Developmental outcomes in abusive head trauma.

Abusive head trauma (AHT) is associated with high mortality and poorer outcomes compared to accidental head injuries. The short and long-term developmental outcomes for AHT are not well identified. Variability in outcome measures, small sample sizes, difficulty in measuring domain-specific developmental skills, co-existence of comorbidities, genetic and environmental factors and high attrition rates all contribute to the challenges on providing data in this area. The objective of this article is to review the scientific literature on the developmental outcomes of AHT, highlighting factors that affect outcomes, the available assessment tools, and short and long-term developmental outcomes, recommended follow up, societal costs, and future opportunities for research. Authors searched OVID Medline and PubMed for articles published between 2013 and 2023 using the terms "abuse", "craniocerebral trauma" and "development". Fifty-five records were included for this review. The data shows that injuries sustained from AHT result in a spectrum of outcomes ranging from normal development to death. There are more than 100 outcome assessment tools limiting the ability to compare studies. More than half of patients are left with disabilities post discharge. Gross motor and cognition/academics are the 2 most common domains studied. Advancement in surgical and neurocritical care management has influenced AHT outcomes. Close long-term follow up is recommended to maximize each child's developmental potential, irrespective of the presence of disability at discharge. We suggest that future research should focus on adopting a consistent diagnostic and assessment approach and explore the social environmental factors that can affect recovery.

Epidemiological trends in the presentation of diabetic ketoacidosis in children newly diagnosed with type 1 diabetes from 2011 to 2017 in Kuwait.

Background: Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait. Material and methods: This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017. Results: A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years. Conclusion: This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study.

OBJECTIVES: Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship. METHODS: Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE. RESULTS: A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73-2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001). CONCLUSIONS: Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

Underwater vs conventional endoscopic mucosal resection in the management of colorectal polyps: a systematic review and meta-analysis.

Background Recently, underwater endoscopic mucosal resection (UEMR) has shown promising results in the management of colorectal polyps. Some studies have shown better outcomes compared to conventional endoscopic mucosal resection (EMR). We conducted this systematic review and meta-analysis to compare UEMR and EMR in the management of colorectal polyps. Methods We searched several databases from inception to November 2019 to identify studies comparing UEMR and EMR. Outcomes assessed included rates of en bloc resection, complete macroscopic resection, recurrent/residual polyps on follow-up colonoscopy, complete resection confirmed by histology and adverse events. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a fixed effect model. Heterogeneity was assessed by I 2 statistic. Funnel plots and Egger's test were used to assess publication bias. We used the Newcastle-Ottawa scale (NOS) for assessment of quality of observational studies, and the Cochrane tool for assessing risk of bias for RCTs Results Seven studies with 1291 patients were included; two were randomized controlled trials and five were observational. UEMR demonstrated statistically significantly better efficacy in rates of en bloc resection, pooled RR 1.16 (1.08, 1.26), complete macroscopic resection, pooled RR 1.28 (1.18, 1.39), recurrent/residual polyps; pooled RR 0.26 (0.12, 0.56) and complete resection confirmed by histology; pooled RR 0.75 (0.57, 0.98). There was no significant difference in adverse events (AEs); pooled RR 0.68 (0.44, 1.05). Conclusions This meta-analysis found statistically significantly better rates of en bloc resection, complete macroscopic resection, and lower risk of recurrent/residual polyps with UEMR compared to EMR. We found no significant difference in AEs between the two techniques.

Prophylactic hemoclips in prevention of delayed post-polypectomy bleeding for ≥ 1 cm colorectal polyps: meta-analysis of randomized controlled trials.

Background and aim Studies evaluating the role of prophylactic hemoclips (HC) in prevention of delayed post-polypectomy bleeding (DPPB) have reported conflicting results. We conducted a meta-analysis of randomized controlled trials (RCTs) to evaluate the role of prophylactic HC placement in prevention of DPPB for polyps ≥ 1 cm in size. Methods We reviewed several databases to identify RCTs evaluating the role of HC in prevention of DPPB. The outcomes assessed included prevention of DPPB with polyps 1 to 1.9 cm, ≥ 2 cm, any polyp ≥ 1 cm, proximal colon polyps, distal colon polyps, and perforation. We analyzed data using a fixed effect model and reported summary pooled risk ratios (RR) with 95 % confidence intervals (CI). We assessed heterogeneity with the I 2 statistic. Results We included nine RCTs with 4550 patients. For polyps ≥ 2 cm, there was a statistically significantly lower risk of DPPB with use of HC; RR 0.55, 95 % CI 0.36, 0.86. There was also a statistically significantly lower risk for proximal colon polyps ≥ 2 cm; RR 0.41 (0.24, 0.70) but no significant difference for distal polyps; RR 1.23 (0.45, 3.32). There was also no significant difference in risk for polyps 1 to 1.9 cm; RR 1.07 (0.59, 1.97). There was no significant reduction in risk of perforation with HC use for any polyp size. Conclusions Prophylactic HC placement is effective in prevention of DPPB from proximal colon polyps ≥ 2 cm, but of no significant benefit for polyps 1 to 1.9 cm in size or for distal colon polyps ≥ 2 cm.

Management of Postcholecystectomy Biliary Complications: A Narrative Review.

Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).

Efficacy of naldemedine for the treatment of opioid-induced constipation: A meta-analysis.

BACKGROUND AND AIM: Opioid induced constipation (OIC) is the most common side effect of opioid therapy. It can lead to a decreased quality of life. Naldemedine is a peripherally acting µ-opioid receptor antagonist that has been recently studied in randomized controlled trials (RCTs) for the management of OIC. The aim of this study is to perform a meta-analysis of existing clinical trials to estimate the efficacy and safety of naldemedine in opioid-induced constipation. METHODS: A systematic search of PubMed, CINAHL, Scopus, Cochrane database of systematic reviews, and ClinicalTrials.gov registry was performed in March 2018. Two independent reviewers systematically identified prospective RCTs published in the English language that compared the effect of oral naldemedine versus placebo in adults with OIC. Meta-analysis was performed using a random effects model to assess the primary outcome: spontaneous bowel movement (SBM) responder rates. Assessed secondary outcomes were: a change in SBM frequency per week from baseline during the treatment period, change from baseline in the frequency of complete SBM and incidence of treatment-emergent adverse events. Review Manager 5.3 software program was utilized for statistical analysis. RESULTS: Six RCTs met the inclusion criteria. A total of 2,762 patients were included in the meta-analysis. The proportion of SBM responders was significantly higher in the naldemedine group compared to the placebo group (56.4%, vs. 34.7%, p<0.00001). There was no statistically significant difference in treatment-emergent adverse events between naldemedine group and placebo group (mean odds ratio=1.18, p = 0.25, 95% CI: 0.89-1.55). Change in SBM frequency was higher in the naldemedine group versus placebo group (p<0.00001), as well as the change in complete SBM frequency. CONCLUSIONS: Naldemedine 0.2 mg daily significantly improved symptoms in patients with opioid-induced constipation and was generally well tolerated. These results support the use of naldemedine for the treatment of opioid-induced constipation.

Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis.

Endoscopic submucosal dissection (ESD) and gastrectomy with lymph node dissection are considered acceptable treatment modalities for early gastric cancer (EGC). In the last decade, ESD has become more favorable than surgery as it offers faster recovery, lower costs, and a superior quality of life when compared to gastrectomy. The aim of this study is to compare the long-term outcome of ESD versus surgery in EGC. We performed a systematic and comprehensive search of major reference databases (Medline, Embase, CINHAL) for all studies that compared the outcome of EGC for patients underwent ESD or surgery in the same cohort. A systematic review was conducted through November 2017, using pooled analysis to calculate 5-year overall survival (OS) rate, disease-specific survival (DSS) rate, disease-free survival (DFS) rate, and recurrence-free survival (RFS) rate of ESD versus gastrectomy. Five-year OS and DSS were similar between ESD and gastrectomy groups 96 versus 96% and 99.4 versus 99.2%, respectively. Likewise, DFS was similar in both groups 95.9 versus 98.5% odds ratio 1.86 (0.57-6.0) P=0.3. However, ESD had a lower RFS compared to surgery 92.4 versus 98.3% odds ratio 0.17 (0.1-4.9) P=0.001. Overall, there was a higher recurrence rate in patients who underwent ESD compared to surgery [40/2943 (1.4%) vs. 12/3116 (0.4) risk ratio (RR) 2.5 (1.3-4.8) P=0.005]. Moreover, synchronous and metachronous cancers were more prevalent in the ESD group compared to the surgery group [1.5 vs. 0.1% RR 5.7 (1.5-21.9) P=0.01] [16/1082 (1.5%) vs. 1/1485 (0.1%) RR 10.1 (5.9-17.1) P=0.0001]. Five-year OS, DSS and DFS were similar between ESD and surgery groups. However, recurrent, synchronous and metachronous cancers were more prevalent in patients treated by ESD compared to patients treated by surgery, resulting in a lower RFS. Adequate surveillance with upper endoscopy is crucial after ESD to detect early recurrence and metachronous lesions.

Miralax with gatorade for bowel preparation: a meta-analysis of randomized controlled trials.

OBJECTIVES: Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax-Gatorade (M-G) vs. PEG for bowel preparation before colonoscopy. METHODS: Multiple databases were searched (January 2014). RCTs on adults comparing M-G (238-255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8-4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models. RESULTS: Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M-G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43-0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88-10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M-G vs. split-dose PEG. CONCLUSIONS: M-G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M-G for bowel preparation before colonoscopy.

Endoscopic surveillance for gastric ulcers.

OBJECTIVE: Gastric ulcers (GUs) can be caused by a malignancy, and endoscopists are challenged with the question of how to rule out underlying malignancy. Although routine endoscopic surveillance is not advised, it is still overused. The purpose of this study was to explore the practice in our tertiary referral center during the last 3 years. METHODS: We retrospectively reviewed all inpatient and outpatient esophagogastroduodenoscopies (EGDs) that were performed between November 2009 and November 2012 for GUs. Patients with GUs who normally would not undergo biopsy, such as patients who present with bleeding or had stigmata of high-risk bleeding, were excluded. RESULTS: A total of 165 patients were diagnosed between November 2009 and November 2012 as having GUs on EGD. Fifty-two patients were excluded because they presented with bleeding or had GUs that had stigmata of high-risk bleeding. We reviewed the charts of 113 patients and endoscopic surveillance was recommended for 96 (85%). Of those 96 patients, 72 (64%) underwent repeat EGD. In those 72 patients, GU was still present in 9 patients and was completely healed or healing in 63 patients. Only 25 (22%) GUs were biopsied at initial EGD, 23 of which were benign and 2 were adenocarcinomas. No additional malignancy was found on surveillance EGD. CONCLUSIONS: EGD surveillance for GUs is a common practice, although the guidelines discourage such a practice. Our rate of endoscopic surveillance was significantly higher than reported previously (64% vs 25%). In our experience, such a high rate of surveillance did not reveal any additional gastric malignancy. Alternatively, the rate of biopsy of GUs at initial EGD is low (22%), which also reflects endoscopists' preference for endoscopic surveillance.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis.

OBJECTIVES: Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). METHODS: A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. RESULTS: Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34-0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32-0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24-0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. CONCLUSIONS: Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.