https://www.medpagetoday.com/upload/2014/3/3/02536-1.pdf

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Background and objective The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary. Methods A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained. Results The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images. Conclusions This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption.

/pdf/classification-of-acute-pancreatitis-2012-revision-of-the-608d2rjeud.pdf

Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus

Jeffrey L. Anderson, MD, FACC, FAHA, Chair , Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect , Nancy M. Albert, PhD, CCNS, CCRN, FAHA, Biykem Bozkurt, MD, PhD, FACC, FAHA, Ralph G. Brindis, MD, MPH, MACC, Mark A. Creager, MD, FACC, FAHA[§§][1], Lesley H. Curtis, PhD, FAHA, David DeMets, PhD,

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

BACKGROUND In the National Polyp Study (NPS), colorectal cancer was prevented by colonoscopic removal of adenomatous polyps. We evaluated the long-term effect of colonoscopic polypectomy in a study on mortality from colorectal cancer. METHODS We included in this analysis all patients prospectively referred for initial colonoscopy (between 1980 and 1990) at NPS clinical centers who had polyps (adenomas and nonadenomas). The National Death Index was used to identify deaths and to determine the cause of death; follow-up time was as long as 23 years. Mortality from colorectal cancer among patients with adenomas removed was compared with the expected incidence-based mortality from colorectal cancer in the general population, as estimated from the Surveillance Epidemiology and End Results (SEER) Program, and with the observed mortality from colorectal cancer among patients with nonadenomatous polyps (internal control group). RESULTS Among 2602 patients who had adenomas removed during participation in the study, after a median of 15.8 years, 1246 patients had died from any cause and 12 had died from colorectal cancer. Given an estimated 25.4 expected deaths from colorectal cancer in the general population, the standardized incidence-based mortality ratio was 0.47 (95% confidence interval [CI], 0.26 to 0.80) with colonoscopic polypectomy, suggesting a 53% reduction in mortality. Mortality from colorectal cancer was similar among patients with adenomas and those with nonadenomatous polyps during the first 10 years after polypectomy (relative risk, 1.2; 95% CI, 0.1 to 10.6). CONCLUSIONS These findings support the hypothesis that colonoscopic removal of adenomatous polyps prevents death from colorectal cancer. (Funded by the National Cancer Institute and others.)

/pdf/colonoscopic-polypectomy-and-long-term-prevention-of-26sw5itn6w.pdf

Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths

Endoscopic Transmural Drainage of Pancreatic Fluid Collections in Outpatients

Direct visualization of the biliary tree by transpapillary cholangioscopy can be helpful for establishing the diagnosis of indeterminate biliary strictures by visual inspection, for obtaining biopsies, and for guiding bile duct stone therapy [2– 4]. Although the first use of peroral cholangioscopy was described in the 1970s, its widespread adoption has been limited by the cost and fragility of cholangioscopes, their technology (difficulty with irrigation, limited tip deflection, and suboptimal optics), and the need for two operators [1]. The single-operator cholangioscopy (SOC) system (SpyGlass Direct Visualization System; Boston Scientific Corp., Natick, Massachusetts, USA) was designed to overcome such limitations [5,6]. The system features two separate irrigation channels, 4-way tip deflection for better steerability, and with the system secured to the duodenoscope handle cholangioscopy can be performed by a single operator. Thus far there are limited data demonstrating improved patient outcomes, and the advanced endoscopic skill required in these complex cases has limited both the potential for prospective data collection and replication of the initial prospective results from the initial single institution [7]. The later study by Chen et al., [1] was a large scale, multicenter, prospective, observational study of SOC procedures and was conducted to provide confirmatory evidence that direct visualization is valuable in the diagnosis of biliary disease and the treatment of choledocholithiasis. A total of 297 patients underwent SOC (diagnostic indications in 226, stone therapy in 66, primary site of interest unable to be accessed in 5); 93% completed the study (of those who did not, 11 died, 7 were lost to follow-up, and 2 withdrew). Success rates, adverse events, and the sensitivity and specificity of visual impression and SOC-directed biopsies were reported. Success was defined for non-stone cases as the ability to visualize target lesions and, if indicated, to perform biopsies; for stone cases, success was defined as the ability to identify and initiate stone fragmentation and removal. The overall success rate was 89% (95% confidence interval [CI] 84%–92%). Adequate tissue for histological evaluation was obtained in 88% of 140 patients who underwent biopsy. The sensitivity for the diagnoses of malignancy was 78% by visual impression and 49% for SOC-directed biopsy, with respective specificities of 82% and 98%. Sensitivity was higher for intrinsic bile duct malignancies (SOC visual impression 84%, SOC-directed biopsy 66%) than for extrinsic cancers (62% and 8%, respectively). Diagnostic SOC procedures altered clinical management in 64% of patients. Procedural success was achieved in 61/66 patients (92%) with bile duct stones, with complete stone clearance achieved in one session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy. This large, multicenter study, which included 10 centers from the USA and five from Europe, demonstrated an 89% overall success rate, the value of direct cholangioscopy, and reproducibility when used by expert endoscopists in tertiary centers. SOC altered management in nearly two-thirds of patients, similar to the results from a previously published retrospective study from three US centers [8]. However, the exact visual features that allow differentiation of benign frommalignant lesions using this device are yet to be determined. In our experience, the optical images obtained with the cholangioscope system that was used in this study, are often suboptimal and can make determination of benign and malignant disease by

Biliary endoscopic retrograde cholangiopancreatography.

https://www.cghjournal.org/article/S1542-3565(11)00809-3/pdf

Esophageal Avulsion Following Removal of a Partially Covered Esophageal Stent: Lessons Learned 10 Years Later

We present a case involving a patient who required enteral feeding after implantation of an abdominally positioned left ventricular assist device. The position of the device occupied most of the abdomen, precluding percutaneous endoscopic gastrostomy tube placement. However, in the case presented, direct percutaneous endoscopic jejunostomy (DPEj) tube placement was achieved without interfering with the intracorporeal device. To our knowledge, there are no previous reports in the literature of successful DPEJ placement in a patient with an abdominally positioned heart assist device. DPEJ should be considered as a long-term enteral feeding route when structural barriers prevent percutaneous gastric access.

Todd H. Baron

Papers

Endoscopic Transmural Drainage of Pancreatic Fluid Collections in Outpatients

Biliary endoscopic retrograde cholangiopancreatography.

Esophageal Avulsion Following Removal of a Partially Covered Esophageal Stent: Lessons Learned 10 Years Later

Direct percutaneous endoscopic jejunostomy placement in a patient with intracorporeal left ventricular assist device.

Endoscopic ultrasound training in mid-to-late career: Falling prey to the dark side or the bright side?