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Medical Sciences	94%

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Hepatitis C virus load and survival among injection drug users in the United States,

HEPATOLOGY, Issue 6 2005
Michie Hisada
Persons chronically infected with hepatitis C virus (HCV), some of whom may be coinfected with HIV and human T-lymphotropic virus type II (HTLV-II), are at high risk for end-stage liver disease (ESLD). We evaluated whether ESLD death was associated with premorbid HCV RNA level or specific HCV protein antibodies among persons with or without HIV/HTLV-II coinfection in a cohort of 6,570 injection drug users who enrolled in 9 US cities between 1987 and 1991. We compared 84 ESLD descendents and 305 randomly selected cohort participants with detectable HCV RNA, stratified by sex, race, HIV, and HTLV-II strata. Relative hazard (RH) of ESLD death was derived from the proportional hazard model. Risk of ESLD death was unrelated to the intensity of antibodies against the HCV c-22(p), c-33(p), c-100(p), and NS5 proteins, individually or combined, but it increased with HCV RNA level (RHadj= 2.26 per log10 IU/mL, 95% CI: 1.45-5.92). The association between HCV RNA level and ESLD death remained significant after adjustment for alcohol consumption (RHadj= 2.57 per log10 IU/mL, 95% CI: 1.50-8.10). Deaths from AIDS (n = 45) and other causes (n = 43) were unrelated to HCV RNA (RHadj= 1.14 and 1.29 per log10 IU/mL, respectively). HIV infection was not associated with ESLD risk in multivariate analyses adjusted for HCV RNA. Men had an increased risk of ESLD death in unadjusted analyses (RH = 1.92, 95% CI: 1.15-3.56) but not in multivariate analysis (RHadj= 0.98, 95% CI: 0.48-2.88). Non-black patients were at increased risk for ESLD death (RHadj= 2.76, 95% CI: 1.49-10.09). In conclusion, HCV RNA level is a predictor of ESLD death among persons with chronic HCV infection. (HEPATOLOGY 2005.) [source]

Early neurodevelopmental markers predictive of mortality in infants infected with HIV-1

DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 2 2003
Antolin Llorente PhD
One-hundred and fifty-seven vertically infected HIV-1 positive infants (85 males, 72 females) underwent longitudinal assessment to determine whether early neurodevelopmental markers are useful predictors of mortality in those infants who survive to at least 4 months of age. Survival analysis methods were used to estimate time to death for quartiles of 4-month scores (baseline) on the Bayley Scales of Infant Development (BSID). Cox proportional hazards progression was used to estimate relative hazard (RH, 95% CI) of death for BSID scores and potential confounders. Thirty infants with BSID scores at 4 months of age died during follow-up. Survival analysis revealed greater mortality rates in infants with BSID (Mental Developmental Index and Psychomotor Developmental Index) scores in the lower quartile(p=0.004,p=0.036). Unadjusted univariate analyses revealed increased mortality associated with baseline CD4+ 29%, gestational age <37 weeks, smaller head circumference, advanced HIV and higher plasma viral load. BSID scores independently predicted mortality after adjusting for treatment, clinical category, gestational age, plasma viral load and CD4+ percentage. [source]

Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users

ADDICTION, Issue 5 2010
Sasha Uhlmann
ABSTRACT Aims Despite proven benefits of antiretroviral therapy (ART), many human immunodeficiency virus (HIV)-infected injection drug users (IDU) do not access treatment even in settings with free health care. We examined whether methadone maintenance therapy (MMT) increased initiation and adherence to ART among an IDU population with free health care. Design We examined prospectively a cohort of opioid-using antiretroviral-naive HIV-infected IDU and investigated factors associated with initiation of antiretroviral therapy as well as subsequent adherence. Factors associated independently with time to first initiation of antiretroviral therapy were modelled using Cox proportional hazards regression. Findings Between May 1996 and April 2008, 231 antiretroviral-naive HIV-infected opioid-using IDU were enrolled, among whom 152 (65.8%) initiated ART, for an incidence density of 30.5 [95% confidence interval (CI): 25.9,35.6] per 100 person-years. After adjustment for time-updated clinical characteristics and other potential confounders, use of MMT was associated independently with more rapid uptake of antiretroviral therapy [relative hazard = 1.62 (95% CI: 1.15,2.28); P = 0.006]. Those prescribed methadone also had higher rates of ART adherence after first antiretroviral initiation [odds ratio = 1.49 (95% CI: 1.07,2.08); P = 0.019]. Conclusion These results demonstrate that MMT contributes to more rapid initiation and subsequent adherence to ART among opioid-using HIV-infected IDU. Addressing international barriers to the use and availability of methadone may increase dramatically uptake of HIV treatment among this population. [source]

Rate of detoxification service use and its impact among a cohort of supervised injecting facility users

ADDICTION, Issue 6 2007
Evan Wood
ABSTRACT Background Vancouver, Canada recently opened a medically supervised injecting facility (SIF) where injection drug users (IDU) can inject pre-obtained illicit drugs. Critics suggest that the facility does not help IDU to reduce their drug use. Methods We conducted retrospective and prospective database linkages with residential detoxification facilities and used generalized estimating equation (GEE) methods to examine the rate of detoxification service use among SIF participants in the year before versus the year after the SIF opened. In secondary analyses, we used Cox regression to examine if having been enrolled in detoxification was associated with enrolling in methadone or other forms of addiction treatment. We also evaluated the impact of detoxification use on the frequency of SIF use. Results Among 1031 IDU, there was a statistically significant increase in the uptake of detoxification services the year after the SIF opened. [odds ratio: 1.32 (95% CI, 1.11,1.58); P = 0.002]. In turn, detoxification was associated independently with elevated rates of methadone initiation [relative hazard = 1.56 (95% CI, 1.04,2.34); P = 0.031] and elevated initiation of other addiction treatment [relative hazard = 3.73 (95% CI, 2.57,5.39); P < 0.001]. Use of the SIF declined when the rate of SIF use in the month before enrolment into detoxification was compared to the rate of SIF use in the month after discharge (24 visits versus 19 visits; P = 0.002). Conclusions The SIF's opening was associated independently with a 30% increase in detoxification service use, and this behaviour was associated with increased rates of long-term addiction treatment initiation and reduced injecting at the SIF. [source]

Hepatitis C virus infection and incident type 2 diabetes

HEPATOLOGY, Issue 1 2003
M.P.H. Assistant Research Professor, Shruti H. Mehta Ph.D.
Although hepatitis C virus (HCV) infection is more common among adults with type 2 diabetes, it is uncertain whether HCV precedes the development of diabetes. Thus, we performed a prospective (case-cohort) analysis to examine if persons who acquired type 2 diabetes were more likely to have had antecedent HCV infection when enrolled in a community-based cohort of men and women between the ages of 44 and 65 in the United States (Atherosclerosis Risk in Communities Study [ARIC]). Among 1,084 adults free of diabetes at baseline, 548 developed diabetes over 9 years of follow-up evaluation. Incident cases of diabetes were identified by using fasting glucose and medical history and HCV antibodies were assessed at baseline. A priori, persons were categorized as low-risk or high-risk for diabetes based on their age and body mass index, factors that appeared to modify the type 2 diabetes-HCV infection incidence estimates. The overall prevalence of HCV in this population was 0.8%. Among those at high risk for diabetes, persons with HCV infection were more than 11 times as likely as those without HCV infection to develop diabetes (relative hazard, 11.58; 95% confidence interval, 1.39-96.6). Among those at low risk, no increased incidence of diabetes was detected among HCV-infected persons (relative hazard, 0.48; 95% confidence interval, 0.05-4.40). In conclusion, pre-existing HCV infection may increase the risk for type 2 diabetes in persons with recognized diabetes risk factors. Additional larger prospective evaluations are needed to confirm these preliminary findings. [source]

Insights into reasons for discontinuation according to year of starting first regimen of highly active antiretroviral therapy in a cohort of antiretroviral-naïve patients

HIV MEDICINE, Issue 2 2010
P Cicconi
Objectives The aim of the study was to determine whether the incidence of first-line treatment discontinuations and their causes changed according to the time of starting highly active antiretroviral therapy (HAART) in an Italian cohort. Methods We included in the study patients from the Italian COhort Naïve Antiretrovirals (ICoNA) who initiated HAART when naïve to antiretroviral therapy (ART). The endpoints were discontinuation within the first year of ,1 drug in the first HAART regimen for any reason, intolerance/toxicity, poor adherence, immunovirological/clinical failure and simplification. We investigated whether the time of starting HAART (stratified as ,early', 1997,1999; ,intermediate', 2000,2002; ,recent', 2003,2007) was associated with the probability of reaching the endpoints by a survival analysis. Results Overall, the 1-year probability of discontinuation of ,1 drug in the first regimen was 36.1%. The main causes of discontinuation were intolerance/toxicity (696 of 1189 patients; 58.5%) and poor adherence (285 of 1189 patients; 24%). The hazards for all-reason change were comparable according to calendar period [2000,2002, adjusted relative hazard (ARH) 0.82, 95% confidence interval (CI) 0.69,0.98; 2003,2007, ARH 0.94, 95% CI 0.76,1.16, vs. 1997,1999; global P -value=0.08]. Patients who started HAART during the ,recent' period were less likely to change their initial regimen because of intolerance/toxicity (ARH 0.67, 95% CI 0.51,0.89 vs. ,early' period). Patients who started in the ,intermediate' and ,recent' periods had a higher risk of discontinuation because of simplification (ARH 15.26, 95% CI 3.21,72.45, and ARH 37.97, 95% CI 7.56,190.64, vs. ,early' period, respectively). Conclusions It seems important to evaluate reason-specific trends in the incidence of discontinuation in order to better understand the determinants of changes over time. The incidence of discontinuation because of intolerance/toxicity has declined over time while simplification strategies have become more frequent in recent years. Intolerance/toxicity remains the major cause of drug discontinuation. [source]

Superior virological response to boosted protease inhibitor-based highly active antiretroviral therapy in an observational treatment programme

HIV MEDICINE, Issue 2 2007
E Wood
Background The use of boosted protease inhibitor (PI)-based antiretroviral therapy has become increasingly recommended in international HIV treatment consensus guidelines based on the results of randomized clinical trials. However, the impact of this new treatment strategy has not yet been evaluated in community-treated cohorts. Methods We evaluated baseline characteristics and plasma HIV RNA responses to unboosted and boosted PI-based highly active antiretroviral therapy (HAART) among antiretroviral-naïve HIV-infected patients in British Columbia, Canada who initiated HAART between August 1997 and September 2003 and who were followed until September 2004. We evaluated time to HIV-1 RNA suppression (<500 HIV-1 RNA copies/mL) and HIV-1 RNA rebound (,500 copies/mL), while stratifying patients into those that received boosted and unboosted PI-based HAART as the initial regimen, using Kaplan,Meier methods and Cox proportional hazards regression. Results During the study period, 682 patients initiated therapy with unboosted PI and 320 individuals initiated HAART with a boosted PI. Those who initiated therapy with a boosted PI were more likely to have a CD4 cell count <200 cells/,L and to have a plasma HIV RNA>100 000 copies/mL, and to have AIDS at baseline (all P<0.001). However, when we examined virological response rates, those who initiated HAART with a boosted PI achieved more rapid virological suppression [relative hazard 1.26, 95% confidence interval (CI) 1.06,1.51, P=0.010]. Conclusions Patients prescribed boosted PIs achieved superior virological response rates despite baseline factors that have been associated with inferior virological responses to HAART. Despite the inherent limitations of observational studies which require this study be interpreted with caution, these findings support the use of boosted PIs for initial HAART therapy. [source]

Plasma Hypertonicity: Another Marker of Frailty?

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2004
Jodi D. Stookey PhD
Objectives: To determine whether plasma hypertonicity might be a marker of early frailty, this study tested the associations between plasma hypertonicity, incident disability, and mortality in nondisabled older adults. Design: Longitudinal, observational study. Setting: Community-based. Participants: Older adults (,70), who reported no disability and gave blood in the 1992 Duke Established Populations for Epidemiologic Studies of the Elderly survey (n=705), were re-interviewed in 1996 for functional status (n=561) and followed for all deaths up to January 1, 2000. Measurements: Plasma tonicity was estimated from plasma glucose, sodium, and potassium measures and used to classify subjects as normo- (285,294 mOsm/L) or hypertonic (,300 mOsm/L). Disability was defined as any impairment on the Rosow-Breslau, activity of daily living (ADL), and instrumental activity of daily living (IADL) scales. The relative risk (RR) of any new disability and relative hazard of death associated with hypertonicity were estimated using logistic regression models and Cox proportional hazards models, respectively. All models were controlled for age, sex, race, weight status, current smoking, activity level, plasma blood urea nitrogen and creatinine, cognitive impairment, depression, and chronic disease status. To determine whether observed effects were attributable to plasma glucose alone, all models were repeated on a subsample of nondiabetic, normoglycemic subjects. Results: Plasma hypertonicity (observed in 15% of subjects) was associated with increased risk of new Rosow-Breslau (RR=2.1, 95% confidence interval (CI)=1.2,3.6), IADL (RR=2.3, 95% CI=1.2,4.3), and ADL (RR=2.7 95% CI=1.3,5.6) disability by 1996 and mortality by 2000 (RR=1.4, 95% CI=1.0,1.9). Results were similar for the normoglycemic subgroup (ADL: RR=2.9, 95% CI=1.0,8.0; IADL: RR=2.5, 95% CI=1.0,6.3; Rosow-Breslau: RR=1.8, 95% CI=0.8,3.9; mortality: RR=1.5, 95% CI=0.9,2.3). Conclusion: Plasma hypertonicity may be a marker of early frailty. It was prevalent in this sample of nondisabled community-dwelling older adults and predicted incident disability and mortality. Further research to identify its determinants and consequences may help inform interventions against frailty. [source]

Biochemical Markers of Bone Turnover, Hip Bone Loss, and Fracture in Older Men: The MrOS Study,

JOURNAL OF BONE AND MINERAL RESEARCH, Issue 12 2009
Douglas C Bauer
Abstract We used data from the Osteoporotic Fractures in Men (MrOS) study to test the hypothesis that men with higher levels of bone turnover would have accelerated bone loss and an elevated risk of fracture. MrOS enrolled 5995 subjects >65 yr; hip BMD was measured at baseline and after a mean follow-up of 4.6 yr. Nonspine fractures were documented during a mean follow-up of 5.0 yr. Using fasting serum collected at baseline and stored at ,190°C, bone turnover measurements (type I collagen N-propeptide [PINP]; , C-terminal cross-linked telopeptide of type I collagen [,CTX]; and TRACP5b) were obtained on 384 men with nonspine fracture (including 72 hip fractures) and 947 men selected at random. Among randomly selected men, total hip bone loss was 0.5%/yr among those in the highest quartile of PINP (>44.3 ng/ml) and 0.3%/yr among those in the lower three quartiles (p = 0.01). Fracture risk was elevated among men in the highest quartile of PINP (hip fracture relative hazard = 2.13; 95% CI: 1.23, 3.68; nonspine relative hazard = 1.57, 95% CI: 1.21, 2.05) or ,CTX (hip fracture relative hazard = 1.76, 95 CI: 1.04, 2.98; nonspine relative hazard = 1.29, 95% CI: 0.99, 1.69) but not TRACP5b. Further adjustment for baseline hip BMD eliminated all associations between bone turnover and fracture. We conclude that higher levels of bone turnover are associated with greater hip bone loss in older men, but increased turnover is not independently associated with the risk of hip or nonspine fracture. [source]

Pretreatment Levels of Bone Turnover and the Antifracture Efficacy of Alendronate: The Fracture Intervention Trial

JOURNAL OF BONE AND MINERAL RESEARCH, Issue 2 2006
Douglas C Bauer MD
Abstract The influence of pretreatment bone turnover on alendronate efficacy is not known. In the FIT, we examined the effect of pretreatment bone turnover on the antifracture efficacy of daily alendronate given to postmenopausal women. The nonspine fracture efficacy of alendronate was significantly greater among both osteoporotic and nonosteoporotic women with higher baseline levels of the bone formation marker PINP. Introduction: Previous trials have shown that high bone turnover is associated with greater increases in BMD among bisphosphonate-treated women. The influence of pretreatment bone turnover levels on antifracture efficacy has not been well studied. Materials and Methods: We randomized women 55,80 years of age with femoral neck BMD T scores , ,1.6 to alendronate (ALN), 5,10 mg/day (n = 3105), or placebo (PBO; n = 3081). At baseline, 3495 women were osteoporotic (femoral neck BMD T score , ,2.5 or prevalent vertebral fracture), and 2689 were not osteoporotic (BMD T score > ,2.5 and no prevalent vertebral fracture). Pretreatment levels of bone-specific alkaline phosphatase (BSALP), N-terminal propeptide of type 1 collagen (PINP), and C-terminal cross-linked telopeptide of type 1 collagen (sCTx) were measured in all participants using archived serum (20% fasting). The risk of incident spine and nonspine fracture was compared in ALN- and PBO-treated subjects stratified into tertiles of baseline bone marker level. Results and Conclusions: During a mean follow-up of 3.2 years, 492 nonspine and 294 morphometric vertebral fractures were documented. Compared with placebo, the reduction in nonspine fractures with ALN treatment differed significantly among those with low, intermediate, and high pretreatment levels of PINP levels (p = 0.03 for trend). For example, among osteoporotic women in the lowest tertile of pretreatment PINP (<41.6 ng/ml), the ALN versus PBO relative hazard for nonspine fracture was 0.88 (95% CI: 0.65, 1.21) compared with a relative hazard of 0.54 (95% CI: 0.39, 0.74) among those in the highest tertile of PINP (>56.8 ng/ml). Results were similar among women without osteoporosis at baseline. Although they did not reach statistical significance, similar trends were observed with baseline levels of BSALP. Conversely, spine fracture treatment efficacy among osteoporotic women did not differ significantly according to pretreatment marker levels. Spine fracture treatment efficacy among nonosteoporotic women was related to baseline BSALP (p = 0.05 for trend). In summary, alendronate nonspine fracture efficacy is greater among both osteoporotic and nonosteoporotic women with high pretreatment PINP. If confirmed in other studies, these findings suggest that bisphosphonate treatment may be most effective in women with elevated bone turnover. [source]

Which patients benefit from hemodialysis therapy in hepatorenal syndrome?

JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 12 2004
OLIVER WITZKE
Abstract Background and Aim:, Hepatorenal syndrome (HRS) occurs in patients with advanced liver cirrhosis and has a poor outcome. The aim of the present study was to investigate which patients with HRS are likely to benefit from hemodialysis. Methods:, Data were collected prospectively from 30 patients with Child-Pugh C liver cirrhosis and HRS. Patients were either treated with continuous veno-venous hemodialysis (CVVHD) if they were mechanically ventilated, or with intermittent hemodialysis (HD) if they were not mechanically ventilated. Prognosis was assessed by the Child-Pugh and by the Model for End-Stage Liver Disease (MELD) score. The primary aim of the study was the analysis of overall and 30-day patient survival during hemodialysis therapy. To identify predictive factors of survival, variables obtained before the initiation of dialysis therapy were evaluated. Results:, Patients' 30-day survival was 8/30 (median survival time 21 days). Among patients treated with mechanical ventilation, 30-day survival time was 0/15 while 8/15 patients without mechanical ventilation survived more than 30 days (P < 0.001). Using a multivariate model, the relative hazards for serum albumin, international normalized ratio (INR) and catecholamine therapy were not different from one another (P > 0.05), indicating that these parameters were not independent predictors of survival. Mechanical ventilation was an independent risk factor for 30-day (relative hazard 6.6 [1.6,27.7], P < 0.001) and overall survival (relative hazard 6.3 [1.5,26.5], P = 0.01). Child-Pugh (P < 0.01) and the MELD (P < 0.01) score were predictive for overall survival independent of mechanical ventilation. Conclusions:, Patients with HRS without mechanical ventilation may benefit from hemodialysis, whereas hemodialysis seems to be futile in patients with mechanical ventilation. [source]

Early Personality Traits as Predictors of Mortality Risk Following Conjugal Bereavement

JOURNAL OF PERSONALITY, Issue 3 2009
Keiko A. Taga
ABSTRACT This study explored pre-bereavement personality traits and gender as predictors of post-widowhood mortality risk, using newly derived life span data for participants originally recruited for Lewis Terman's classic study of the gifted. Personality traits measured in 1940 were used to predict mortality risk from 1940 through 2004 for married participants who were either widowed between 1940 and 1986 or who remained married. Results indicated that widowhood predicted a decrease in mortality risk for these (intelligent) individuals (relative hazard [rh]=0.68, N=843, p<.001) and neuroticism significantly moderated this effect. Specifically, neuroticism in young adulthood was significantly associated with decreased mortality risk among men who were later widowed (rh=0.50, N=66, p<.02) but not among women or consistently married men. Conclusions reveal the importance of personality,situation interactions and the adoption of a long-term perspective. [source]

Body mass index and risk of stroke among Chinese men and women

ANNALS OF NEUROLOGY, Issue 1 2010
Lydia A. Bazzano MD
Objective The relationship between body mass index (BMI) and stroke incidence and mortality remains controversial, particularly in Asian populations. Methods We conducted a prospective cohort study in a nationally representative sample of 169,871 Chinese men and women age 40 years or older. Data on body weight was obtained at baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 to 2000, with a response rate of 93.4%. Results After excluding those participants with missing body weight or height values, 154,736 adults were included in the analysis. During a mean follow-up of 8.3 years, 7,489 strokes occurred (3,924 fatal). After adjustment for age, gender, physical inactivity, urbanization, geographic variation, cigarette smoking, diabetes, and education, compared with participants of normal weight (BMI 18.5,24.9), relative hazard (95% confidence interval) of incident stroke was 0.86 (0.80,0.93) for participants who were underweight (BMI < 18.5), 1.43 (1.36,1.52) for those who were overweight (BMI 25,29.9), and 1.72 (1.55,1.91) for those who were obese (BMI , 30). The corresponding relative hazards were 0.76 (0.66,0.86), 1.60 (1.48,1.72), and 1.89 (1.66,2.16) for ischemic stroke and 1.00 (0.89,1.13), 1.18 (1.06,1.31), and 1.54 (1.27,1.87) for hemorrhagic stroke. For stroke mortality, the corresponding relative hazards were 0.94 (0.86,1.03), 1.15 (1.05,1.25), and 1.47 (1.26,1.72). Linear trends were significant for all outcomes (p < 0.0001). Interpretation These results suggest that elevated BMI increases the risk of both ischemic and hemorrhagic stroke incidence, and stroke mortality in Chinese adults. ANN NEUROL 2010;67:11,20 [source]

Prognostic factors in laryngeal carcinoma: the role of apoptosis, p53, proliferation (Ki-67) and angiogenesis

APMIS, Issue 4 2003
HEIKKI TEPPO
Even though the roles of different known or suggested prognostic factors in laryngeal cancer have been studied in detail, clinical stage at time of diagnosis and anatomic subsite of the tumour remain the only practical predictors of clinical outcome and offer the only guidelines in the planning of treatment. In this study, the relative roles of known demographic and clinical prognostic factors, in addition to four histopathological factors, were evaluated in a sample of 100 laryngeal carcinoma patients with multivariate analysis using the Cox regression model. In addition to advanced stage (stage III-IV) (relative hazard of death (HR) 8.9, p=0.01) and supraglottic disease (HR 5.6, p=0.02), high apoptotic index (HR 11.1, p=0.05) was significantly associated with poor survival. Cell proliferation, p53 and angiogenesis did not significantly affect the prognosis. In the future, high degree of apoptosis could be used to identify patients with poor prognosis in laryngeal cancer. [source]

Association of prediagnosis endoscopy with stage and survival in adenocarcinoma of the esophagus and gastric cardia,

CANCER, Issue 1 2002
Gregory S. Cooper M.D.
Abstract BACKGROUND Barrett esophagus, a consequence of chronic gastroesophageal reflux disease, is a premalignant condition for adenocarcinoma of the esophagus and, possibly, the gastric cardia. However, the actual use and clinical impact of upper gastrointestinal endoscopy in screening and surveillance for Barrett esophagus are unknown. METHODS A cohort included 1633 patients with adenocarcinoma (777 esophagus, 856 cardia) who were 70 years or older. They were diagnosed between 1993 and 1996 and were identified from the Surveillance, Epidemiology and End Results program registry. All claims for upper endoscopy and a diagnosis of Barrett esophagus from 1991 through 1 year before diagnosis were identified from linked Medicare files. RESULTS One or more upper endoscopies before diagnosis were performed in 9.7% of patients (13.0% esophagus, 6.8% cardia) and a diagnosis of Barrett esophagus was present in only 3.7% of patients. A shift toward earlier stage at diagnosis was observed in patients with previous endoscopy or Barrett diagnosis. For example, 62% of patients with esophageal and 49% of patients with cardia tumors who underwent previous endoscopy presented with in situ or local stage carcinoma, compared with 35% and 27% of other patients, respectively. Receipt of endoscopy was also associated with a reduced risk of death for esophageal adenocarcinoma (relative hazard 0.73, 95% confidence interval 0.57,0.93; P = 0.01), but not for adenocarcinoma of the cardia. CONCLUSIONS Receipt of upper endoscopy at least 1 year before diagnosis of adenocarcinoma, which may reflect prediagnosis screening, was associated with an earlier tumor stage and improved survival. These data support the role of endoscopic screening and surveillance for Barrett esophagus and highlight the underdiagnosis of populations at risk. Cancer 2002;95:32,8. © 2002 American Cancer Society. DOI 10.1002/cncr.10646 [source]