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

Early evidence indicates that omitting the dilating skin incision at PEG tube placement is feasible and associated with lower infectious complications

Biliary self-expandable metal stents

Pancreaticoduodenectomy Following Endoscopic Placement of an Expandable Metal Biliary Stent

Over the last 20 years there have been refinements in the understanding and nomenclature of acute pancreatitis. Over a several week period following the onset of acute necrotizing pancreatitis, the necrosis becomes demarcated and organized. The term walled-off necrosis (WON) is now an accepted term. Endoscopic approaches have evolved from creation of small transmural tracts into the WON with irrigation to the creation of large transmural tracts, which allow flexible endoscopes to be advanced directly into the necrotic cavity to perform direct endoscopic necrosectomy (DEN). This chapter concentrates on DEN for WON.

Direct Endoscopic Necrosectomy

Gastric outlet obstruction (GOO) is a mechanical blockage that clinically progresses based on the degree of obstruction. Patients often experience debilitating symptoms with intractable nausea, vomiting, and limited peroral intake that can quickly lead to malnutrition, decreased quality of life, and potential delays in chemotherapy [1]. While surgical gastroenterostomy (SGE) has been the mainstay of treatment with long-term palliation, it is associated with significant morbidity and mortality that may delay treatment in the postoperative period [2]. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as an effective minimally invasive alternative for suboptimal operative candidates [1]. Comparing these techniques is paramount, especially as increased operator experience with EUS-GE expands and advancements in chemotherapy treatment extends the life expectancy in this patient population. In a recent issue of Endoscopy International Open, Jaruvongvanich et al [3] compare the outcomes of patients undergoing EUS-GE, enteral stenting (ES), or SGE for benign and malignant etiologies of GOO. This was a dual-center retrospective study of 436 patients with a median follow up of 185.5 days, of which 233 were in the EUS-GE cohort. Baseline characteristics between EUS-GE and SGE were largely similar, although the EUSGE group had higher rates of ascites, peritoneal carcinomatosis, ECOG status, a malignant indication, and symptomatic GOO. The technical success rate was similar in all groups. However, the clinical success rate was significantly higher in the EUS-GE group compared to ES and SGE (98.3% vs 91.6% vs 90.4%, P =0.002) with lower rates of reintervention (0.9% vs 12.2% vs 13.7%, P < 0.0001) and median length of stay (LOS) (2 vs 3 vs 5 days, P < 0.0001). A subgroup analysis examining the 360 patients with malignant GOO demonstrated similar findings. There were also lower rates of adverse events in the EUS-GE group (8.6%) compared to SGE (27.4%) and ES (38.9%). There were limited instances of stent obstruction, migration, and inadequate stent expansion after EUS-GE. The longterm outcomes of EUS-GE appear to be reliable, especially in a sicker patient population, as was the case in this cohort. This is a well-designed study that advances the current literature supporting the efficacy and durability of EUS-GE, particularly in sick patients. Yet, before these data can alter practice management, one must consider that this study did not differentiate surgical approaches (open and laparoscopic) in their outcomes. Laparoscopic SGE is now the preferred method because it is associated with improved outcomes, decreased LOS, and shorter time to resumption of oral intake [4]. Analyzing outcomes should ideally be done in this context, although such a comparison is limited in a retrospective study. Patients who undergo conversion from laparoscopic to open approaches will likely have fundamentally different outcomes than those whose procedures can be completed laparoscopically. There is selection bias and heterogeneity in all studies to date pertaining to EUS-GE versus SGE. Patients undergoing EUS-GE are generally sicker with more advanced cancers and comorbidities [5]. A more focused comparison between laparoscopic SGE and EUS-GE, therefore, may either blunt or further cement the advantages of a purely endoscopic approach. Prospective studies comparing these techniques are needed as we continue to define the optimal role of EUSGE for GOO. Conflict of Interest

/pdf/eus-gastroenterostomy-primetime-for-all-2kv6qhy0.pdf

Todd H. Baron

Papers

Early evidence indicates that omitting the dilating skin incision at PEG tube placement is feasible and associated with lower infectious complications

Biliary self-expandable metal stents

Pancreaticoduodenectomy Following Endoscopic Placement of an Expandable Metal Biliary Stent

Direct Endoscopic Necrosectomy

EUS Gastroenterostomy: Primetime for All?