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Biomedical subjects

T W Rice

Publications and source records attributed to T W Rice.

At least 55 records · Page 3Linked to original sources
PubMed1999

Midthoracic esophageal diverticula.

Periesophageal inflammation, most commonly secondary to tuberculosis, was a frequent cause of midthoracic diverticula. Today, the majority of these diverticula are the result of esophageal motility disorders. Although many patients are asymptomatic, it is the underlying motility disturbances that produce most symptoms. A barium esophagogram is the best study to show midthoracic diverticula. Esophageal manometry may be difficult to perform because of the obstruction of passage of the motility catheter by the diverticulum, but it is useful in defining the cause of the diverticulum and directing therapy. Esophagoscopy is helpful in the assessment of complications or associated esophageal abnormalities. It adds little to the evaluation of the diverticulum. In patients requiring surgery, a diverticulectomy with a myotomy performed on the esophageal wall opposite the diverticulum is the preferred treatment. Lesser procedures have been reported to be successful in select patients.

Barium Sulfate↗
PubMed1999

Mature results from a phase II trial of accelerated induction chemoradiotherapy and surgery for poor prognosis stage III non-small-cell lung cancer.

Mature results are reported from a phase II trial of accelerated induction chemoradiotherapy and surgical resection for stage III non-small-cell lung cancer whose prognosis is poor. Surgically staged patients with poor prognosis stage III non-small-cell lung cancer were eligible for this study. Four-day continuous intravenous infusions of cisplatin 20 mg/m2/day, 5-fluorouracil 1,000 mg/m2/day, and etoposide 75 mg/m2/day were given concurrently with accelerated fractionation radiation therapy, 1.5 Gy twice a day, to a total dose of 27 Gy. Surgical resection followed in 4 weeks. Identical postoperative chemotherapy and concurrent radiation to a total dose of 40 to 63 Gy was subsequently given. Between February 1991 and June 1994, 42 eligible and evaluable patients, 23 with stage IIIA disease and 19 with stage IIIB disease, were entered in this trial. Treatment was well tolerated. The pathologic response rate was 40%. This response was complete in 5%. With a median follow-up of 54 months, the Kaplan-Meier 4-year survival estimate is 19%: 26% for stage IIIA and 11% for stage IIIB patients. Patients with a pathologic response, resectable disease, or pathologic downstaging to stage 0, I, or II had a better survival. The 4-year estimates of locoregional and distant disease control are 70% and 19%, respectively. It is concluded that although the ultimate role of concurrent chemoradiotherapy and surgery in stage III non-small-cell lung cancer must await the results of phase III clinical trials, survival and locoregional control in this study appear improved in comparison with historical experience. There is a subset of patients, able to undergo resection with pathologic downstaging, who have a projected survival equivalent to that of patients with more limited disease. Clinical or pathologic tools to identify these patients before treatment would be highly useful.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1999

Cisplatin ototoxicity: the importance of baseline audiometry.

The role and optimal use of audiometry in monitoring for cisplatin ototoxicity are incompletely defined. Audiograms were obtained from 217 patients before treatment with cisplatin-based chemotherapy for cancers of the esophagus, lung, or head and neck. Posttreatment audiometry then was conducted in 53 of these patients. Chemotherapy consisted of two (87%) or three (13%) courses of cisplatin at a dose of 20 mg/m2/day given as a continuous intravenous infusion over 4 days. Simultaneous 5-fluorouracil or paclitaxel also was given, and 38% received concurrent radiation therapy to the head and neck. Air-conduction thresholds for each ear were obtained at 250, 500, 1000, 2000, 4000, 6000, and 8000 Hz. Three three-frequency pure-tone averages (PTA) also were calculated. Framingham gender-specific, age-adjusted norms were used, beginning at age 60 to correct for presbycusis, and the upper limit of normal was calculated as the greater of the Framingham mean plus twice the standard error, or 25 dB. Hearing abnormality was defined as a threshold >10 dB above the norm for any PTA, or >20 dB above the norm for any individual frequency. Hearing loss was defined as an elevation over baseline threshold of >10 dB for any PTA or >20 dB for any individual frequency. Of the 217 patients who underwent baseline testing, 57 (26%) were found to have hearing abnormality in excess of the expected presbycusis. Post-cisplatin audiograms demonstrated hearing loss in 19 of the 53 retested patients (36%) when compared with their own baseline. As determined by tympanometry, none of these subjects had a conductive component to their hearing loss. These observations were independent of the duration of follow-up after treatment and of the total dose of cisplatin administered. The authors conclude that significant preexisting hearing abnormality is common in this patient population and that, even after low-dose cisplatin administration, additional hearing loss occurs frequently. Baseline testing is mandatory if follow-up studies are to be adequately interpreted.

Adult↗
PubMed1999

Long-term outcome of achalasia treatment: the need for closer follow-up.

Treatment of achalasia includes pneumatic dilation (PD) and surgical myotomy (SM). Success rates range from 32% to 98% and are mostly based on symptomatic response. Our aims were to determine the long-term outcome of patients treated for achalasia and the adequacy of long-term follow-up. Patients treated with PD or SM between 1986 and 1990 were contacted by telephone after a minimum of 4 years after treatment, and asked about symptoms and need for retreatment since their discharge from our institution. Symptomatic response was classified as excellent/good or fair/poor using the Vantrappen score. Treatment was deemed a failure if patients were symptomatic on callback, needed retreatment, technical problems occurred during PD, or perforation occurred. Forty-seven PD patients and 15 SM patients were studied. There were no significant differences in clinical parameters between groups. Median time to callback was 82 and 73 months, respectively. Failure rates were high, respectively 74% and 67%. Importantly, 38% of PD and 33% of SM patients failed to seek help despite symptom recurrence. Achalasia treatment failures are higher than anticipated. This may be because of the lack of routine follow-up as well as patients' failure to seek help when symptoms recur. Achalasia patients need closer follow-up and may benefit from early intervention based on objective tests rather than symptoms alone.

Adult↗
PubMed1999

Endoscopic ultrasound cannot determine suitability for esophagectomy after aggressive chemoradiotherapy for esophageal cancer.

OBJECTIVE: Endoscopic ultrasound (EUS) provides important information in the initial staging of patients with esophageal cancer. With recent modifications in chemoradiotherapy protocols, a significant number of patients have no residual tumor at esophagectomy. The high surgical morbidity and mortality might be avoided if complete response to chemoradiotherapy could be predicted. Previously published clinical trials, with relatively small patient numbers, have suggested that EUS may accurately stage esophageal cancer after chemoradiotherapy. The aim of this study was to verify the accuracy of EUS in staging esophageal cancer after effective chemoradiotherapy. METHODS: EUS staging was performed before and after concurrent cisplatin, 5-fluorouracil, and hyperfractionated radiotherapy in 59 patients with newly diagnosed esophageal cancer. All patients underwent subsequent esophagectomy and pathological staging. The accuracy of preoperative, postchemoradiotherapy EUS was evaluated in a retrospective fashion by comparison to pathological staging. RESULTS: After chemoradiotherapy, 18 patients (31%) had no residual disease at pathological staging (T0N0). However, EUS correctly predicted complete response to chemoradiotherapy (T0N0) in only three patients (17%). The accuracy of postchemoradiotherapy EUS for pathological T stage was only 37%, and its sensitivity for N1 disease was only 38%. EUS was unable to distinguish postradiation fibrosis and inflammation from residual tumor. CONCLUSION: When aggressive preoperative chemoradiotherapy is provided to patients with esophageal cancer, the predictive value of postchemoradiotherapy EUS is inadequate for use in clinical decision making.

Adenocarcinoma↗
PubMed1999

Resectable esophageal carcinoma: local control with neoadjuvant chemotherapy and radiation therapy.

PURPOSE: To evaluate the usefulness of neoadjuvant chemotherapy and radiation therapy before esophagectomy for invasive cancer of the esophagus or gastroesophageal junction (GEJ). MATERIALS AND METHODS: The authors conducted a retrospective analysis of 154 patients who underwent esophagectomy for invasive cancer between September 1, 1991, and December 31, 1995. The end points evaluated were overall, disease-free, local-regional relapse-free, and systemic relapse-free survival. RESULTS: Seventy of the 154 patients received neoadjuvant combined-modality therapy (CMT) consisting of concurrent cisplatin and fluorouracil administration and accelerated, hyperfractionated radiation therapy. The remaining 84 patients underwent immediate esophagectomy. With a median follow-up of 34.7 months, the 3-year overall, disease-free, and distant metastatic relapse-free survival rates were 38.0%, 41.9%, and 56.0%, respectively. Although neoadjuvant therapy did not appear to prevent distant metastases, there was a dramatic effect on local control. After CMT, the 5-year local control rate was 90% compared to 64% after surgery (P < .001). Tumors in the GEJ recurred more frequently (P = .01); however, multivariate analysis showed CMT was the only independent predictor of local control. Postoperative mortality was 15.7% after CMT versus 5.9% without CMT (P = .05). CONCLUSION: Local control of esophageal cancer is excellent following neoadjuvant chemotherapy and radiation therapy. However, the effects of CMT on overall and disease-free survival are less clear due to significant differences between the treatment groups.

Adenocarcinoma↗
PubMed1999

TNM staging of lung cancer: a quick reference chart.

Lung cancer is the leading cause of cancer mortalities. TNM Staging, which has recently been revised, remains an important guide to treatment and prognosis of lung cancer. In this article, we propose a simple chart that can be used as a quick reference consolidating all the information necessary to obtain an accurate staging.

Humans↗
PubMed1999

Overexpression of p53 protein associates decreased response to chemoradiotherapy in patients with esophageal carcinoma.

Induction chemoradiotherapy before esophagectomy for esophageal carcinoma seems to improve patient survival. Given the toxicity of this regimen, it would be useful to predict those patients likely to benefit. p53 is known to mediate apoptosis in response to DNA damage, but there are few data evaluating the relationship between p53 expression and chemoradiosensitivity in human tissues. We immunohistochemically evaluated p53 protein expression in 95 biopsy specimens from patients with esophageal carcinoma before chemoradiotherapy. p53 expression was correlated to the pathologic response identified in subsequent esophagectomy specimens. p53 immunoreactivity was recorded semiquantitatively using the following scale: neg, < 5%; 1+, 5-25%; 2+, 26-50%; 3+, 51-75%; 4+, > or = 76%. Pathologic response in esophagectomy specimens was categorized as overt residual tumor (ORT), minimal residual tumor, and no residual tumor. Of the 95 patients, 64 had adenocarcinoma, and 31 had squamous cell carcinoma. Of those with adenocarcinoma, 46 (72%) of 64 were positive for p53. Thirty-seven (80%) of 46 p53+ patients had ORT, compared with 4 (22%) of 18 p53- patients (P < .001). There was no correlation between the degree of p53 staining and pathologic response. Of those with squamous cell carcinoma, 13 (42%) of 18 were positive for p53. Three (23%) of 13 p53+ patients had ORT, compared with 4 (22%) of 18 p53- patients (P = .96). Our data indicate that overexpression of p53 protein is associated with decreased responsiveness to induction chemoradiotherapy in patients with esophageal adenocarcinoma but that no such association exists in patients with esophageal squamous cell carcinoma.

Adenocarcinoma↗
PubMed1999

Techniques of pneumonectomy. Standard pneumonectomy.

An understanding of the anatomical, three-dimensional organization of the pulmonary hilum is the foundation necessary for pneumonectomy. The incision type and sequence of control of hilar structure are determined by anatomic position, extent of tumor, and patient safety factors.

Humans↗
PubMed1998

Chest computed tomography and mediastinoscopy in the diagnosis of sarcoidosis-associated uveitis.

PURPOSE: To report the usefulness of chest computed tomography and mediastinoscopy in diagnosing sarcoidosis in elderly patients with uveitis. METHODS: Case reports. Two Caucasian women, aged 73 and 70 years, underwent evaluations for uveitis, which included chest computed tomography and mediastinoscopy. RESULTS: A chest computed tomographic scan of each woman disclosed mediastinal lymphadenopathy and warranted mediastinal lymph node biopsy by mediastinoscopy. In both patients, histopathologic and microbiologic studies demonstrated sterile noncaseating granulomas consistent with the diagnosis of sarcoidosis. CONCLUSIONS: The diagnosis of sarcoid-associated uveitis in the elderly may be facilitated by chest computed tomography, which may be more sensitive than conventional chest roentgenography. Laboratory studies of biopsied mediastinal nodes obtained by mediastinoscopy can confirm the diagnosis.

Aged↗
PubMed1998

Esophageal carcinoma: depth of tumor invasion is predictive of regional lymph node status.

BACKGROUND: The depth of tumor invasion (T) and regional lymph node status (N) are two factors that define the stage of an esophageal carcinoma. However, the arrangement of staging groups assumes that these factors are independent variables. A retrospective review of 359 consecutive patients undergoing esophageal resection was conducted to define the relationship between T and N and to determine whether T is a significant predictor of regional lymph node metastasis (N1). METHODS: Primary treatment was operation without preoperative therapy. There were 295 (82%) adenocarcinomas, 55 (15%) squamous cell carcinomas, and 9 (3%) adenosquamous carcinomas. T status was Tis in 29 (8%) patients, T1 in 65 (18%), T2 in 37 (10%), T3 in 219 (61%), and T4 in 9 (3%). N status was N0 in 161 (45%) patients and N1 in 198 (55%). M status was M0 in 327 (91%) patients and M1 in 32 (9%). Stage was 0 in 29 (8%) patients, I in 58 (16%), IIA in 70 (20%), IIB in 22 (6%), III in 148 (41%), and IV in 32 (9%). RESULTS: The likelihood of N1 disease occurring with increasing T was tested using the trend test. The percentage of patients with N1 disease is 0% for Tis, 11% for T1, 43% for T2, 77% for T3, and 67% for T4 (p < 0.001). This relationship existed for both adenocarcinoma and squamous cell carcinoma. Multivariable analysis identified increasing T, adenocarcinoma, and lack of well-differentiated histologic features as significant predictors of N1 disease. Compared with a T1 patient, a T2 patient is 6 times more likely to have N1 disease, a T3 patient 23 times, and a T4 patient 35 times. CONCLUSIONS: We conclude that for patients with esophageal carcinoma, T is an important predictor of N and this association should be included with other established factors used in clinical staging and treatment decisions.

Adenocarcinoma↗
PubMed1998

Short-course induction chemoradiotherapy with paclitaxel for stage III non-small-cell lung cancer.

BACKGROUND: This study assessed toxicity, tumor response, disease control, and survival after short-course induction chemoradiotherapy and surgical resection in patients with stage III non-small-cell lung carcinoma. METHODS: Forty-five patients with stage III non-small-cell lung carcinoma received 12-day induction therapy of a 96-hour continuous infusion of cisplatin (20 mg/m2 per day), 24-hour infusion of paclitaxel (175 mg/m2), and concurrent accelerated fractionation radiation therapy (1.5 Gy twice daily) to a dose of 30 Gy. Surgical resection was scheduled for 4 weeks later. Postoperatively, a second identical course of chemotherapy and concurrent radiation therapy (30 to 33 Gy) was given. RESULTS: Induction toxicity resulted in hospitalization of 18 (40%) patients for neutropenic fever. No induction deaths occurred. Of 40 (89%) patients who underwent thoracotomy, resection for cure was possible in 32 (71%) patients. Pathologic response was noted in 21 (47%) patients, and 14 (31%) were downstaged to mediastinal node negative (stage 0, I, or II). At a median follow-up of 19 months, 24 patients were alive, 10 with recurrent disease. Of 21 deaths, 16 were from recurrent disease, three were from treatment, and two were unrelated. Recurrent disease was distant in 21 patients, distant and locoregional in 2, and locoregional in 3. The Kaplan-Meier projected 24-month survival is 49%. Projected 24-month survival is 61% for stage IIIA, 17% for stage IIIB (p = 0.035); 84% for pathologic responders, 22% for nonresponders (p<0.001); 83% for downstaged patients (stage 0, I, or II), 33% for those not downstaged (p = 0.005); and 63% for resectable patients, 14% for unresectable patients (p = 0.007). CONCLUSIONS: We conclude that short-course neoadjuvant therapy with paclitaxel (1) has manageable toxicity and a low treatment mortality, (2) results in good tumor response and downstaging, (3) provides excellent locoregional control with most recurrences being distant, and (4) has improved the median survival compared with historical controls. Survival was better in stage IIIA patients, resectable patients, pathologic responders, and patients downstaged to mediastinal node negative disease (stage 0, I, or II).

Antineoplastic Agents, Phytogenic↗
PubMed1998

The seroprevalence of cagA-positive Helicobacter pylori strains in the spectrum of gastroesophageal reflux disease.

BACKGROUND & AIMS: The role of Helicobacter pylori in the pathogenesis of gastroesophageal reflux disease (GERD) is unknown. We determined the prevalence of cagA-positive (cagA+) H. pylori strains in patients with GERD or its complications compared with controls of similar age. METHODS: A total of 153 consecutive patients with GERD, Barrett's esophagus, and Barrett's esophagus complicated by dysplasia or adenocarcinoma were compared with 57 controls who underwent upper endoscopy for reasons other than GERD. H. pylori infection and CagA antibody status were determined by histology and enzyme-linked immunosorbent assay. RESULTS: H. pylori prevalence was lower (34%) in patients with GERD and its sequelae than in the control group (45.6%)(P = 0.15). Regardless of the group, increasing age was associated with higher prevalence of H. pylori (P = 0.003). When compared with controls (42.3%), the prevalence of cagA+ H. pylori strains decreased (P = 0.008) in patients with more severe complications of GERD (GERD, 36.7% [nonerosive GERD, 41.2%; erosive GERD, 30.8%]; Barrett's esophagus, 13.3%; and Barrett's with adenocarcinoma/dysplasia, 0%). CONCLUSIONS: Prevalence of H. pylori in patients with GERD and its sequelae was lower but not significantly different than that of a control group. However, patients carrying cagA+ strains of H. pylori may be protected against the complications of GERD, especially Barrett's esophagus and its associated dysplasia and adenocarcinoma.

Adult↗
PubMed1998

Inflammation and intestinal metaplasia of the gastric cardia: the role of gastroesophageal reflux and H. pylori infection.

BACKGROUND & AIMS: Whether inflammation of the cardia indicates gastroesophageal reflux disease (GERD) and/or is a manifestation of pangastritis caused by Helicobacter pylori infection is unknown. The aim of this study was to evaluate the relationship between cardia inflammation, H. pylori infection, and cardia intestinal metaplasia in patients with and without GERD. METHODS: Patients with GERD were compared with controls undergoing endoscopy for a variety of other conditions. Endoscopic biopsy specimens from the distal esophagus and cardia, fundus, and antrum were evaluated for inflammation, H. pylori infection, and intestinal metaplasia. RESULTS: Neither the prevalence of H. pylori infection (controls, 48%; GERD, 41%) nor cardia inflammation (controls, 41%; GERD, 40%) differed between groups. All 11 controls and 22 of 23 patients with GERD (96%) and cardia inflammation had H. pylori infection. Esophagitis was more common among GERD patients (33%) than controls (7%; P = 0.01). Cardia intestinal metaplasia was more common among controls (22%) than GERD patients (3%; P = 0.01); all had cardia inflammation, 7 had H. pylori infection, and 6 had metaplasia elsewhere in the stomach. CONCLUSIONS: The prevalence of cardia inflammation is similar in patients with and without GERD and is associated with H. pylori infection (P < 0.001). Cardia intestinal metaplasia is associated with H. pylori-related cardia inflammation (P = 0.01) and intestinal metaplasia elsewhere in the stomach, indicating that it is distinct from Barrett's esophagus.

Adult↗
PubMed1998

Viridans streptococcal bacteremia after esophageal stricture dilation.

BACKGROUND: The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation. METHODS: Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation. RESULTS: A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients (p = 0. 001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation. CONCLUSIONS: These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis.

Antibiotic Prophylaxis↗
PubMed1998

Postoperative portable chest radiographs: optimum use in thoracic surgery.

PURPOSE: Daily portable chest radiographs are routinely ordered in many institutions after thoracic surgery. Our purpose was to assess the efficacy and cost of this practice and to determine the optimum use of postoperative x-ray studies. METHODS: A prospective review of all portable chest x-ray films after 100 consecutive elective thoracotomies (DRG 75) was conducted. Each x-ray study initiated a three-part survey. First, the surgeon listed whether the x-ray study was routine and the anticipated management had it not been available. The radiologist then interpreted and scored the x-ray study as follows: negative, expected findings; A, minor findings necessitating no intervention; B, minor findings necessitating intervention; or C, major findings necessitating intervention. Finally, the x-ray film and the interpretation were returned to the surgeon. Any interventions necessitated by the x-ray study were recorded. RESULTS: In 6 months, 99 patients underwent 82 pulmonary resections and 18 other major procedures. In the postoperative period, 769 portable chest x-ray studies were ordered, median five per patient (range 2 to 49). Of these, 731 (95%) were routine and 38 (5%), nonroutine. Severity scores were as follows: negative in 106 (13.8%), A in 558 (72.5%), B in 59 (7.7%), and C in 46 (6.0%). X-ray findings altered management in 43 of 769 studies (5.6%): in 33 routine (4.5%), in 10 nonroutine (26.3%), in 13 A (2.3%), in 22 B (37.3%), and in 8 C (17.4%). CONCLUSIONS: These results demonstrate that routine daily portable chest x-ray studies have a minimal impact on management. It is, in fact, nonroutine x-ray studies that more often alter management. Had routine portable chest x-ray studies, which cost $114 each in our institution, been limited to one immediately after the operation, only 133 such studies (100 routine and 33 nonroutine) would have been needed in the care of these patients. Elimination of 636 (82.7%) x-ray studies reduces the cost of care by $725 per patient ($286,000 annually). For major thoracic procedures, it is safe, efficacious, and cost effective to eliminate routine postoperative portable chest x-ray studies and order nonroutine portable studies only when clinically indicated.

Adult↗
PubMed1998

Stability of vancomycin-resistant enterococcal genotypes isolated from long-term-colonized patients.

Genotypic variation and stability of isolates of vancomycin-resistant enterococci (VRE) were studied to determine genetic diversity and whether strain definition based on pulsed-field gel electrophoresis (PFGE) is applicable to an endemic setting. Twenty-two PFGE types were identified among 455 VRE isolates. One-on-one comparisons of 10 vanA Enterococcus faecium strain types all yielded > 10 band differences. Variations among vanA and vanB E. faecium isolates from individual long-term-colonized (4-160 days) patients yielded < 3 band differences for > 85% of comparisons. Comparison of all strains without grouping by vancomycin resistance types yielded two peaks of band differences: one with < 3 and one with > 10 band differences. These data show that VRE isolates were genetically closely related or very different; demonstrate that within individual patients, VRE isolates show little genetic variation; and provide empirical evidence that PFGE can be used to study the epidemiology of VRE endemicity.

Anti-Bacterial Agents↗