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Abstract: Background: Several studies have evaluated predictors for complications of endoscopic retrograde cholangiopancreatography (ERCP), but their relative importance is unknown. In addition, currently used blood tests to detect post-ERCP pancreatitis are inconsistent. The aim of this study was to determine predictors of post-ERCP complications that could discriminate between patients at highest and lowest risk of post-ERCP complications and to develop a model that is able to identify patients that can safely be discharged shortly after ERCP. Methods: In a single-center, retrospective analysis over the period 2002–2007, predictors of post-ERCP complications were evaluated in a multivariable analysis and compared with those identified from a literature review. A prognostic model was developed based on these risk factors, which was further evaluated in a prospective patient population. Results: From our retrospective analysis and literature review, we selected the eight most important risk factors for post-ERCP pancreatitis and cholangitis. In the prognostic model, the risk factors (precut) sphincterotomy, sphincter of Oddi dysfunction, younger age, female gender, history of pancreatitis, pancreas divisum, and difficult cannulation accounted for a score of 1 each, whereas primary sclerosing cholangitis (PSC) accounted for a score of 2. A sum score of 4 or more in the prognostic model was associated with a high risk of developing pancreatitis and cholangitis (27%; 6/22) in the prospective patient population, whereas a sum score of 3 or less was associated with a low to intermediate risk (8%; 20/252). Conclusions: We identified specific patient- and procedure-related factors that are associated with post-ERCP complications. The prognostic model based on these factors is able to identify patients who can be safely discharged the same day after ERCP.

Giant pedunculated esophageal polyps are very rare. They may stay asymptomatic for a long time, and first come to the attention of the patient and the clinician after regurgitation into the mouth. Regurgitation, however, can be dangerous and has been known to lead to asphyxia and death due to closure of the larynx by the polyp mass. For this reason resection of the giant polyp is essential when it is discovered. We have seen four cases of giant esophageal polyps (GEP) at our institution. All four patients have undergone removal of the giant polyps. The histological diagnoses were fibrovascular polyp, liposarcoma, hamartoma and multiple lipomas. The mode of clinical presentation, radiological appearances, variable histological diagnoses, and therapy options in these four patients are presented along with a review of the literature.

Abstract:Alan Strudler has written a stimulating and provocative article about deception in negotiation. He presents his views, in part, in contrast with our earlier work on the Mutual Trust Perspective. We believe that Strudler is wrong in his account of the ethics of deception in negotiation and in his quick dismissal of the Mutual Trust Perspective. Though his mistakes may be informative, his views are potentially harmful to business practice. In this paper, we present arguments against Strudler’s position and attempt to salvage the Mutual-Trust Perspective from his attack. Strudler’s work reaffirms the need for a more pragmatic approach to business ethics. We close the paper with a renewed call for more constructive and practical approaches to business ethics research.

In a competitive and morally imperfect world, business people are often faced with serious ethical challenges. Harboring suspicions about the ethics of others, many feel justified in engaging in less-than-ideal conduct to protect their own interests. The most sophisticated moral arguments are unlikely to counteract this behavior. We believe that this morally defensive behavior is responsible, in large part, for much undesirable deception in negotiation. Drawing on recent work in the literature of negotiations, we present some practical guidance on how negotiators might build trust, establish common interests, and secure credibility for their statements, thereby promoting honesty. We also point out the types of social and institutional arrangements, many of which have become commonplace, that work to promote credibility, trust, and honesty in business dealings. Our approach is offered not only as a specific response to the problem of deception in negotiation, but as one model of how research in business ethics might offer constructive advice to practitioners.…there is such a gap between how one lives and how one ought to live that anyone who abandons what is done for what ought to be done learns his ruin rather than his preservation …—Niccolo MachiavelliWe must make the world honest before we can honestly say to our children that honesty is the best policy.—George Bernard Shaw

Alan Wertheimer's paper on “Unconscionability and Contracts” presents an enlightening discussion of a complex and contentious legal concept. His primary objective is not to contribute to legal scholarship, but to use the law to shed light on the ethics of exchange relationships. Specifically, he wants to “use the doctrine of unconscionability in contracts as a lens through which to get a clearer understanding of exploitation—its essential characteristics and moral force” (p. 480). It is apparent that he sees exploitation (and unconscionability) as closely linked to a more general notion of fairness.

During the period 1978-1981 172 patients were referred to the Rotterdam Joint Group on Esophageal Carcinoma. Ninety-one patients were considered for combined therapy, comprising radiation therapy and surgery, and 10 patients refused surgery. The figures given in this material are actuarial survival values corrected for intercurrent death (the actuarial overall survival in parentheses). The 4-year survival in 69 patients who completed this treatment was 39 per cent (26%) (significantly better for women compared with men; significantly better for tumors <2 vertebrae compared with tumors 2 2 vertebrae). The resectability rate was 85 per cent and the operation mortality rate 20 per cent. Thirty-eight patients had curative radiation therapy with a 4-year corrected survival of 5 per cent (3%). For palliative treatment, radiation therapy and endoscopic introduction of a Celestin tube were mostly used. The results of curative as well as of palliative treatment of esophageal carcinoma have shown improvement during the past decade compared with an earlier period.

The time-course of aminopyrine in plasma and of14CO2 in breath was determined for 6 hours after oral administration of (14C-methyl) aminopyrine to healthy controls and to patients with hepatitis and hepatic fibrosis, cirrhosis and hepatic bilharziasis.14CO2 in breath declined about 1.8 times more slowly than aminopyrine plasma levels, which suggests the occurrence of metabolite demethylation. This was confirmed by the slow elimination of14C from plasma, the formation of14CO2 after aminopyrine had disappeared and the presence of a considerable amount of monomethyl-aminopyrine in plasma. The mean14CO2 concentration in breath was correlated with but was not proportional to aminopyrine clearance, which was attributed to individual differences in aminopyrine half-life. Both a correlation and proportionality were found when14CO2 extrapolated to zero time was used as a parameter of14CO2 production. Hepatic disease affected aminopyrine clearance to a variable extent. In the hepatitis and fibrosis group, aminopyrine clearance was affected in 2 out of five subjects. In all except one cirrhotic subject aminopyrine clearance was markedly decreased. Moreover, in three out of seven cases aminopyrine absorption was impaired, presumably due to decreased gastrointestinal blood-flow. This may produce an erroneously low14CO2 concentration in breath during the first two hours after aminopyrine administration. Hepatic bilharziasis was accompanied by very low aminopyrine clearance in all four cases. In two patients high apparent Vd values were observed, probably due to “first-pass” metabolism. Patients with ascites had Vd values within normal limits.

A multicentre maintenance trial was conducted in 63 peptic ulcer patients to investigate the efficacy and safety of continuous cimetidine maintenance therapy for up to 5 years. In Amsterdam the male patients were investigated yearly for possible endocrinologic changes and to monitor gastric acid secretory capacity. Patients with healed ulcers entered maintenance treatment with a 400-mg bedtime dose of cimetidine. The yearly relapse rates decreased from 20% to 6% from year 1 to year 4. Adverse reactions observed in this study were not different from those previously reported with cimetidine. Endocrinologic studies in 10 male patients showed a small but consistent increase in basal gastrin in the 3rd and 4th year, stabilizing in the 5th year. Prolactin levels showed a gradual increase during the first 3 years but remained well within the normal range. In the 4th and 5th year they decreased again; however, the changes noted were rather modest. It is concluded from this study that weak nocturnal acid inhibition with cimetidine maintenance treatment not only continues to be effective and safe beyond 1 year but also reduces the risk of relapse over time. No relevant endocrinologic abnormalities are to be expected with this regimen of modest nocturnal acid suppression.

An analytical electron microscopic study, utilizing scanning transmission electron microscopy and energy-dispersive x-ray spectroscopy, was made of two types of mitochondrial inclusions identified in canine myocardial infarcts. The data were obtained from thin sections of tissues that were fixed in aldehyde, osmicated and embedded in epoxy resin. Calcium peaks of variable intensity were detected in inclusions which contained very electron-dense spicular material and which were localized to muscle cells at the peripheries of the infarcts. These findings indicate that the spicular inclusions represent early stages in the process of mitochondrial calcification in myocardial infarcts. In contrast, calcium or other trace elements were not detected in moderately electron-dense amorphous inclusions which were present in mitochondria of muscle cells throughout the infarcts. With the tissue preparative techniques employed, the possibility cannot be excluded that the amorphous inclusions contained calcium, either in small amounts or in a readily diffusable state, in vivo. The data, however, are in accord with the previously advanced hypothesis that the amorphous inclusions represent precipitates of denatured mitochondrial protein formed during the evolution of irreversible cellular injury. This study provides further evidence that analytical electron microscopy can yield important information regarding the nature of various inclusions occurring in normal and diseased tissues.

Background: Self-expanding metal stents seem to be safer than conventional prostheses for palliation of malignant esophagogastric obstruction. However, recurrent dysphagia caused by tumor ingrowth in uncoated types remains a problem. In addition, prior radiation and/or chemotherapy may entail an increased risk of complications. Methods: Seventy-five patients with an esophagogastric carcinoma were randomly assigned to placement of a latex prosthesis under general anesthesia or a coated, self-expanding metal stent under sedation. At entry, patients were stratified for location of the tumor in the esophagus or cardia and for prior radiation and/or chemotherapy. Results: Technical success and improvement in dysphagia score were similar in both groups. Major complications were more frequent with latex prostheses (47%) than with metal stents (16%) (odds ratio 4.07: 95% CI [1.35, 12.50], p = 0.014). Recurrent dysphagia was not different between latex prostheses (26%) and metal stents (24%). Hospital stay was longer, on average, after placement of latex prostheses than metal stents (6.3 +/- 5.2 versus 4.3 +/- 2.3 days; p = 0.043). Only prior radiation and/or chemotherapy increased the risk of specific device-related complications with respect to the esophagus (12 of 28 [43%] versus 8 of 47 [17%]; odds ratio 3.66: 95% CI [1.24, 10.82], p = 0.029). Conclusions: Coated, self-expanding metal stents are associated with fewer complications and shorter hospital stay as compared with latex prostheses, and prior radiation and/or chemotherapy increases the risk of device-related complications with respect to the esophagus. (Gastrointest Endosc 1998;47:113-20)

In the search for effective chemotherapy regimens which can be used in multimodality treatment programmes for patients with cancer of the oesophagus, we conducted a phase II trial to determine the activity and toxicity of the combination of cisplatin and etoposide in patients with advanced squamous cell carcinoma of the oesophagus. Seventy-three consecutive patients with unresectable or metastatic squamous cell carcinoma of the thoracic oesophagus were treated with cisplatin 80 mg m-2 by 4 h infusion on day 1, etoposide 100 mg (fixed dose) by 2 h infusion on day 1 and 2, and etoposide 200 mg m-2 orally on day 3 and 5. Courses were repeated every 4 weeks, for a maximum of six courses. The oral dosages of etoposide were modified individually until a significant degree of myelosuppression was reached. Of 65 evaluable patients, five complete responses (CRs) and 26 partial responses (PRs) were seen, for an overall response rate of 48% (95% confidence interval 35-60%). Median time to progression was 7 months (range 3-72 + months). There were two toxic deaths (neutropenic sepsis). The response rate equals that of other cisplatin-based regimens. Its toxicity profile allows addition of a third active drug such as 5-fluorouracil.

Giant oesophageal polyp (GOP) is a very rare intraluminal tumour. It is usually a benign, fibrovascular polyp arising from the proximal third of the oesophagus. We describe a patient with such a polyp but with a histological diagnosis of hamartoma. Regurgitation of the polyp into the mouth, which can lead to asphyxia, is a feared complication. A barium swallow and oesophagoscopy are the common diagnostic procedures. The site of the polyp and its volume often define the method of resection.

From a traditional moral point of view, business practitioners often seem overly concerned about the behavior of their peers in deciding how they ought to act. We propose to account for this concern by introducing a mutual trust perspective, where moral obligations are grounded in a sense of trust that others will abide by the same rules. When grounds for trust are absent, the obligation is weakened. We illustrate this perspective by examining the widespread ambivalence with regard to deception about one's settlement preferences in negotiation. On an abstract level, such deception generally seems undesirable, though in many individual cases it is condoned, even admired as shrewd bargaining. Because of the difficulty in verifying someone's settlement preferences, it is hard to establish a basis for trusting the revelations of the other party, especially in competitive negotiations with relative strangers.Brer Rabbit had got himself caught by Brer Fox and was well on his way to becoming evening dinner. Brer Rabbit was in a great deal of deep trouble.There didn’t seem much he could do about this one, but he didn’t seem concerned at all at being the Fox’s dinner. He just said, “Brer Fox I don’t mind if you eat me. But, oh, whatever you do don’t throw me in that briar patch.”Now Brer Fox was surely looking forward to eating his old enemy, but he was mighty curious about Brer Rabbit’s sweating and crying about being thrown into the briar patch.And the more he questioned it the more Brer Rabbit wailed about how much he hated and feared that briar patch.Pretty soon it did seem that Brer Rabbit would rather be eaten than be set among those briars. So Brer Fox threw Brer Rabbit into the heart of the briar patch. Brer Rabbit gleefully scampered away.From the tales of Brer Rabbit

Early oesophageal and gastric cancer are unique forms of oesophageal and gastric carcinoma with an excellent prognosis. Remarkable changes have taken place in the epidemiology of upper gastrointestinal malignancies. In particular, the incidence of adenocarcinoma of the distal oesophagus and the gastric cardia has risen over the past two decades. In the United States and Europe, early detection is dependent on a low threshold for upper gastrointestinal endoscopy with biopsy, because specific symptoms and physical findings are rarely present in patients with early oesophageal and gastric cancer. In addition to histology, the detection of possible markers of malignancy, such as aneuploidy (detected by flow cytometry) and the presence of oncogenes and tumour-suppressor genes, in biopsy material may be of value in the diagnosis of early cancers. For patients with early oesophageal or gastric cancer, surgery offers the best hope of cure. If patients are at high risk for surgery, an endoscopic resection may be an alternative option. This review discusses the definitions, the changes in epidemiology, the current options for diagnosis and treatment, and the value of screening programs for patients with early oesophageal or gastric cancer.