Benefit of Extended Surveillance of Low-Risk Pancreatic Cysts After 5-Year Stability: A Systematic Review and Meta-Analysis.

BACKGROUND & AIMS: Low-risk branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) lacking worrisome features (WF) and high-risk stigmata (HRS) warrant surveillance. However, their optimal duration, especially among cysts with initial 5 years of size stability, warrants further investigation. We systematically reviewed the surveillance of low-risk BD-IPMNs and investigated the incidence of WF/HRS and advanced neoplasia, high-grade dysplasia, and pancreatic cancer during the initial (<5 years) and extended surveillance period (>5-years). METHODS: A systematic search (CRD42020117120) identified studies investigating long-term IPMN surveillance outcomes of low-risk IPMN among the Cochrane Library, Embase, Google Scholar, Ovid Medline, PubMed, Scopus, and Web of Science, from inception until July 9, 2021. The outcomes included the incidence of WF/HRS and advanced neoplasia, disease-specific mortality, and surveillance-related harm (expressed as percentage per patient-years). The meta-analysis relied on time-to-event plots and used a random-effects model. RESULTS: Forty-one eligible studies underwent systematic review, and 18 studies were meta-analyzed. The pooled incidence of WF/HRS among low-risk BD-IPMNs during initial and extended surveillance was 2.2% (95% CI, 1.0%-3.7%) and 2.9% (95% CI, 1.0%-5.7%) patient-years, respectively, whereas the incidence of advanced neoplasia was 0.6% (95% CI, 0.2%-1.00%) and 1.0% (95% CI, 0.6%-1.5%) patient-years, respectively. The pooled incidence of disease-specific mortality during initial and extended surveillance was 0.3% (95% CI, 0.1%-0.6%) and 0.6% (95% CI, 0.0%-1.6%) patient-years, respectively. Among BD-IPMNs with initial size stability, extended surveillance had a WF/HRS and advanced neoplasia incidence of 1.9% (95% CI, 1.2%-2.8%) and 0.2% (95% CI, 0.1%-0.5%) patient-years, respectively. CONCLUSIONS: A lower incidence of advanced neoplasia during extended surveillance among low-risk, stable-sized BD-IPMNs was a key finding of this study. However, the survival benefit of surveillance among this population warrants further exploration through high-quality studies before recommending surveillance cessation with certainty.

First Clostridioides difficile Recurrence Is Highest Following Concomitant Antimicrobial Administration During and Within 30 Days of Treatment.

BACKGROUND: Clostridioides difficile infection (CDI) is an epidemic with the strongest risk factor being antibiotic usage. Patients who get CDI frequently require concomitant antibiotics for other indications around the time of their infection. AIMS: To assess the recurrence of CDI (rCDI) in patients receiving concomitant antibiotics at the same time or shortly thereafter treatment of CDI. METHODS: We retrospectively reviewed records for patients with their first inpatient CDI episode. Patients were grouped into those who didn't receive concomitant antibiotics (noABx), those receiving antibiotics at the same time as treatment of CDI (ABxDURING), those receiving antibiotics within 30-days of completion of CDI therapy (ABxAFTER) and those who received antibiotics both during and after CDI treatment (ABxDuringAfter). Our primary outcome was recurrence within 14-90 days; other outcomes included ICU stay at the time of diagnosis, 30-day ICU transfer, 30-day colectomy, and readmission. RESULTS: 457 patients had CDI during admission (mean age: 66.4 years, 51.9% female). 64.1% were exposed to concomitant antibiotics. Recurrence rates were 4.3%, 6.1%, 13.8% and 19.1%, for noABx, ABxDURING, ABxAFTER and ABxDuringAfter, respectively. Patients with ABxDuringAfter had the highest rates of rCDI when compared to noABx [OR 5.67, 95% CI (2.18-14.72)]. CONCLUSIONS: There is a high rate of utilization of non-CDI antibiotics during or shortly after completing CDI treatment with high rates of recurrence within 90-days. Concomitant antimicrobials alter the opportunity for the microbiota to re-grow and worsens dysbiosis leading to increases in recurrence. Concomitant antimicrobial stewardship remains important in patients being treated for CDI and shortly after treatment.

Is peroral endoscopic myotomy the new gold standard for achalasia therapy?

Our review focuses on critical analysis of the literature to determine whether peroral endoscopic myotomy (POEM) is poised to replace laparoscopic Heller myotomy (LHM) as the new "gold standard" for achalasia therapy. POEM matches or exceeds the efficacy of LHM. The difference in objective gastroesophageal reflux disease (GERD) between POEM and LHM is modest at best and dissipates with time. Post-POEM GERD can be easily managed medically in most patients without long-term GERD sequelae or the need for surgical fundoplication. Emerging POEM technique modifications can further decrease GERD. Endoscopic antireflux procedures such as transoral incisionless fundoplication (TIF) or POEM + F (POEM + fundoplication) can be used in the rare cases of medication-refractory GERD, but their long-term efficacy remains in question. In this comprehensive review, we summarize the current status of POEM with emphasis on GERD evaluation, prevention, treatment, and comparative data vs. LHM. Based on this analysis, it appears that POEM is indeed the new gold standard in the therapy of achalasia.

Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis.

BACKGROUND: Despite literature and guidelines recommending same admission cholecystectomy (CCY) after endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute gallstone pancreatitis, clinical practice remains variable. The aim of this study was to investigate the role of clinical and socio-demographic factors in the management of acute gallstone pancreatitis. METHODS: Patients with acute gallstone pancreatitis who underwent ERCP during hospitalization were reviewed from the U.S. Nationwide Inpatient Sample database between 2008 and 2014. Patients were classified by treatment strategy: ERCP + same admission CCY (ERCP + CCY) versus ERCP alone. Measured variables including age, race/ethnicity, Charlson Comorbidity Index (CCI), hospital type/region, insurance payer, household income, length of hospital stay (LOS), hospitalization cost, and in-hospital mortality were compared between cohorts using χ2 and ANOVA. Multivariable logistic regression was performed to identify specific predictors of same admission CCY. RESULTS: A total of 205,012 patients (ERCP + CCY: n = 118,318 versus ERCP alone: n = 86,694) were analyzed. A majority (53.4%) of patients that did not receive same admission CCY were at urban-teaching hospitals. LOS was longer with higher associated costs for patients with same admission CCY [(6.8 ± 5.6 versus 6.4 ± 6.5 days; P < 0.001) and ($69,135 ± 65,913 versus $52,739 ± 66,681; P < 0.001)]. Mortality was decreased significantly for patients who underwent ERCP + CCY versus ERCP alone (0.4% vs 1.1%; P < 0.001). Multivariable regression demonstrated female gender, Black race, higher CCI, Medicare payer status, urban-teaching hospital location, and household income decreased the odds of undergoing same admission CCY + ERCP (all P < 0.001). CONCLUSION: Based upon this analysis, multiple socioeconomic and healthcare-related disparities influenced the surgical management of acute gallstone pancreatitis. Further studies to investigate these disparities are indicated.

Balloon enteroscopy versus spiral enteroscopy for small-bowel disorders: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Two novel enteroscopic procedures, balloon enteroscopy and spiral enteroscopy, have revolutionized the diagnostic and therapeutic approach to small-bowel disorders. These disorders that historically required surgical interventions are now investigated and managed nonsurgically. Only a few weakly powered studies have compared the outcomes of spiral enteroscopy and balloon enteroscopy. We conducted a systematic review and meta-analysis to compare the efficacy and safety of these 2 procedures. METHODS: PubMed, Cochrane Library, Scopus, and clinicaltrials.gov databases were searched for all studies published up to January 12, 2017 comparing the efficacy and safety of balloon enteroscopy (single or double) and spiral enteroscopy. Primary outcomes of interest were diagnostic and therapeutic success rates. Other outcomes included procedure length, depth of maximal insertion (DMI), rate of complete enteroscopy, and adverse events. We calculated Odds ratios (ORs) for categorical variables and mean difference (MD) for continuous variables. The Mantel-Haenszel method was used to analyze the data. Fixed and random effect models were used for <50% heterogeneity and >50% heterogeneity, respectively. RESULTS: Eight studies met the inclusion criteria for this meta-analysis. A total of 615 procedures were analyzed, which included 394 balloon enteroscopy and 221 spiral enteroscopy procedures. There were no significant differences in diagnostic and therapeutic success rates (OR, 1.27; 95% confidence interval [CI], .86-1.88; P = .22; and OR, 1.23; 95% CI, .82-1.84; P = .32, respectively) between the 2 procedures. Similarly, DMI was not significantly different between the 2 groups (MD, 26.29; 95% CI, 20.92-73.49; P = .28). However, the procedure time was significantly shorter for the spiral enteroscopy group compared with the balloon enteroscopy group (MD, 11.26; 95% CI, 2.72-19.79; P = .010). A subgroup analysis comparing double balloon enteroscopy with spiral enteroscopy yielded similar results. CONCLUSIONS: Both procedures achieved similar diagnostic and therapeutic outcomes and with similar depth of insertion. Spiral enteroscopy has the benefit of shorter procedural time.

Colon Ischemia After Weight-Loss Medication in a 36-Year-Old Woman.

Weight-loss medications have been associated with many conditions, including valvular heart disease, ischemic colitis, and pulmonary hypertension. There is a constant increase in the use of these drugs, especially new medications with better efficacy. Phentermine is one such drug, approved for short-term use to lose weight. We report a case of ischemic colitis in a female patient linked to inappropriate phentermine intake. The patient presented with symptoms of severe abdominal pain and repeated bowel movement associated with rectal bleeding for two weeks. Initial blood work was unremarkable for infectious and inflammatory causes. A CT scan was performed which revealed findings of ischemic colitis extending from transverse to descending colon. A biopsy study confirmed the same. Upon further questioning, the patient admitted to taking 37.5 mg of phentermine for two years beyond her prescribed period of 12 weeks. Hence, we propose that inappropriate use of phentermine caused ischemic colitis. With the widespread use of these medications, there is a need for heightened awareness among clinicians regarding adverse effects of phentermine.

Posterior Reversible Encephalopathy Syndrome (PRES) Presenting as Status Epilepticus: A Case Report and Literature Review.

Posterior reversible encephalopathy syndrome (PRES) is one of many causes of status epilepticus (SE). Itis defined classically as a clinical radiographic entity, characterized by presentation of headache, altered mental status, visual disturbances, seizures, and typical neuroradiographic findings of symmetrical white-matter edema. Predisposing conditions include uncontrolled hypertension, eclampsia, and use of chemotherapeu- tic and immunosuppressant agents. Bevacizumab (Avastin), a monoclonal antibody against vascular endothelial growth factor (VEGF), is used in a combination with FOLFOX [FOL - Folinic acid; F - Fluorouracil (5-FU); OX - Oxaliplatin] as a first-line treatment for patients with metastatic colorectal cancer. We present a case of a 52-year-old male on systemic chemotherapy with FOLFOX and bevacizumab who presented with SE and was diagnosed with PRES. His symptoms resolved with intensive control of blood pressure and discontinuation of chemotherapy. Bevacizumab-induced vasospasm, endothelial and blood-brain-barrier dysfunction, in combination with elevated blood pressure, were likely the underlying mechanism of PRES in our patient.

Transfusion-free management of gastrointestinal bleeding: the experience of a bloodless institute.

GOALS: The Institute for Patient Blood Management and Bloodless Medicine at the Englewood Hospital has considerable experience in managing patients with gastrointestinal bleeding who do not accept blood-derived products. We present our data and experience over the last 8 years in managing such patients. BACKGROUND: There is paucity of data on management and outcomes of gastrointestinal bleeding in patients who do not accept blood-derived products. STUDY: We performed a retrospective study of patients from 2003 to 2011 presenting with gastrointestinal bleeding who do not accept blood-derived products. Inclusion criteria were either overt bleeding with a presenting hemoglobin (Hb) of <12 g/dL or a decrease in Hb of >1.5 g/dL. RESULTS: Ninety-six patients who met the inclusion criteria were included. Forty-one upper and 48 lower gastrointestinal bleeding sources were identified. Mean Hb was 8.8 g/dL and mean nadir was 6.9 g/dL. Among 37 patients (80.5%) with Hb ≤6.0 g/dL, 30 (81%) survived. Four of 7 patients (57%) with a Hb <3 g/dL survived. The overall mortality rate was 10.4%. In unadjusted logistic regression models, age [1.06 (1.01-1.12 y)], admission to ICU [6.37(1.27-31.9)], and anticoagulation use [6.95 (1.57-30.6)] were associated with increased mortality. Initial Hb [0.68 (0.51-0.92)] and nadir Hb [0.48 (0.29-0.78)] inversely predicted mortality. CONCLUSIONS: These results suggest that transfusion-free management of gastrointestinal hemorrhage can be effective with mortality comparable with the general population accepting medically indicated transfusion. Management of these patients is challenging and requires a dedicated multidisciplinary team approach knowledgeable in techniques of blood conservation.

Network Representation of fMRI Data Using Visibility Graphs: The Impact of Motion and Test-Retest Reliability.

Visibility graphs provide a novel approach for analysing time-series data. Graph theoretical analysis of visibility graphs can provide new features for data mining applications in fMRI. However, visibility graphs features have not been used widely in the field of neuroscience. This is likely due to a lack of understanding of their robustness in the presence of noise (e.g., motion) and their test-retest reliability. In this study, we investigated visibility graph properties of fMRI data in the human connectome project (N = 1010) and tested their sensitivity to motion and test-retest reliability. We also characterised the strength of connectivity obtained using degree synchrony of visibility graphs. We found that strong correlation (r > 0.5) between visibility graph properties, such as the number of communities and average degrees, and motion in the fMRI data. The test-retest reliability (Intraclass correlation coefficient (ICC)) of graph theoretical features was high for the average degrees (0.74, 95% CI = [0.73, 0.75]), and moderate for clustering coefficient (0.43, 95% CI = [0.41, 0.44]) and average path length (0.41, 95% CI = [0.38, 0.44]). Functional connectivity between brain regions was measured by correlating the visibility graph degrees. However, the strength of correlation was found to be moderate to low (r < 0.35). These findings suggest that even small movement in fMRI data can strongly influence robustness and reliability of visibility graph features, thus, requiring robust motion correction strategies prior to data analysis. Further studies are necessary for better understanding of the potential application of visibility graph features in fMRI.

Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study.

Background: The Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal. Methods: We conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers. Results: A total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies. Conclusion: Government stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized.

Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal.

BACKGROUND: Nepal's national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal. METHODS: A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses. RESULTS: The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout. CONCLUSION: In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members' reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers' behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

Efficient Agrobacterium tumefaciens-mediated stable genetic transformation of green microalgae, Chlorella sorokiniana.

The green oleaginous microalgae, Chlorella sorokiniana, is a highly productive Chlorella species and a potential host for the production of biofuel, nutraceuticals, and recombinant therapeutic proteins. The lack of a stable and efficient genetic transformation system is the major bottleneck in improving this species. We report an efficient and stable Agrobacterium tumefaciens-mediated transformation system for the first time in C. sorokiniana. Cocultivation of C. sorokiniana cells (optical density at λ 680 = 1.0) with Agrobacterium at a cell density of OD600 = 0.6, on BG11 agar medium (pH 5.6) supplemented with 100 µM of acetosyringone, for three days at 25 ± 2 °C in the dark, resulted in significantly higher transformation efficiency (220 ± 5 hygromycin-resistant colonies per 106 cells). Transformed cells primarily selected on BG11 liquid medium with 30 mg/L hygromycin followed by selecting homogenous transformants on BG11 agar medium with 75 mg/L hygromycin. PCR analysis confirmed the presence of hptII, and the absence of virG amplification ruled out the Agrobacterium contamination in transformed microalgal cells. Southern hybridization confirmed the integration of the hptII gene into the genome of C. sorokiniana. The qRT-PCR and Western blot analyses confirmed hptII and GUS gene expression in the transgenic cell lines. The specific growth rate, biomass doubling time, PSII activity, and fatty-acid profile of transformed cells were found similar to wild-type untransformed cells, clearly indicating the growth and basic metabolic processes not compromised by transgene expression. This protocol can facilitate opportunities for future production of biofuel, carotenoids, nutraceuticals, and therapeutic proteins. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13205-021-02750-7.

Healthcare Disparities in the Management of Acute Cholecystitis: Impact of Race, Gender, and Socioeconomic Factors on Cholecystectomy vs Percutaneous Cholecystostomy.

BACKGROUND: While percutaneous cholecystostomy (PC) is a recommended treatment strategy in lieu of cholecystectomy (CCY) for acute cholecystitis among patients who may not be considered good surgical candidates, reports on disparities in treatment utilization remain limited. The aim of this study was to investigate the role of demographic, clinical, and socioeconomic factors in treatment of acute cholecystitis. METHODS: Patients with a diagnosis of acute cholecystitis who underwent CCY versus PC were reviewed from the U.S. Nationwide Inpatient Sample (NIS) database between 2008-2014. Measured variables including age, race/ethnicity, Charlson comorbidity index (CCI), hospital type/region, insurance payer, household income, length of stay (LOS), hospital cost, and mortality were compared using chi-square and ANOVA. Multivariable logistic regression was performed to identify specific predictors of cholecystitis treatment. RESULTS: A total of 1,492,877 patients (CCY:n=1,435,255 versus PC:n=57,622) were analyzed. The majority of patients that received PC were at urban teaching hospitals (65.2%). LOS was significantly longer with higher associated costs for PC [(11.1±11.0 versus 4.5±5.3 days; P<0.001) and ($99577±138850 versus $48399±58330; P<0.001)]. Mortality was also increased for patients that received PC compared to CCY (8.8% versus 0.6%; P<0.001). Multivariable regression demonstrated multiple socioeconomic and healthcare-related factors influencing the utilization of PC including male gender, Black or Asian race/ethnicity, Medicare payer status, urban hospital location, and household income (all P<0.001). CONCLUSION: Although patients receiving PC had higher CCI scores, multiple socioeconomic and healthcare related factors appeared to also influence this treatment decision. Additional studies to investigate these disparities are indicated to improve outcomes for all individuals with this condition.

Chylous ascites in cirrhosis from retroperitoneal lymphoma.

Chylous ascites occurs due to processes that elevate pressures within or obstruct the lymphatics in the retroperitoneum. In cirrhosis, spontaneous chylous ascites can occur but is uncommon. We describe a case of a 74-year-old man with cirrhosis from nonalcoholic steatohepatitis who presented with worsening abdominal distension and chylous ascites on paracentesis; an infiltrating retroperitoneal lymphoma was subsequently detected on computed tomography imaging.

Safety of Bariatric Surgery in Morbidly Obese Patients with Human Immunodeficiency Virus: A Nationwide Inpatient Sample Analysis, 2004-2014.

Background: Despite rising rates of obesity among human immunodeficiency virus (HIV)-positive individuals, the safety and tolerability of surgery in this population have not been established. The primary aim of this study was to examine the safety of bariatric surgery and rate of in-hospital postoperative complications in morbidly obese patients with HIV. Materials and Methods: The U.S. Nationwide Inpatient Sample database was queried between 2004 and 2014 for discharges with codiagnoses of morbid obesity and bariatric surgery. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay, hospitalization costs, and multiple categories of complications, including systemic complications, surgical complications, and nutritional and behavioral complications. Results: Among 267,082 patients with discharge diagnoses of morbid obesity and bariatric surgery, 346 (0.13%) were diagnosed with HIV. On multivariable analysis, HIV did not influence in-hospital mortality (p = 0.530). HIV was not associated with increased risk of renal failure (p = 0.274), thromboembolism (p = 0.713), myocardial infarction (p = 0.635), sepsis (p = 0.757), hemorrhage (p = 0.303), or wound infection (p = 0.229). Other measured surgical complications were not significantly different (p > 0.05). Notably, HIV-positive patients had an increased risk for postoperative pneumonia (p = 0.002), pancreatitis (p = 0.049), and thiamine deficiency (p = 0.016). Conclusion: Bariatric surgery among HIV-positive patients appears to be acceptably safe with the risk of postoperative complications comparable with non-HIV patients.

Alternative uses of lumen apposing metal stents.

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

Comparative effectiveness of pharmacologic and endoscopic interventions for prevention of post-ERCP pancreatitis: a network meta-analysis.

Background and study aims While several interventions may decrease risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, it remains unclear whether one strategy is superior to others. The purpose of this study was to compare the effectiveness of pharmacologic and endoscopic interventions to prevent post-ERCP pancreatitis among high-risk patients. Methods A systematic review was performed to identify randomized controlled trials from PubMed, Embase, Web of Science, and Cochrane database through May 2017. Interventions included: rectal non-steroidal anti-inflammatory drugs (NSAIDs), aggressive hydration with lactated ringer's (LR) solution, and pancreatic stent placement compared to placebo. Only studies with patients at high-risk for post-ERCP pancreatitis were included. Bayesian network meta-analysis was performed and relative ranking of treatments was assessed using surface under the cumulative ranking (SUCRA) probabilities. Results We identified 29 trials, comprising 7,862 participants comparing four preventive strategies. On network meta-analysis, compared with placebo, rectal NSAIDs (B = - 0.69, 95 % CI [-1.18; - 0.21]), pancreatic stent (B = - 1.25, 95 % CI [-1.81 to -0.69]), LR (B = - 0.67, 95 % CI [-1.20 to -0.13]), and combination of LR plus rectal NSAIDs (B = - 1.58; 95 % CI [-3.0 to -0.17]), were all associated with a reduced risk of post-ERCP pancreatitis. Pancreatic stent placement had the highest SUCRA probability (0.81, 95 % CI [0.83 to 0.80]) of being ranked the best prophylactic treatment. Conclusions Based on this network meta-analysis, pancreatic stent placement appears to be the most effective preventive strategy for post-ERCP pancreatitis in high-risk patients.

Impact of Bariatric Surgery on Outcomes of Patients with Sickle Cell Disease: a Nationwide Inpatient Sample Analysis, 2004-2014.

BACKGROUND: With advances in disease-specific treatments and improved overall survival, obesity rates are rising among patients with sickle cell disease (SCD). The primary aim of this study was to evaluate the role of bariatric surgery on clinical outcomes among hospitalized obese patients with SCD. METHODS: The United States Nationwide Inpatient Sample database was queried between 2004 and 2014 for discharges with co-diagnoses of morbid obesity and SCD. The primary outcome was in-hospital mortality. Secondary outcomes included vaso-occlusive crisis, acute chest syndrome, biliary-pancreatic complications, renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, wound infection, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared to those without bariatric surgery. RESULTS: Among 2549 patients with a discharge diagnosis of SCD and morbid obesity, only 42 patients (1.7%) had bariatric surgery. On multivariable analysis, bariatric surgery did not influence mortality (P = 0.98). Bariatric surgery was not associated with increased risk for acute chest syndrome, sepsis, multi-organ failure, biliary-pancreatic, or surgery-related complications (all P > 0.05). Interestingly, bariatric surgery decreased risk of vaso-occlusive crises (IRR 0.21; 95% CI, 0.07-0.69; P = 0.01) in these patients and was associated with a shorter length of stay (P < 0.001) but higher hospitalization costs (P < 0.001). CONCLUSIONS: Bariatric surgery may lower rates of vaso-occlusive crises in morbidly obese sickle cell patients without significantly affecting mortality and other adverse outcomes. In spite of this, these weight loss surgeries are underutilized in this select population.

Impact of bariatric surgery on outcomes of patients with celiac disease: a nationwide inpatient sample analysis, 2004-2014.

BACKGROUND: While patients with celiac disease have increasingly developed an atypical pattern of weight gain and obesity, the role of bariatric surgery remains unclear. The primary aim of this study was to evaluate the effect of bariatric surgery on clinical outcomes among hospitalized patients with celiac disease. METHODS: The United States Nationwide Inpatient Sample database was queried for discharges with co-diagnoses of morbid obesity and celiac disease between 2004 and 2014. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, urinary tract infection, malnutrition, sepsis, pneumonia, respiratory failure, thromboembolic events, strictures, micronutrient deficiency, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior bariatric surgery compared to those without bariatric surgery. RESULTS: Among 1499 patients with a discharge diagnosis of celiac disease and morbid obesity, 126 patients (8.4%) underwent bariatric surgery. Despite an increase in morbid obesity over the study period, the proportion of morbidly obese patients with celiac disease who had bariatric surgery declined by 18.5% (Ptrend<0.05). On multivariable analysis, bariatric surgery did not influence mortality (P=0.98), but was associated with a lower risk of renal failure, pneumonia, sepsis, urinary tract infection and respiratory failure (all P<0.05). Bariatric surgery increased the risk of vitamin D deficiency (IRR 3.5; 95% confidence interval [CI] 1.6-7.7; P=0.002) and post-operative strictures (IRR 3.3; 95%CI 1.5-7.5; P=0.004). CONCLUSION: Despite the underutilization of bariatric surgery in morbidly obese celiac disease patients, the procedure is safe and appears to significantly reduce morbidity.

Neoadjuvant vs. adjuvant chemotherapy for cholangiocarcinoma: A propensity score matched analysis.

BACKGROUND: Chemotherapy is frequently used in cholangiocarcinoma as an adjunct to surgical resection, but the appropriate sequence of chemotherapy with surgery is unclear. PATIENTS AND METHODS: Using the National Cancer Database, we identified patients who underwent surgery and chemotherapy for stage I-III cholangiocarcinoma between 2006 and 2014. The propensity score reflecting the probability of receiving neoadjuvant chemotherapy was estimated by multivariate logistic regression method. Patients in the neoadjuvant and adjuvant chemotherapy study arms were then propensity-matched in 1:3 ratios using the nearest neighbor method. Overall Survival (OS) in the matched data set was estimated using the Kaplan-Meier method. Hazard ratios (HRs) were calculated using Cox proportional hazard regression model. RESULTS: Of the 1450 patients who met our inclusion criteria, 299 (20.6%) received neoadjuvant chemotherapy while 1151 (79.3%) received adjuvant chemotherapy. The median age at diagnosis was 63 years. 278 patients in the neoadjuvant group were matched to 700 patients in the adjuvant group. In the matched cohort, patients who received neoadjuvant chemotherapy had a superior OS compared to those who received adjuvant chemotherapy (Median OS: 40.3 vs. 32.8 months; HR: 0.78; 95% CI: 0.64-0.94, p = 0.01). The 1- and 5-year OS rates for the neoadjuvant chemotherapy group were 85.8% and 42.5% respectively compared to 84.6% and 31.7% for the adjuvant chemotherapy group. CONCLUSION: In this large national database study, neoadjuvant chemotherapy was associated with a longer OS in a select group of patients with cholangiocarcinoma compared to those who underwent upfront surgical resection followed by adjuvant chemotherapy.