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Objective: As the population ages, we will present the reality around being able to meet the health care needs of our population. In particular, we will present that providing cardiothoracic services in 2035 with a shortage of surgeons and an unknown caseload may be an impossibility., Methods: By using data from the American Board of Thoracic Surgery, we estimate that in 2010, 4000 cardiothoracic surgeons performed more than 530,000 cases. Additionally, cardiothoracic residency programs train and certify on average 90 new surgeons every year. To estimate the number of cases for 2035, we consulted the Census Bureau figures for 2010 and population projections for 2035. We then estimated the expected caseload for cardiothoracic surgeons relative to heart surgery, as well as lung and esophageal surgery. We found that among 2010 cardiothoracic surgeons in the United States, they completed more than 530,000 cases., Results: We project that by 2035 there will be 853,912 cases to perform, representing an increase from 2010 to 2035 of approximately 61% nationally. The cases per surgeon, per year, in 2010 averaged 135 for almost each of the 4000 surgeons. In 2035, the average caseload per surgeon will be 299 cases, representing an increase of 121% for the individual surgeon., Conclusions: We conclude that by 2035, cardiothoracic surgeons will be responsible for more than 850,000 patients requiring surgery. This represents a 61% increase in the national case load and a potential for a 121% increase for each cardiothoracic surgeon. We believe this is not feasible and a sign of trouble ahead., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The occurrence of reflux disease seems to be rising in the United States. The aim of the present study was to follow the time trends of hospitalization for gastroesophageal reflux disease (GERD) and other esophageal disease during the past 4 decades., Methods: US hospital utilization data were available for individual years from 1970 to 2010 through the National Hospital Discharge Survey. Esophageal diagnoses were stratified by their ninth revision of the International Classification of Diseases codes. Annual hospitalizations were expressed as rates per 100,000 living US population., Results: GERD was by far the most common esophageal disorder resulting in hospitalization. However, in only 5% of instances did GERD-related diagnoses constitute the primary cause of hospitalization. Between 1970 and 2010 the rates of GERD-related hospitalizations increased in an exponential manner almost 10-fold. This rise affected both sex and all age groups alike. A 3-fold rise was noted in hospitalizations for esophageal adenocarcinoma. Other esophageal diagnoses, such as achalasia, dyskinesia, or stricture were characterized by falling or stable trends., Conclusions: US hospitalization data show a continued exponential rise in the occurrence of GERD without any signs of leveling off. These trends are likely to represent ongoing changes in the underlying incidence and prevalence of the disease.

Oral leukoplakia is a relatively common, painless disorder of the oral mucosa. It predominantly affects middle-aged to elderly men and has a strong association with tobacco smoking and alcohol intake. Concomitant histological findings of hyperorthokeratosis and a well-developed granular cell layer, termed orthokeratotic dysplasia, are often associated with oral squamous cell carcinoma. In contrast, analogous lesions within the esophagus, termed esophageal epidermoid metaplasia, are rarely encountered and poorly described in the literature. To better characterize the clinicopathological features of this entity, we have collected 25 cases from 18 patients. Patients ranged in age from 37 to 81 years (mean, 61.5 years), with a slight female predominance (10/18, 56%). On presentation, a majority of patients complained of dysphagia (10/18, 56%). Past medical history was significant for tobacco smoking or long history of second-hand smoke in 11 (61%) patients and alcohol intake in 7 (39%) patients. Seventeen (94%) patients with esophageal epidermoid metaplasia were located within the middle-to-distal esophagus. Histologically, all cases were sharply demarcated and characterized by epithelial hyperplasia, a thickened basal layer, acanthotic midzone, a prominent granular cell layer, and superficial hyperorthokeratosis. Adjacent high-grade squamous dysplasia and/or squamous cell carcinoma were seen in 3 out of 18 (17%) patients. Follow-up information was available for 13 out of 18 (72%) patients and ranged from 2 to 8.3 years (mean, 2.3 years). Seven of the 13 (54%) patients had persistent disease; however, none of them developed squamous dysplasia or squamous cell carcinoma. In an effort to assess the incidence of esophageal epidermoid metaplasia, 198 consecutive esophageal biopsies were prospectively surveyed over a 6-month period at three academic institutions. No cases were identified within this time frame. In summary, esophageal epidermoid metaplasia is a rare condition affecting the middle-to-distal esophagus in middle-aged to elderly females. The occurrence of adjacent high-grade squamous dysplasia and/or squamous cell carcinoma warrants close follow-up.

Herpesviruses have been recognized in marine mammals, but their clinical relevance is not always easy to assess. A novel otarine herpesvirus-3 (OtHV3) was detected in a geriatric California sea lion (Zalophus californianus), and using a newly developed quantitative PCR assay paired with histology, OtHV3 was associated with esophageal ulcers and B cell lymphoblastic lymphoma in this animal. The prevalence and quantities of OtHV3 were then determined among buffy coats from 87 stranded and managed collection sea lions. Stranded sea lions had a higher prevalence of OtHV3 compared to managed collection sea lions (34.9% versus 12.5%; p = 0.04), and among the stranded sea lions, yearlings were most likely to be positive. Future epidemiological studies comparing the presence and viral loads of OtHV3 among a larger population of California sea lions with and without lymphoid neoplasia or esophageal ulcers would help elucidate the relevance of OtHV3-associated pathologies to these groups.

Background: Limited published data exist on the associated comorbid conditions with functional dyspepsia (FD)., Aims: This study aimed to assess the prevalence, services, and costs related to comorbid conditions associated with FD and the risk of having FD for each comorbid condition., Methods: A retrospective database analysis was undertaken using payroll data and adjudicated claims from January 1, 2001, through December 31, 2004 among >300,000 employees. Employees with FD were compared to propensity-score-matched employees without FD (controls). Outcome measures included the prevalence, costs, and utilization of health services for comorbid conditions as defined by the Agency for Healthcare Research and Quality (AHRQ) and the odds ratios of having FD from a multivariate model., Results: FD employees (N = 1,669) and a 50:1 matched control cohort (N = 83,450) were compared. Compared to matched controls, FD employees were more likely to have all major diagnostic categories. Moreover, 199/261 of the AHRQ's specific categories were more common in the FD cohort. Annual medical costs for the FD cohort were greater than for controls in 155/261 (59%) specific categories and significantly greater (P ≤ 0.05) in 76 categories (29%). Similarly, services were greater for 179/261 (69%) specific categories and significantly greater (P ≤ 0.05) in 110 categories (42%). In a multivariate model, esophageal disorders, gastritis and duodenitis, and abdominal pain were the most associated with having FD (odds ratios 3.8, 3.7, and 3.6, respectively). Only hypertension complications and disorders of the teeth and jaw were significantly negatively associated with FD., Conclusion: There is unexplained excess comorbidity associated with FD which may be a major determining factor for excess healthcare services and costs.

For the most part, the management of benign esophageal disease in all patients is in evolution. Advances in laparoscopic, thoracoscopic, and endoscopic techniques have lessened the morbidity and mortality associated with the traditional approaches to this pathology. Our understanding of the pathophysiology of primary motor disorders remains incomplete but is certainly more advanced than our understanding just a decade ago. As research continues in this area, our knowledge will increase. Persistent development efforts with industry will continue to provide less invasive options for the management of these patients, and, eventually, the results associated with these techniques will improve as well. For the management of these pathologies in the elderly, the critical issues are the associated comorbidities, the current quality of life, the life expectancy, and the desired quality of life. The optimal treatment strategy may be determined by consideration of all of these factors along with the relative effectiveness and durability of each treatment strategy for the individual elderly patient.

Background: US and Brazilian studies indicate that highly active antiretroviral therapy (HAART) has been effective in reducing morbidity and mortality from HIV/AIDS. Differences exist in the adoption and patterns of antiretroviral drug use and in the incidence of AIDS-defining illness (ADI) between the 2 countries, however, and there has not been a direct comparison of clinical response between Brazil and the United States. We sought to determine if there have been differences in the clinical response to HAART from HIV clinical practices in the United States and Brazil., Methods: We compared 2 similarly designed clinical cohorts from Baltimore, Maryland and Rio de Janeiro, Brazil. Patients who started HAART from 1997 to 2004 were compared for HIV-1 RNA suppression and CD4+ T-lymphocyte count change by 1 year of therapy and for development of an ADI up to 6 years of follow-up. A total of 1368 patients from Baltimore and 1045 patients from Rio de Janeiro were studied., Results: There was no difference by location in achieving an HIV-1 RNA level <400 copies/mL (46.9% in Rio de Janeiro, 50.8% in Baltimore), in the log change in HIV-1 RNA level (-1.65 log in Rio de Janeiro, - 1.63 log in Baltimore), or in the change in CD4 count (116 cells/mm3 in Rio de Janeiro, 122 cells/mm3 in Baltimore) by 12 months after starting HAART. By Kaplan-Meier analysis and Cox regression adjusted for demographic and clinical prognostic factors, there was no difference by location in development of the first ADI after starting HAART (relative hazard = 1.02; 95% confidence interval: 0.82 to 1.25 for Rio de Janeiro vs. Baltimore). The most commonly occurring ADI in Rio de Janeiro was tuberculosis (27.7% of patients), and the most commonly occurring ADI in Baltimore was esophageal candidiasis (36.8% of patients)., Conclusions: There were only minor differences in clinical response to the use of HAART comparing Rio de Janeiro with Baltimore, despite differences in patterns of antiretroviral drug use and ADI incidence. This analysis indicates that HAART can be similarly effective in treating HIV/AIDS in countries with different economies.

Objective: This study evaluated the overall safety and tolerability of once-weekly (OW) alendronate 70 mg oral solution (OS) versus OW placebo OS., Methods: Postmenopausal, osteoporotic women were enrolled at 51 centers in the United States in a 6-month double-blind, randomized trial. Patients were randomized (1:1) to OW alendronate 70 mg OS or placebo OS. The primary end point was the proportion of patients reporting any upper gastrointestinal (UGI) adverse event (AE) at 6 months. Secondary end points included mean percentage change in urinary N-telopeptide of type I human collagen (NTx) and serum bone-specific alkaline phosphatase (BSAP) at 6 months., Results: Initially, 454 women were enrolled; 392 (86.3%) completed the study. The mean (SD) age was 65.2 (10) years, and the mean (SD) time since menopause was 19.1 (12) years. The proportion of patients experiencing any UGI AE was significantly higher with alendronate OS (23.7%) compared with placebo solution (15.3%), with a treatment difference of 8.3% (95% CI, 0.8%-15.8%; P = 0.024). The proportion of patients experiencing any esophageal AE was 4.0% with alendronate and 3.0% with placebo (treatment difference, 1.0% [95% CI, -2.7% to 4.8%]). In addition, 4.5% of alendronate and 8.7% of placebo patients discontinued the study due to any clinical AE, and 3.3% of alendronate and 1.8% of placebo patients discontinued due to a UGI AE (difference, 1.5% [95% CI, -1.5% to 4.4%]). Alendronate OS produced significantly greater reductions in both NTx and BSAP than placebo (differences, -47.5% and -38.7%, respectively [both, P < 0.001])., Conclusions: In this 6-month study, patients receiving OW alendronate 70 mg OS had a higher rate of UGI AEs than placebo patients. However, rates of serious UGI AEs, discontinuations due to UGI AEs, and esophageal AEs were similar between groups. UGI AEs in the study were generally mild to moderate in severity and did not result in treatment discontinuation. In addition, OW alendronate 70 mg OS significantly reduced biochemical markers of bone turnover.

This article discusses the evidence linking obesity to the different manifestations of gastroesophageal reflux disease and colorectal cancer.

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder. Despite its frequent occurrence, only a minority of patients seek medical attention, making it difficult to ascertain the true epidemiologic distribution of the disorder. A causal association between GERD and esophageal complications such as esophagitis, esophageal ulcer, and esophageal stricture is well accepted. Recent epidemiologic evidence suggests that GERD may likewise represent a risk factor for the development of supraesophageal conditions, such as asthma, chronic bronchitis, laryngitis, and even laryngeal cancer. Although epidemiologic associations do not establish a cause-and-effect relationship, they may indicate potential etiologic risk factors. Nevertheless, confirmation of the causal role of GERD in supraesophageal disorders awaits further investigation.

Aims: To study the epidemiology and natural history of gastro-oesophageal reflux disease (GORD)., Methods: Retrospective cohort study involving all 172 hospitals of the Department of Veterans Affairs. A total of 194,527 patients with GORD were followed between 1981 and 1994. Distribution of oesophagitis, oesophageal ulcer, oesophageal stricture, strictured hiatus hernia, hiatus hernia, and pyrosis by age, sex, and ethnicity were determined. The comorbid occurrence of various forms of GORD in identical patients was analysed by an age and race standardised morbidity ratio. The population of all hospitalised veterans was used for comparison., Results: Severe forms of GORD associated with oesophageal erosions, ulcers, or strictures, affected elderly, white, male patients more often than their corresponding opposite demographic group. All forms of GORD clustered in the same patient population; on average, any form of GORD was 10 times more likely to occur in a patient with another form of GORD than without. The highest morbidity ratio (22) was found in oesophageal ulcer and stricture. About one third of all patients with oesophageal erosions, ulcers, or strictures also had hiatus hernia; 46% of patients with hiatus hernia were diagnosed as having other forms of GORD. While one third of all oesophageal strictures appeared in patients without other forms of GORD diagnosed at any time, oesophageal ulcers were always associated with some other form of GORD. No clear cut progression in different forms of GORD was found., Conclusions: Older age, male sex, and white ethnicity are risk factors in the development of severe forms of GORD. The most severe grade of GORD is reached at the onset of the disease.

Despite the frequent occurrence of gastroesophageal reflux disease, until now only very few studies have dealt with the epidemiology of this common disorder. The Health Care Financing Administration complies annually 10 million records of all hospital discharges among Medicare beneficiaries distributed throughout the United States. The purpose of the present study was to take advantage of this large data set and analyze the demographic characteristics of patients discharged with esophagitis, esophageal ulcer, or esophageal stricture. The hospital discharge rates of all three diagnoses showed an age-related rise, the rise being most pronounced for esophageal stricture and, less significant, esophageal ulcer. The marked age dependency of esophageal stricture and ulcer may reflect the time necessary for complications to develop. While simple esophagitis affected women more frequently than men, significantly more men contracted its severe forms involving ulcers and strictures. All forms were more common in whites than blacks, and living in the southern parts of the United States was associated with an increased risk for esophagitis and strictures. The data suggest that besides varying exposure to environmental risk factors, differences in the pathophysiology among demographically stratified groups contribute to the occurrence of esophagitis.

Objective: To describe the spectrum of disease in persons with human immunodeficiency virus (HIV) infection., Design: Retrospective survey of medical records., Setting: More than 50 clinics, hospitals, and private medical practices in nine US cities., Patients: A total of 626 women and 7008 men 13 years of age or older with HIV infection who received medical care from January 1990 through March 1991 were consecutively enrolled., Main Outcome Measures: Any history of diseases in the 1987 case definition for the acquired immunodeficiency syndrome (AIDS), and during the 12-month period preceding enrollment (baseline period), the occurrence of other major diseases, hospitalizations, and results of CD4+ lymphocyte counts., Results: Thirty-two percent of persons met the 1987 case definition for AIDS. The occurrence of an AIDS-indicator disease during the baseline period ranged from 3% (33/1011) to 46% (1254/2748) among persons with CD4+ lymphocyte counts of 0.50 x 10(9)/L or greater and fewer than 0.20 x 10(9)/L (greater than or equal to 500 and less than 200 CD4+ lymphocytes per microliter), respectively, and, at comparable CD4+ lymphocyte levels, was similar among women compared with men, and among persons who reported intravenous drug use compared with men who reported male-to-male sex. The frequency of one or more other major infectious diseases (eg, other pneumonias, bacterial sepsis, pulmonary tuberculosis) ranged from 6% to 16% among persons with CD4+ lymphocyte counts of 0.50 x 10(9)/L or greater and fewer than 0.20 x 10(9)/L, respectively; these illnesses were also associated with a history of intravenous drug use. Among persons who did not meet the 1987 AIDS case definition, 30% of those with an available CD4+ lymphocyte count had fewer CD4+ cells than 0.20 x 10(9)/L, 8% had one or more major infectious diseases, and 14% had one or more hospital admissions., Conclusions: For every person with AIDS at these sites, two additional persons with HIV infection were receiving medical care, many of whom had severe immunosuppression and a broad spectrum of serious HIV-related disease.