Mary Fredericksen - Academia.edu (original) (raw)

Papers by Mary Fredericksen

Dysphagia, Sep 1, 2010

The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to ... more The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to measure esophageal dysphagia, by adapting items from validated instruments for use in clinical trials, and assess its feasibility, reproducibility, and concurrent validity. Outpatients referred to endoscopy for dysphagia or seen in a specialty clinic were recruited. Feasibility testing was done to identify problematic items. Reproducibility was measured by test-retest format. Concurrent validity reflects agreement between information gathered in a structured interview versus the patients' written responses. The MDQ-30, a 28-item instrument, took 10 min (range = 5-30 min) to complete. Four hundred thirty-one outpatients [210 (49%) men; mean age = 61 years] participated. Overall, most concurrent validity kappa values for dysphagia were very good to excellent with a median of 0.78 (min 0.28, max 0.95). The majority of reproducibility kappa values for dysphagia were moderate to excellent with a median kappa value of 0.66 (min 0.07, max 1.0). Overall, concurrent validity and reproducibility kappa values for gastroesophageal reflux disease (GERD) symptoms were 0.81 (95% CI = 0.72, 0.91) and 0.66 (95% CI = 0.55, 0.77), respectively. Individual item percent agreement was generally very good to excellent. Internal consistency was excellent. We conclude that the MDQ-30 is an easy-to-complete tool to evaluate reliably dysphagia symptoms over the last 30 days.

European Journal of Cancer Supplements, 2007

efficacy endpoints were evaluated up to wk 13. Efficacy was evaluated by transfusions (weeks 5 to... more efficacy endpoints were evaluated up to wk 13. Efficacy was evaluated by transfusions (weeks 5 to 13) and hematologic response at week 13. Safety analyses included hazard ratio (HR) estimates of events from a Cox regression analyses (stratified by study). Events were identified as follows: deaths based on reasons given for drug or study discontinuation, or fatal AE; progressive disease (PD) if given as reason for drug or study termination or end-of-study disease status; progression-free survival (PFS) as time until death or PD, whichever earlier; and thromboembolic events (TEs). To consistently define TEs, adverse events (AEs) across trials were mapped to a common reporting dictionary (MedDRA v.9). Results: Analyses included 1515 pts (901 DA, 614 PBO). Demography was similar between DA and PBO groups: %women (54.6% and 52.0%, respectively) and mean ages (62.3 [12.3] and 62.3 [11.8] yrs). Results are presented in the table. The difference between groups in the rates of transfusions and hematologic response favored DA. Risk for a TE was 50% higher in DA group. Risks of death, DP, and PFS were similar between groups. Conclusions: This analysis reconfirms data from DA RCTs, demonstrating a decrease in transfusions, improvement in hematologic response, and an increased risk of TE. Risks of PFS and death did not differ between groups. Difference* or HR (95% CI) [DA vs PBO] Transfusion wk 5−13, Diff. in KM rate −19.2* (−21.4, −16.9) Hematologic response at wk 13, Diff. in KM rate 39.8* (37.1−42.5) TEs 1.50 (0.97−2.33) Death -On-study (OS)/OS+FU 1.14 (0.76−1.70)/0.99 (0.82−1.19) Disease progression -OS 0.87 (0.70−1.09) PFS -OS/OS+FU 0.91 (0.74−1.12)/0.88 (0.76−1.01) OS = on-study; FU = follow-up; KM = Kaplan-Meier; HR = hazard ratio; Diff = difference (DA-PBO). HR < 1 favors DA. Hematologic response = Hb increase by 2 g/dL or Hb 12.0 g/dL.

The American Journal of Gastroenterology, 2002

(1) BE occurs in at least 9 -10% of all subgroups coming to endoscopy.

The American Journal of Gastroenterology, 2002

The American Journal …, 2004

Fredericksen MB, Vazquez-Sequeiros E., Romero Y., Cameron AJ, Zais TG, Wadum LK, Schaid DJ, Wang ... more Fredericksen MB, Vazquez-Sequeiros E., Romero Y., Cameron AJ, Zais TG, Wadum LK, Schaid DJ, Wang KK, Reddy R., Burgart LJ//The American Journal of Gastroenterology, 2001. Поиск в библиотеке, Расширенный поиск. ...

PLoS ONE, 2008

Background: Barrett's esophagus predisposes to esophageal adenocarcinoma. However, the value of e... more Background: Barrett's esophagus predisposes to esophageal adenocarcinoma. However, the value of endoscopic surveillance in Barrett's esophagus has been debated because of the low incidence of esophageal adenocarcinoma in Barrett's esophagus. Moreover, high inter-observer and sampling-dependent variation in the histologic staging of dysplasia make clinical risk assessment problematic. In this study, we developed a 3-tiered risk stratification strategy, based on systematically selected epigenetic and clinical parameters, to improve Barrett's esophagus surveillance efficiency.

International Journal of Radiation Oncology*Biology*Physics, 2007

Purpose/Objective(s): To evaluate changes in quality of life (QOL) of patients with esophageal ca... more Purpose/Objective(s): To evaluate changes in quality of life (QOL) of patients with esophageal carcinoma following treatment with chemotherapy and radiotherapy. Materials/Methods: The Mayo Clinic Esophageal and Barrett's Esophagus Registry (EABE) is a multi-institutional resource that includes blood, fresh-frozen and formalin-fixed tissue, linked pathologic and clinical data, and serial validated symptom and quality of life (QOL) questionnaires obtained over time. The current investigation was performed using patients from the EABE Registry who had have completed at least 2 QOL assessments (at baseline and 1 year later). Each QOL measurement consisted of the Linear Analogue Self Assessment (LASA) which contained 12 questions relating to overall QOL and sub-components of QOL including social, spiritual, physical, mental, emotional, social support, financial, pain (2 questions), fatigue and legal issues. 42 patients in the EABE Registry had received chemotherapy and were identified as having a QOL assessment completed pre-and post-therapy. 41 of those 42 also received radiation therapy (RT). 29 (69%) underwent esophagectomies. Kruskal-Wallis tests were performed for the difference in continuous data between groups and Chi-square (or Fischer-Exact) tests were performed for differences in categorical data between groups. Results: Median Age was 60 (35.0-83.0 range). 35 (83%) were male and 7 (17%) were female. 37 (88%) had locally advanced tumors (T 3-4 N x M 0 or T x N 1 M 0 or T x N x M 1a ), 2 (5%) were early stage tumors (T 1-2 N 0 M 0 ), and 3 (7%) were metastatic (T x N x M 1b ) at diagnosis. 7 (17%) patients developed recurrence. Pain Frequency (p = 0.02) and Pain Severity (p = 0.01) were both statistically significantly worse over time. Financial Well-being (p = 0.06) and Overall QOL (p = 0.09) were both marginally significantly worse. There were no significant differences to report when comparing QOL scores by relapse status, however, a subset analysis of only patients without recurrent disease revealed that there was significantly worse Pain Severity (p = 0.04) and a trend toward a worse Pain Frequency (p = 0.07). Between genders, there was a marginal difference in Social Activity. (p = 0.07). Between marital status, there were statistically significant differences between Mental Well-being (p = 0.01), Physical Well-being (p = 0.02), Overall QOL (p = 0.002) and Spiritual Well-being (p = 0.03) with single people having more improvement with time. When LASA QOL is evaluated by stage, comparing the locally advanced patients to the rest, the locally advanced patients did significantly worse than the other stages in both change in Financial Well-being (p = 0.02) and change in Legal Concerns (p = 0.02) but did better when considering change in Pain Frequency (p = 0.05). Conclusions: Survivors of esophageal cancer may require ongoing attention regarding pain management, both in terms of severity and frequency, even in the absence of recurrence. Although patients receiving multi-modality therapy for locally advanced tumors may experience less pain frequency in comparison to similar stage patients not receiving such therapy, the increased complexity in medical treatment may impact financial and legal aspects of QOL to a greater degree.

Journal of Econometrics, 2011

Gastrointestinal Endoscopy, 2010

recording the raw radiofrequency (RF) signals received by the EUS probe prior to image formation,... more recording the raw radiofrequency (RF) signals received by the EUS probe prior to image formation, calibrating these signals by a known standard to remove system artifacts, and analyzing the calibrated signal spectra, objective and quantitative information related to tissue properties can be obtained which can provide additional information to conventional grayscale images.Methods: In the studies with the single-element scope, an Olympus Exera EU-M60 system was employed with GF-UM160 radial scope. Calibration was performed using specular reflection from a cylinder filled with a tissue-mimicking phantom. In the array scope studies, an Olympus Exera EU-ME1 system was used with GF-UE160-AL5 radial and GF-UC140P-AL5 curvilinear scopes. To account for the adjustable focal distances of these scopes, calibration was performed using a set of phantom-filled cylindrical chambers for the radial scope and a set of phantom cavities at various distances from a plate for the curvilinear scope. In all studies, MATLAB-based software was written to select the RF data from clinically relevant regions of interest and perform the spectral analysis. Linear regression of calibrated spectra was then obtained, and the resulting mean slope, intercept, mid-band fit, and correlation coefficient were compared between normal pancreas (NP), pancreatic adenocarcinoma (PC), and chronic pancreatitis (CP) as well as between benign (BLN) and malignant lymph nodes (MLN).Results: In the single-element scope studies, RF data were acquired from 26 LN images (15 benign, 11 malignant; 16 subjects) and from 60 pancreas images (40 NP, 13 PC, and 7 CP; 41 subjects). The mean mid-band fit and intercept differed significantly between the BLN and MLN cases (pϽ0.002), and subsequent linear discriminant analysis (LDA) with these two parameters classified with 73% accuracy. The mean mid-band fit and correlation coefficient differed significantly between NP, CP, and PC cases (all pϽ0.05). Subsequent LDA achieved accuracy of 93% distinguishing NP from diseased pancreas and 85% distinguishing PC from CP. In the array scope studies, RF data have been acquired from 28 pancreas and 9 LN images, and collection and analysis of data is ongoing.Conclusions: EUS spectrum analysis of RF data from single-element scopes is a promising method to objectively differentiate between NP, PC, and CP as well as BLN from MLN, and the technique can be extended to electronic-array scopes.

Gastroenterology, 2010

model was developed based on logistic regression by combining three PWS markers extracted from sq... more model was developed based on logistic regression by combining three PWS markers extracted from squamous cell nuclei (disorder strength, phase, standard deviation of phase). We were able to accurately discriminate adenocarcinoma/dysplasia in 12 out of 13 patients while correctly identifying 4 out of 6 non-dysplastic control patients for a sensitivity of 92% and specificity of 67%. Conclusion: The use of optical markers appears promising for detecting esophageal dysplasia and adenocarcinoma through the assessment of normal appearing squamous cells without the need for meticulous examination of the entire esophagus. Future studies including expansion of our training set and subsequent validation are warranted.

Gastroenterology, 2010

No abstract is available. To read the body of this article, please view the PDF online. ... © 201... more No abstract is available. To read the body of this article, please view the PDF online. ... © 2010 AGA. Published by Elsevier Inc. All rights reserved. ... Advertisements on this site do not constitute a guarantee or endorsement by the journal, Association, or publisher of the quality or ...

Gastroenterology, 2008

the mean difference in C between pull and push endoscopy was 0.4 cm (95% confidence interval (CI)... more the mean difference in C between pull and push endoscopy was 0.4 cm (95% confidence interval (CI) 0.19 to 2.12), with limits of agreement from -2.78 to 3.58 cm. For M, the mean difference between pull and push endoscopy was 0.77 cm (95% CI -0.19 to 2.18), with limits of agreement from -2.33 to 3.86 cm. The mean difference in C between doctor and nurse was -0.17 cm (95% CI -0.92 to 2.77), with limits of agreement from -4.20 to 3.87 cm. For M the mean difference between doctor and nurse was -0.63 cm (95% CI -1.35 to 2.63), with limits of agreement from -4.47 to 3.21 cm. Conclusions: The correlation coefficients for pull against push endoscopy and doctor against nurse demonstrate the strong relationship between these variables. However, there were considerable discrepancies between C & M values in both comparisons, with wide limits of agreement. Possible explanations for a reduced level of agreement in this real-time clinical setting include: patient movement and retching, differences in landmark interpretation and measurement technique, and the lack of 1 cm markings on the endoscope.

Gastroenterology, 2010

52 years; range: 18-79 years). 22 patients fulfilled the inclusion criteria and completed the stu... more 52 years; range: 18-79 years). 22 patients fulfilled the inclusion criteria and completed the study. 9 patients with normal acid exposure in BRAVO pH monitoring were excluded and did not receive esomeprazole treatment. Endoscopically, 7 patients were found with NERD, 10 patients with ERD and 2 patients with Barretts esophagus. 19 patients (86%) achieved complete symptom relief after 4 weeks of treatment with esomeprazole 40 mg o.d. Mean scores of individual RDQ scores pre-and post treatment differed 6-times in total (19.1 ± 2.4 vs. 3.2 ± 1.4), 8-times for heartburn (6.5 ± 0.9 vs. 0.8 ± 0.5), 5-times for regurgitation (7.2 ± 1.2 vs. 1.4 ± 0.64) and 4-times for dyspepsia (5.4 ± 0.99 vs. 1.3 ± 0.52). 2 patients had incomplete symptom relief. After escalating dosage, only 1 patient presented with persisting symptoms. In case of incomplete symptom relief, pH metry confirmed a pathological 48 hours pH tracing and an unchanged reflux cluster. Discussion: PPI naïve patients with characteristic GERD-related symptoms and abnormal finding in pH metry respond to standard dose esomeprazole. The combination of structured symptom recording and functional testing allows to predict a high response to standard dose PPI. For non-responders with abnormal 48 hours pH metry, it is appropriate to escalate PPI to double standard dose.

Dysphagia, 2010

The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to ... more The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to measure esophageal dysphagia, by adapting items from validated instruments for use in clinical trials, and assess its feasibility, reproducibility, and concurrent validity. Outpatients referred to endoscopy for dysphagia or seen in a specialty clinic were recruited. Feasibility testing was done to identify problematic items. Reproducibility was measured by test-retest format. Concurrent validity reflects agreement between information gathered in a structured interview versus the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; written responses. The MDQ-30, a 28-item instrument, took 10 min (range = 5-30 min) to complete. Four hundred thirty-one outpatients [210 (49%) men; mean age = 61 years] participated. Overall, most concurrent validity kappa values for dysphagia were very good to excellent with a median of 0.78 (min 0.28, max 0.95). The majority of reproducibility kappa values for dysphagia were moderate to excellent with a median kappa value of 0.66 (min 0.07, max 1.0). Overall, concurrent validity and reproducibility kappa values for gastroesophageal reflux disease (GERD) symptoms were 0.81 (95% CI = 0.72, 0.91) and 0.66 (95% CI = 0.55, 0.77), respectively. Individual item percent agreement was generally very good to excellent. Internal consistency was excellent. We conclude that the MDQ-30 is an easy-to-complete tool to evaluate reliably dysphagia symptoms over the last 30 days.

Diseases of the Esophagus, 2007

While multiple instruments characterize upper gastrointestinal symptoms, a validated instrument d... more While multiple instruments characterize upper gastrointestinal symptoms, a validated instrument devoted to the measurement of a spectrum of esophageal dysphagia attributes is not available. Therefore, we constructed and validated the Mayo Dysphagia Questionnaire (MDQ). The 27 items of the MDQ underwent content validity, feasibility, concurrent validity, reproducibility, internal consistency, and construct validity testing. To assess content validity, five esophageal subspecialty gastroenterologists reviewed the items to ensure inclusion of pertinent domains. Feasibility testing was done with eight outpatients who refined problematic items. To assess concurrent validity, 70 patient responses on the MDQ were compared to responses gathered in a structured patient-physician interview. A separate group of 70 outpatients completed the MDQ twice to assess the reproducibility of each item. A total of 148 patients participated in the validation process (78 [53%] men; mean age 62). On average, the MDQ took 6 minutes to complete. A single item (odynophagia) tested poorly with a kappa value of < 0.4. Otherwise, the majority of concurrent validity kappa values were in the good to excellent range with a mean of 0.63 (95% CI 0.22-0.89). The majority of reproducibility kappa values were also in the good to excellent range with a median kappa value of 0.76 (interquartile range: 0.67-0.81). Cronbach's alpha values were excellent in the range of 0.86-0.88. Spearman rank correlation coefficients to assess construct validity were also excellent in the range of 0.87-0.98. Thus, the MDQ is a concise instrument that demonstrates overall excellent concurrent validity, reproducibility, internal consistency, and construct validity for the features of esophageal dysphagia.

Digestive Diseases and Sciences, 2010

Background Patients with esophageal carcinoma (EC) report deficits in quality of life (QOL), depe... more Background Patients with esophageal carcinoma (EC) report deficits in quality of life (QOL), depending on the extent of malignant disease and the goals of treatment at the time of QOL measurement. Aims To quantify the association of marital status and changes in QOL over time in patients with EC and patients with Barrett's esophagus (BE). Methods Eligible patients in the Mayo Clinic Esophageal Adenocarcinoma and Barrett's Esophagus Registry completed QOL assessments at baseline and approximately 1 year later. QOL was determined with a ten-point linear analog self-assessment scale evaluating overall QOL and 12 subscales. Results Overall, 489 BE patients and 212 EC patients were evaluated. Married EC patients reported higher baseline QOL in legal concerns (8.1 vs. 7.1; p = .04) and friend and family support (9.3 vs. 8.4; p = .02) than single EC patients. Over time, married EC patients had a decrease in pain frequency QOL compared to single EC patients (-0.9 vs. ?0.6; p = .02), with other QOL measures being stable. Married BE patients showed higher social activity QOL at baseline than single BE patients (7.5 vs. 6.9; p = .02); QOL was stable over time between the marital status groups. Conclusions Minor, but statistically significant, changes were reported regarding QOL in two categories at baseline and over time among married and single patients with EC. Minor differences may be present between married and single EC patients regarding spiritual QOL at baseline and in overall physical well-being QOL at baseline and over time, although these differences did not reach statistical significance.

Digestive Diseases and Sciences, 2014

Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe re... more Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis. Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid(®)) (IR-OME) on esophagitis and gastroesophageal reflux symptoms. Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed. Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19-86), median BMI 29 (range 21-51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s esophagus was 14 % with half diagnosed only after treatment. Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s esophagus.

Dysphagia, Sep 1, 2010

The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to ... more The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to measure esophageal dysphagia, by adapting items from validated instruments for use in clinical trials, and assess its feasibility, reproducibility, and concurrent validity. Outpatients referred to endoscopy for dysphagia or seen in a specialty clinic were recruited. Feasibility testing was done to identify problematic items. Reproducibility was measured by test-retest format. Concurrent validity reflects agreement between information gathered in a structured interview versus the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; written responses. The MDQ-30, a 28-item instrument, took 10 min (range = 5-30 min) to complete. Four hundred thirty-one outpatients [210 (49%) men; mean age = 61 years] participated. Overall, most concurrent validity kappa values for dysphagia were very good to excellent with a median of 0.78 (min 0.28, max 0.95). The majority of reproducibility kappa values for dysphagia were moderate to excellent with a median kappa value of 0.66 (min 0.07, max 1.0). Overall, concurrent validity and reproducibility kappa values for gastroesophageal reflux disease (GERD) symptoms were 0.81 (95% CI = 0.72, 0.91) and 0.66 (95% CI = 0.55, 0.77), respectively. Individual item percent agreement was generally very good to excellent. Internal consistency was excellent. We conclude that the MDQ-30 is an easy-to-complete tool to evaluate reliably dysphagia symptoms over the last 30 days.

European Journal of Cancer Supplements, 2007

efficacy endpoints were evaluated up to wk 13. Efficacy was evaluated by transfusions (weeks 5 to... more efficacy endpoints were evaluated up to wk 13. Efficacy was evaluated by transfusions (weeks 5 to 13) and hematologic response at week 13. Safety analyses included hazard ratio (HR) estimates of events from a Cox regression analyses (stratified by study). Events were identified as follows: deaths based on reasons given for drug or study discontinuation, or fatal AE; progressive disease (PD) if given as reason for drug or study termination or end-of-study disease status; progression-free survival (PFS) as time until death or PD, whichever earlier; and thromboembolic events (TEs). To consistently define TEs, adverse events (AEs) across trials were mapped to a common reporting dictionary (MedDRA v.9). Results: Analyses included 1515 pts (901 DA, 614 PBO). Demography was similar between DA and PBO groups: %women (54.6% and 52.0%, respectively) and mean ages (62.3 [12.3] and 62.3 [11.8] yrs). Results are presented in the table. The difference between groups in the rates of transfusions and hematologic response favored DA. Risk for a TE was 50% higher in DA group. Risks of death, DP, and PFS were similar between groups. Conclusions: This analysis reconfirms data from DA RCTs, demonstrating a decrease in transfusions, improvement in hematologic response, and an increased risk of TE. Risks of PFS and death did not differ between groups. Difference* or HR (95% CI) [DA vs PBO] Transfusion wk 5−13, Diff. in KM rate −19.2* (−21.4, −16.9) Hematologic response at wk 13, Diff. in KM rate 39.8* (37.1−42.5) TEs 1.50 (0.97−2.33) Death -On-study (OS)/OS+FU 1.14 (0.76−1.70)/0.99 (0.82−1.19) Disease progression -OS 0.87 (0.70−1.09) PFS -OS/OS+FU 0.91 (0.74−1.12)/0.88 (0.76−1.01) OS = on-study; FU = follow-up; KM = Kaplan-Meier; HR = hazard ratio; Diff = difference (DA-PBO). HR < 1 favors DA. Hematologic response = Hb increase by 2 g/dL or Hb 12.0 g/dL.

The American Journal of Gastroenterology, 2002

(1) BE occurs in at least 9 -10% of all subgroups coming to endoscopy.

The American Journal of Gastroenterology, 2002

The American Journal …, 2004

Fredericksen MB, Vazquez-Sequeiros E., Romero Y., Cameron AJ, Zais TG, Wadum LK, Schaid DJ, Wang ... more Fredericksen MB, Vazquez-Sequeiros E., Romero Y., Cameron AJ, Zais TG, Wadum LK, Schaid DJ, Wang KK, Reddy R., Burgart LJ//The American Journal of Gastroenterology, 2001. Поиск в библиотеке, Расширенный поиск. ...

PLoS ONE, 2008

Background: Barrett's esophagus predisposes to esophageal adenocarcinoma. However, the value of e... more Background: Barrett's esophagus predisposes to esophageal adenocarcinoma. However, the value of endoscopic surveillance in Barrett's esophagus has been debated because of the low incidence of esophageal adenocarcinoma in Barrett's esophagus. Moreover, high inter-observer and sampling-dependent variation in the histologic staging of dysplasia make clinical risk assessment problematic. In this study, we developed a 3-tiered risk stratification strategy, based on systematically selected epigenetic and clinical parameters, to improve Barrett's esophagus surveillance efficiency.

International Journal of Radiation Oncology*Biology*Physics, 2007

Purpose/Objective(s): To evaluate changes in quality of life (QOL) of patients with esophageal ca... more Purpose/Objective(s): To evaluate changes in quality of life (QOL) of patients with esophageal carcinoma following treatment with chemotherapy and radiotherapy. Materials/Methods: The Mayo Clinic Esophageal and Barrett's Esophagus Registry (EABE) is a multi-institutional resource that includes blood, fresh-frozen and formalin-fixed tissue, linked pathologic and clinical data, and serial validated symptom and quality of life (QOL) questionnaires obtained over time. The current investigation was performed using patients from the EABE Registry who had have completed at least 2 QOL assessments (at baseline and 1 year later). Each QOL measurement consisted of the Linear Analogue Self Assessment (LASA) which contained 12 questions relating to overall QOL and sub-components of QOL including social, spiritual, physical, mental, emotional, social support, financial, pain (2 questions), fatigue and legal issues. 42 patients in the EABE Registry had received chemotherapy and were identified as having a QOL assessment completed pre-and post-therapy. 41 of those 42 also received radiation therapy (RT). 29 (69%) underwent esophagectomies. Kruskal-Wallis tests were performed for the difference in continuous data between groups and Chi-square (or Fischer-Exact) tests were performed for differences in categorical data between groups. Results: Median Age was 60 (35.0-83.0 range). 35 (83%) were male and 7 (17%) were female. 37 (88%) had locally advanced tumors (T 3-4 N x M 0 or T x N 1 M 0 or T x N x M 1a ), 2 (5%) were early stage tumors (T 1-2 N 0 M 0 ), and 3 (7%) were metastatic (T x N x M 1b ) at diagnosis. 7 (17%) patients developed recurrence. Pain Frequency (p = 0.02) and Pain Severity (p = 0.01) were both statistically significantly worse over time. Financial Well-being (p = 0.06) and Overall QOL (p = 0.09) were both marginally significantly worse. There were no significant differences to report when comparing QOL scores by relapse status, however, a subset analysis of only patients without recurrent disease revealed that there was significantly worse Pain Severity (p = 0.04) and a trend toward a worse Pain Frequency (p = 0.07). Between genders, there was a marginal difference in Social Activity. (p = 0.07). Between marital status, there were statistically significant differences between Mental Well-being (p = 0.01), Physical Well-being (p = 0.02), Overall QOL (p = 0.002) and Spiritual Well-being (p = 0.03) with single people having more improvement with time. When LASA QOL is evaluated by stage, comparing the locally advanced patients to the rest, the locally advanced patients did significantly worse than the other stages in both change in Financial Well-being (p = 0.02) and change in Legal Concerns (p = 0.02) but did better when considering change in Pain Frequency (p = 0.05). Conclusions: Survivors of esophageal cancer may require ongoing attention regarding pain management, both in terms of severity and frequency, even in the absence of recurrence. Although patients receiving multi-modality therapy for locally advanced tumors may experience less pain frequency in comparison to similar stage patients not receiving such therapy, the increased complexity in medical treatment may impact financial and legal aspects of QOL to a greater degree.

Journal of Econometrics, 2011

Gastrointestinal Endoscopy, 2010

recording the raw radiofrequency (RF) signals received by the EUS probe prior to image formation,... more recording the raw radiofrequency (RF) signals received by the EUS probe prior to image formation, calibrating these signals by a known standard to remove system artifacts, and analyzing the calibrated signal spectra, objective and quantitative information related to tissue properties can be obtained which can provide additional information to conventional grayscale images.Methods: In the studies with the single-element scope, an Olympus Exera EU-M60 system was employed with GF-UM160 radial scope. Calibration was performed using specular reflection from a cylinder filled with a tissue-mimicking phantom. In the array scope studies, an Olympus Exera EU-ME1 system was used with GF-UE160-AL5 radial and GF-UC140P-AL5 curvilinear scopes. To account for the adjustable focal distances of these scopes, calibration was performed using a set of phantom-filled cylindrical chambers for the radial scope and a set of phantom cavities at various distances from a plate for the curvilinear scope. In all studies, MATLAB-based software was written to select the RF data from clinically relevant regions of interest and perform the spectral analysis. Linear regression of calibrated spectra was then obtained, and the resulting mean slope, intercept, mid-band fit, and correlation coefficient were compared between normal pancreas (NP), pancreatic adenocarcinoma (PC), and chronic pancreatitis (CP) as well as between benign (BLN) and malignant lymph nodes (MLN).Results: In the single-element scope studies, RF data were acquired from 26 LN images (15 benign, 11 malignant; 16 subjects) and from 60 pancreas images (40 NP, 13 PC, and 7 CP; 41 subjects). The mean mid-band fit and intercept differed significantly between the BLN and MLN cases (pϽ0.002), and subsequent linear discriminant analysis (LDA) with these two parameters classified with 73% accuracy. The mean mid-band fit and correlation coefficient differed significantly between NP, CP, and PC cases (all pϽ0.05). Subsequent LDA achieved accuracy of 93% distinguishing NP from diseased pancreas and 85% distinguishing PC from CP. In the array scope studies, RF data have been acquired from 28 pancreas and 9 LN images, and collection and analysis of data is ongoing.Conclusions: EUS spectrum analysis of RF data from single-element scopes is a promising method to objectively differentiate between NP, PC, and CP as well as BLN from MLN, and the technique can be extended to electronic-array scopes.

Gastroenterology, 2010

model was developed based on logistic regression by combining three PWS markers extracted from sq... more model was developed based on logistic regression by combining three PWS markers extracted from squamous cell nuclei (disorder strength, phase, standard deviation of phase). We were able to accurately discriminate adenocarcinoma/dysplasia in 12 out of 13 patients while correctly identifying 4 out of 6 non-dysplastic control patients for a sensitivity of 92% and specificity of 67%. Conclusion: The use of optical markers appears promising for detecting esophageal dysplasia and adenocarcinoma through the assessment of normal appearing squamous cells without the need for meticulous examination of the entire esophagus. Future studies including expansion of our training set and subsequent validation are warranted.

Gastroenterology, 2010

No abstract is available. To read the body of this article, please view the PDF online. ... © 201... more No abstract is available. To read the body of this article, please view the PDF online. ... © 2010 AGA. Published by Elsevier Inc. All rights reserved. ... Advertisements on this site do not constitute a guarantee or endorsement by the journal, Association, or publisher of the quality or ...

Gastroenterology, 2008

the mean difference in C between pull and push endoscopy was 0.4 cm (95% confidence interval (CI)... more the mean difference in C between pull and push endoscopy was 0.4 cm (95% confidence interval (CI) 0.19 to 2.12), with limits of agreement from -2.78 to 3.58 cm. For M, the mean difference between pull and push endoscopy was 0.77 cm (95% CI -0.19 to 2.18), with limits of agreement from -2.33 to 3.86 cm. The mean difference in C between doctor and nurse was -0.17 cm (95% CI -0.92 to 2.77), with limits of agreement from -4.20 to 3.87 cm. For M the mean difference between doctor and nurse was -0.63 cm (95% CI -1.35 to 2.63), with limits of agreement from -4.47 to 3.21 cm. Conclusions: The correlation coefficients for pull against push endoscopy and doctor against nurse demonstrate the strong relationship between these variables. However, there were considerable discrepancies between C & M values in both comparisons, with wide limits of agreement. Possible explanations for a reduced level of agreement in this real-time clinical setting include: patient movement and retching, differences in landmark interpretation and measurement technique, and the lack of 1 cm markings on the endoscope.

Gastroenterology, 2010

52 years; range: 18-79 years). 22 patients fulfilled the inclusion criteria and completed the stu... more 52 years; range: 18-79 years). 22 patients fulfilled the inclusion criteria and completed the study. 9 patients with normal acid exposure in BRAVO pH monitoring were excluded and did not receive esomeprazole treatment. Endoscopically, 7 patients were found with NERD, 10 patients with ERD and 2 patients with Barretts esophagus. 19 patients (86%) achieved complete symptom relief after 4 weeks of treatment with esomeprazole 40 mg o.d. Mean scores of individual RDQ scores pre-and post treatment differed 6-times in total (19.1 ± 2.4 vs. 3.2 ± 1.4), 8-times for heartburn (6.5 ± 0.9 vs. 0.8 ± 0.5), 5-times for regurgitation (7.2 ± 1.2 vs. 1.4 ± 0.64) and 4-times for dyspepsia (5.4 ± 0.99 vs. 1.3 ± 0.52). 2 patients had incomplete symptom relief. After escalating dosage, only 1 patient presented with persisting symptoms. In case of incomplete symptom relief, pH metry confirmed a pathological 48 hours pH tracing and an unchanged reflux cluster. Discussion: PPI naïve patients with characteristic GERD-related symptoms and abnormal finding in pH metry respond to standard dose esomeprazole. The combination of structured symptom recording and functional testing allows to predict a high response to standard dose PPI. For non-responders with abnormal 48 hours pH metry, it is appropriate to escalate PPI to double standard dose.

Dysphagia, 2010

The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to ... more The aim of this study was to develop the Mayo Dysphagia Questionnaire-30 Day (MDQ-30), a tool to measure esophageal dysphagia, by adapting items from validated instruments for use in clinical trials, and assess its feasibility, reproducibility, and concurrent validity. Outpatients referred to endoscopy for dysphagia or seen in a specialty clinic were recruited. Feasibility testing was done to identify problematic items. Reproducibility was measured by test-retest format. Concurrent validity reflects agreement between information gathered in a structured interview versus the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; written responses. The MDQ-30, a 28-item instrument, took 10 min (range = 5-30 min) to complete. Four hundred thirty-one outpatients [210 (49%) men; mean age = 61 years] participated. Overall, most concurrent validity kappa values for dysphagia were very good to excellent with a median of 0.78 (min 0.28, max 0.95). The majority of reproducibility kappa values for dysphagia were moderate to excellent with a median kappa value of 0.66 (min 0.07, max 1.0). Overall, concurrent validity and reproducibility kappa values for gastroesophageal reflux disease (GERD) symptoms were 0.81 (95% CI = 0.72, 0.91) and 0.66 (95% CI = 0.55, 0.77), respectively. Individual item percent agreement was generally very good to excellent. Internal consistency was excellent. We conclude that the MDQ-30 is an easy-to-complete tool to evaluate reliably dysphagia symptoms over the last 30 days.

Diseases of the Esophagus, 2007

While multiple instruments characterize upper gastrointestinal symptoms, a validated instrument d... more While multiple instruments characterize upper gastrointestinal symptoms, a validated instrument devoted to the measurement of a spectrum of esophageal dysphagia attributes is not available. Therefore, we constructed and validated the Mayo Dysphagia Questionnaire (MDQ). The 27 items of the MDQ underwent content validity, feasibility, concurrent validity, reproducibility, internal consistency, and construct validity testing. To assess content validity, five esophageal subspecialty gastroenterologists reviewed the items to ensure inclusion of pertinent domains. Feasibility testing was done with eight outpatients who refined problematic items. To assess concurrent validity, 70 patient responses on the MDQ were compared to responses gathered in a structured patient-physician interview. A separate group of 70 outpatients completed the MDQ twice to assess the reproducibility of each item. A total of 148 patients participated in the validation process (78 [53%] men; mean age 62). On average, the MDQ took 6 minutes to complete. A single item (odynophagia) tested poorly with a kappa value of < 0.4. Otherwise, the majority of concurrent validity kappa values were in the good to excellent range with a mean of 0.63 (95% CI 0.22-0.89). The majority of reproducibility kappa values were also in the good to excellent range with a median kappa value of 0.76 (interquartile range: 0.67-0.81). Cronbach's alpha values were excellent in the range of 0.86-0.88. Spearman rank correlation coefficients to assess construct validity were also excellent in the range of 0.87-0.98. Thus, the MDQ is a concise instrument that demonstrates overall excellent concurrent validity, reproducibility, internal consistency, and construct validity for the features of esophageal dysphagia.

Digestive Diseases and Sciences, 2010

Background Patients with esophageal carcinoma (EC) report deficits in quality of life (QOL), depe... more Background Patients with esophageal carcinoma (EC) report deficits in quality of life (QOL), depending on the extent of malignant disease and the goals of treatment at the time of QOL measurement. Aims To quantify the association of marital status and changes in QOL over time in patients with EC and patients with Barrett's esophagus (BE). Methods Eligible patients in the Mayo Clinic Esophageal Adenocarcinoma and Barrett's Esophagus Registry completed QOL assessments at baseline and approximately 1 year later. QOL was determined with a ten-point linear analog self-assessment scale evaluating overall QOL and 12 subscales. Results Overall, 489 BE patients and 212 EC patients were evaluated. Married EC patients reported higher baseline QOL in legal concerns (8.1 vs. 7.1; p = .04) and friend and family support (9.3 vs. 8.4; p = .02) than single EC patients. Over time, married EC patients had a decrease in pain frequency QOL compared to single EC patients (-0.9 vs. ?0.6; p = .02), with other QOL measures being stable. Married BE patients showed higher social activity QOL at baseline than single BE patients (7.5 vs. 6.9; p = .02); QOL was stable over time between the marital status groups. Conclusions Minor, but statistically significant, changes were reported regarding QOL in two categories at baseline and over time among married and single patients with EC. Minor differences may be present between married and single EC patients regarding spiritual QOL at baseline and in overall physical well-being QOL at baseline and over time, although these differences did not reach statistical significance.

Digestive Diseases and Sciences, 2014

Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe re... more Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis. Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid(®)) (IR-OME) on esophagitis and gastroesophageal reflux symptoms. Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed. Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19-86), median BMI 29 (range 21-51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s esophagus was 14 % with half diagnosed only after treatment. Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s esophagus.