOD. Of the 6 children (mean age, 11 years; range, 5-16; 4 girls) with SOD, 3 presented with recurrent pancreatitis and 3 with postcholecystectomy pain. Pancreatic sphincter hypertension was noted in all 6 patients; concomitant biliary sphincter hypertension was noted in 3 patients with postcholecystectomy pain. Patients with recurrent pancreatitis underwent pancreatic sphincterotomy and those with postcholecystectomy pain underwent dual sphincterotomy. Prophylactic pancreatic stents were placed in all patients. One girl experienced mild post-ERCP pancreatitis. At a mean follow-up of 583 days (range, 325-1445), 4 patients were asymptomatic, 1 experienced partial symptom relief and 1 had recurrent symptoms. CONCLUSIONS: As in adults, pancreatic and dual sphincterotomy, in expert hands, is effective and safe in a subgroup of children with SOD. Prospective, randomized trials with larger number of patients are required to validate the efficacy of endotherapy in children with SOD.

Adolescent↗
PubMed2005

Occurrence of gastrointestinal opportunistic disorders in AIDS despite the use of highly active antiretroviral therapy.

Since the introduction of highly active antiretroviral therapy (HAART), the frequency of opportunistic disorders (ODs) of the gastrointestinal (GI) tract in human immunodeficiency virus (HIV)-infected patients has fallen dramatically. We have found, however, that despite the use of HAART, HIV-infected patients can still present with GI ODs. To evaluate the prevalence of GI ODs in HIV-infected patients on HAART who were undergoing endoscopic evaluation for GI-related symptoms. From January 1996 through February 2002, all HIV-infected patients undergoing GI endoscopy were prospectively identified; mucosal biopsies were obtained in a standardized fashion and histologic specimens were examined by a single GI pathologist. All the patients on HAART presenting with a GI OD are described. Results showed that 294 patients (88% men; mean age, 36.5 +/- 10 years; median CD4 lymphocyte count, 64 cells/microl; range, 1-884; median viral RNA level, 40,357 copies/ml; range, 0-7,721,715) underwent 401 upper and/or lower endoscopies during the study period. The use of HAART increased from 10% in early 1996 to 85% in 2002. Nevertheless we found that 27 patients (9%) presented with a GI OD despite HAART. Forty percent of the patients with a GI OD were noncompliant with HAART. We conclude that GI ODs can occur despite HAART and normal CD4 counts. The prevalence of GI ODs in HIV-infected patients taking HAART is 9%. The reasons for this are multifactorial and likely include noncompliance with medications, viral resistance to the drugs, and decreased drug bioavailability. Although the use of HAART has led to a decreased incidence of GI ODs in AIDS, the gastroenterologist evaluating these patients should not discard the possibility that the GI symptoms in HIV-infected patients taking HAART may be secondary to an OD, even when the CD4 count is normal and the viral load is low.

AIDS-Related Opportunistic Infections↗
PubMed2005

Impact of EUS in the evaluation of pancreaticobiliary disorders in children.

BACKGROUND: While the role of EUS in the evaluation of pancreaticobiliary (PB) disorders in adults is well established, its utility in children remains unproven. This prospective study evaluates the feasibility, the safety, and the impact of EUS in the evaluation of PB disorders in children. METHODS: All children (<18 years) referred for ERCP for evaluation of suspected PB disorders who underwent EUS before scheduled ERCP. The main outcome measure was to evaluate the impact of EUS in the evaluation of PB disorders in children. EUS was considered to have a significant impact if a new diagnosis was established or if the findings altered subsequent management. RESULTS: Fourteen patients (mean age 13 years; range 5-17 years) underwent 15 EUS procedures over a 3-year period. Main indications were the following: acute or recurrent pancreatitis (6 patients), suspected biliary obstruction (5), and abdominal pain suggestive of PB origin (3). EUS diagnosed chronic pancreatitis (3 patients), idiopathic fibrosing pancreatitis (2), carcinoid tumor (1), pancreatic pseudocyst (1), pancreas divisum (1), choledocholithiasis (1), duodenal duplication cyst (1), and normal (4). Diagnosis of idiopathic fibrosing pancreatitis and carcinoid tumor was established by EUS-guided FNA. The procedure was successful in all patients, and no complications were encountered. EUS had an impact on patient management in 93% of cases: established new diagnosis (10), precluded need for ERCP (9), and provided additional information that facilitated focused endotherapy (4). A limitation was the small number of enrolled patients and absence of long-term clinical follow-up. CONCLUSIONS: EUS and EUS-guided FNA are feasible, safe, and have significant impact that alters subsequent management in the majority of children with PB disorders. Further studies and dissemination of information is required to facilitate its increased application in children.

Abdominal Pain↗
PubMed2005

Biochemical analysis of pancreatic fluid collections predicts bacterial infection.

BACKGROUND AND AIMS: Despite our understanding of the pathophysiology of different types of pancreatic fluid collections (PFC), few studies have attempted to correlate the biochemical analysis of PFC contents with clinical and radiological characteristics. The aim of this study was to assess the predictive value of fluid analysis for discerning collection type (pseudocyst vs acute fluid collection with necrosis), presence of infection or communication with the pancreatic duct in the setting of acute and chronic pancreatitis. METHODS: Pancreatic fluid from 34 consecutive patients undergoing endotherapy of PFC was prospectively analyzed for seven variables: lactate dehydrogenase (LDH), total protein, albumin, glucose, amylase, lipase and specific gravity. RESULTS: In multivariate analysis, adjusting for age and gender, high intracystic levels of protein (OR 6.2; 95% CI 1.3-37.0), LDH (OR 6.8 [2.3-38.3]), and albumin (OR 7.8 [1.3-67.4]), and low levels of glucose (OR 0.2 [0.03-0.9]) predicted the presence of PFC infection. The optimal threshold value for protein was 1000 g/dL, which achieved a sensitivity of 73% and specificity of 75% for detecting infection; the optimal cut-off for LDH was 1000 U/L (sensitivity 64%, specificity 85%), and the cut-off for albumin was 500 g/dL (sensitivity 75%, specificity 85%). There were no statistically significant differences in biochemical fluid analysis with respect to fluid collection type (pseudocysts vs acute fluid collection with necrosis) and the presence of pancreatic duct communication. CONCLUSIONS: Biochemical analysis of PFC fluid is clinically helpful in detecting fluid infection in patients with bacteria on Gram stain or positive fluid cultures. Our findings fail to support the utility of fluid analysis in characterizing cyst type, and we caution against its use in distinguishing pseudocysts from acute fluid collection with necrosis.

Acute Disease↗
PubMed2005

Cytologic grade independently predicts survival of patients with pancreatic adenocarcinoma.

Our objectives were to devise a cytologic grading system and determine whether it would predict survival of patients with solid-type pancreatic adenocarcinoma. We evaluated 116 consecutive patients from July 2000 to November 2002; they were followed up until September 2003. We scored the following features on rapid Romanowsky-stained endoscopic ultrasound-guided fine-needle aspiration smears: cell group architecture, single cells, nuclear grade, mucus, bizarre cells, and necrosis. A cytologic grade (low vs high) was assigned. The Kaplan-Meier estimate of 6-month survival was 76% (SE, 7%) for patients with low-grade tumors vs 50% (SE, 6%) for patients with high-grade carcinoma. The median survival for patients with low-grade vs high-grade tumors was 1 year vs 6 months, respectively (chi2 = 4.45; P = .035). Cox proportional hazards regression showed tumor stage, cancer-specific treatment, and cytologic grade to be independent predictors of survival (P = .001). No other factors (age, mass location, placement of stent, presence of concomitant chronic pancreatitis, race, sex) predicted survival. We devised a grading system that independently predicted survival in patients with pancreatic adenocarcinoma.

Adenocarcinoma↗