Logically, if GORD is not caught any one point along the line of treatment, certainly one provider, nurse or caregiver will pick it up somewhere along the way. As seen previously, children are especially at risk for GORD. Hashem B. El -- Serag in the journal Clinical Gastroenterology and Hepatology writes about what he sees as the general perception that the incidence of gastroesophageal reflux disease (GORD) is on the rise. However, few studies have tackled the issue head on. By methodologically using a systematic approach, the study aimed assessing whether or not incidence of GORD is has changed with the passage of time (El -- Serag 2007 17).

First of all, population-based studies were subjected to a time-trend analysis with a Poisson regression model that diagnosed the incidence of at least weekly heartburn and/or acid regurgitation.

Secondly, the population-based studies reported the prevalence of the GORD symptoms at two time points in the same source population also were reviewed. Thirdly, the longitudinal studies that charted the incidence of GORD symptoms and also oesophagitis in primary and secondary care venues were examined. The Poisson model revealed a significant (P < .0001) trend for the increase in the incidence of reflux symptoms in the general population with time. An increase in the incidence of GORD or oesophagitis was to be found in the majority of longitudinal studies. There was evidence that the incidence of GORD had increased during the previous two decades. If this trend continues unabated, it could contribute to the rapidly increasing incidence of the more serious complications that are associated with GORD, such as esophageal adenocarcinoma, as well as the costs to healthcare systems and their employers (ibid. 17-18).

To review, diagnostic tools observed in the previous articles were GORD questionnaires, GPRD and five-year follow-up studies. Certainly, tracking over the lifetime of the disease is critical to the treatment of it.

Barrett's Oesophagus

GORD can also lead to Barrett's oesophagus (BO). This malady is a type of intestinal metaplasia, This is in turn a precursor condition for the problem of carcinoma. The risk of a progression from BO to dysplasia is uncertain but can be estimated in approximately 20% of cases. Due to the risk of a chronic heartburn progression to BO and esophagogastroduodenoscopy (EGD) every five years is the recommended treatment for patients with chronic heartburn or who man take drugs for chronic GORD. BO continues to be increasingly recognized by the medical establishment and is also believed to be a major risk factor for the development of cancers. The incidence of adenocarcinoma of the esophagus continues to rise meteorically. The rate of rise is quite alarming and is widespread in the U.K. (Wang Sampliner 2008 788).

The authors of the study claim that there are a few prospective follow-up BO cohorts that assess the risk of extraoesophageal cancer incidence or mortality. Certainly, some additional studies are necessary so that it is possible to understand the overall risks of cancer and death that is experienced by the patients who had contracted BE. In Cook et al., a cohort of 502 patients diagnosed with BO were identified at the Leeds General Infirmary, England. The mortality and cancer incidence information were both provided by the Office for National Statistics. The standardized mortality ratios (SMR) and the standardized incidence ratios (SIR) were calculated by using indirect standardization. Thus, all cause mortality was elevated in patients with BE [SMR, 1.21; 95% confidence interval (95% CI), 1.06, 1.37] and they remained this way after the esophageal cancers were excluded (SMR, 1.16; 95% CI, 1.01-1.32). Also, increased mortality risks were found for malignancies of the esophagus (SMR, 7.26; 95% CI, 3.87-12.42) and also the diseases of the digestive system (SMR, 2.03; 95% CI, 1.11-3.40) (Cook et al. 2007-2091-2092).

The remaining disease categories produced no altered risk estimates and in the case of circulatory disease the mortality rate was statistically significant (SMR, 1.24; 95% CI, 1.00-1.52; P = 0.053) for those with a specialized intestinal metaplasia diagnosis of BO. In the cancer incidence...

All of the remaining analyses provided risks to include colorectal cancer. The author's study showed evidence of the increased risk of esophageal cancer and mortality in BO. It has also been shown in the study that those who have a histological BO diagnosis that may also have an increased risk of mortality due to circulatory disease (ibid. 2092-2095).
In another cancer related article in the journal Alimentary Pharmacology Therapy, the development of BE into carcinoma is further investigated. The authors in that article point out that patients with BE are at and increased risk of oesophageal adenocarcinoma. Their observational studies suggested an increase in over-all mortality, however, the data was conflicting in their general review of data, so this influenced the methodology of their research study. In other words, the study aimed to measure off the incidence of death as a cause of BE against the rate for the general They studied patients diagnosed with BE were identified in four hospitals in Leicestershire, UK that are using electronic endoscopy and histopathology records. The data on the deaths from of the patients were identified through the U.K.'s Office of National Statistics. They were then compared with the age and gender adjusted mortality rate in the Leicestershire, U.K. region (Moayyedi et al. 2008 317).

Some 1737 patients with BE were identified, but medical notes could only be retrieved in

1272 or 73.2% of the patients. These BE patients were identified in 245 deaths in the group . Overall mortality was found to have increased [male standardized mortality ratio (SMR) = 552 and also 95% CI = 466 -- 638; female SMR 455, 95% CI = 357 -- 552]. The main disease areas was responsible for this were oesophageal adenocarcinoma (n = 25, male SMR = 2171, 95% CI = 991 -- 3351; female SMR = 1300, 95% CI = 26 -- 2574), bronchopneumonia (n = 70, male SMR = 146, 95% CI = 55 -- 236; female

SMR = 436, 95% CI = 272 -- 601) and ischaemic heart disease (n = 51, male SMR = 186, 95% CI = 97 -- 2748; female SMR = 205, 95% CI = 105 -- 306). To sum up, patients with BE die more commonly of bronchopneumonia and ischaemic heart disease when compared with oesophageal adeno-

carcinoma. The overall mortality rate in this cohort may have increased (ibid., 317-318).

In terms of strengths, the study's diagnosis of BO was well defined. The cause of death was confirmed from official death certificates viewed against with a patient notes. Community controls were derived as well from the same population group as the BO cases. The weaknesses of the study were that the numbers of BE cases and the length of follow-up were relatively modest. Unfortunately the authors could only evaluate the common causes of mortality and overall mortality. Data were not in existence in some 25% of cases and the study was confined to a single region. The results therefore were not found to be generalizable to the other populations. BO patients were then methodically compared with the expected rates from the general population. The authors therefore did not have the information on potential confounding factors . These factors could not be adjusted for in the analysis (ibid. 319).

In order to overcome the weaknesses in the study methodology, it might be prudent in future research to conduct more detailed research if a questionnaire regarding BO and carcinoma could be distributed to coroners by the Office of National Statistics or if the Office could be persuaded to change the structure of the death certificate paperwork to ask BE and carcinoma related questions. Certainly, it should be a significant enough health issue to justify more attention fro the Office of National Statistics to test specifically for data that would provide more definitive conclusions about BO and carcinoma.

Using this same line of logic, one can only speculate and hope that the future research regarding GORD could be tracked at birth. Certainly, if maternity room personnel could be better educated to detect and record GORD, such data could be useful not just for later statistical analysis (such as our journal articles), but also as a tool for detection and management of the disease in a person's life. The potential improvement in patient quality of life is certainly worth it. We can logically see birth and death as historical life events that serve as access points in the battle to understand and fight acid reflux related disorders. In this way, researchers in future studies of various maladies related to acid reflux can combine and enjoy the best of both worlds of the accuracy of longitudinal information culled from patient notes. In this way, the study and mitigation efforts will truly encompass the problems from cradle to grave.

As mentioned above in…