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

Conclusion: Although the therapy of infected pancreatic collections or organized pancreatic necrosis remains surgical, we have demonstrated that infected organized pancreatic necrosis can be treated endoscopically.
 Background:Stenotrophomonas (Xanthomonas) maltophilia has been increasingly recognized as a nosocomial pathogen associated with meningitis, pneumonia, conjunctivitis, soft tissue infections, endocarditis, and urinary tract infections. This organism is consistently resistant to imipenem, a drug commonly employed in patients with necrotizing pancreatitis to prevent local and systemic infections. Methods and Results: We report the first case of infected pancreatic necrosis by S. (X.) maltophilia. Our patient was treated successfully with endoscopic drainage of the pancreatic fluid collection and appropriate antibiogram-based antibiotic therapy. Endoscopic drainage has emerged as one of the treatment modalities for pancreatic fluid collections.

Stenotrophomonas (Xanthomonas) maltophilia infection in necrotizing pancreatitis.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/lt.23758

Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: a retrospective analysis

Endoscopic pancreaticoduodenostomy for treatment of pancreatic duct disconnection because of severe acute pancreatitis.

AIM Biliary strictures that are suspicious for cholangiocarcinoma (CCA) are commonly encountered in clinical practice in patients with and without primary sclerosing cholangitis (PSC). A definitive histologic diagnosis of CCA via endoscopic retrograde cholangiography (ERCP) is often not obtainable with standard biliary brush cytology. Peroral cholangioscopy is an additional tool to help provide a diagnosis of CCA in patients with suspicious biliary strictures. Aim of the study was to assess the use of peroral cholangioscopy in patients with and without PSC and indeterminate biliary strictures. METHODS Retrospective study. RESULTS 25 patients were included in the study. All patients underwent ERCP with peroral cholangioscopy. Tissue samples obtained included routine cytology, fluorescent in-situ hybridization, and cholangioscopic-directed forceps biopsies. The operating characteristics of cholangioscopy to detect malignancy in 18 PSC patients with suspected cholangiocarcinoma were a sensitivity of 75%, specificity of 55%, and a positive predictive value (PPV) of 23%, and a negative predictive value of 92%. In 7 non-PSC patients with suspected cholangiocarcinoma these values sensitivity=100%, 25%, 50%, and NPV=100%, respectively. The overall operating characteristics of cholangioscopy to detect malignancy in all 25 patients with suspected cholangiocarcinoma were: sensitivity of 86%, specificity of 50%, PPV of 32%, and NPV of 93%. CONCLUSION Cholangioscopy helps identify sites for tissue acquisition in PSC and non-PSC patients with biliary strictures suspicious for malignancy.

Peroral cholangioscopy facilitates targeted tissue acquisition in patients with suspected cholangiocarcinoma.

Colonic self-expandable metal stents can be placed endoscopically or radiologically either for palliation or as a bridge to surgery in the setting of acute malignant colonic obstruction. The bridge to surgery approach aims to decompress the colon in an acutely ill patient and provide time for stabilisation of the patient, staging, bowel cleansing, and conversion of an emergency operation into an elective one, often with a laparoscopic approach. Creation of a primary colonic anastomosis in an unprepared colon is associated with a high rate of anastomotic leakage. Thus, patients who undergo emergency surgery for acute left-sided colonic obstruction often need a second operation to take down a temporary colostomy. Another potential advantage of preoperative colonic stenting, therefore, is the ability to cleanse the colon to enable a one-stage operation and improve quality of life by avoidance of a stoma. Indeed, fi ndings of systematic reviews of several uncontrolled studies and a randomised controlled trial support these benefi ts without a compromise in oncological outcome. In another randomised trial, however, the need for stoma did not diff er between the emergency surgery and colonic stenting groups, although the occurrence of technical failure for colonic stenting was unusually high at 53%. In The Lancet Oncology, van Hooft and colleagues report the fi ndings of a randomised trial of preoperative colonic stenting versus emergency surgery in patients with acute malignant left-sided colonic obstruction. From the standpoint of early adopters of colonic stenting, the results are disappointing from several perspectives, not the least being the potential for a worsened oncological outcome. An absolute risk increase in morbidity was noted at 30 days after colonic stent placement in both the fi rst and second interim analyses, leading to premature cessation of the study. At 6-month followup, no diff erences were recorded between the groups in quality-of-life assessment, morbidity and mortality risks, and rates of colostomy. How can the difference between these results and those from previous studies be reconciled? What immediately stands out is the high perforation rate of 13% (6 of 47 patients) in the colonic stenting group (4% procedure-related and 9% stent-related) relative to reported perforation rates of 5% or less in published reports. Another notable finding is the technical success rate of 70% (33 of 47 patients) for placement of the colonic stent relative to rates of at least 90% in other series. Endoscopist’s experience, particularly in pancreaticobiliary endoscopy, has a role in outcome after colonic stent placement. 21 of 25 participating centres were non-university settings in van Hooft and colleagues’ study. Although all participating endoscopists were pancreaticobiliary endoscopists, their overall experience was not stated. They had placed at least ten colonic stents; however, whether this threshold allows for proficiency in colonic stenting is unknown, particularly in the setting of complete obstruction where the procedure is quite technically difficult. Finally, the most severely ill patients (American Society of Anesthesiologists class 4 and 5, or signs of sepsis) were excluded from the study. From an oncological perspective, stent-related overt or silent tumour perforation might result in distant seeding of malignant cells and convert a potentially curable cancer into a non-curable one. Although the fi ndings of this study did not show a signifi cant diff erence in oncological outcome after colonic stenting, a longer follow-up period is needed, especially in patients in whom perforation occurred. Taken as a whole, the fi ndings from this study are eerily similar to a recent randomised trial of preoperative endoscopic biliary stent placement compared with surgery alone in patients with obstructive jaundice and potentially resectable pancreatic cancers. Therefore, should preoperative colonic stenting for relief of malignant colonic obstruction be routinely done? Unfortunately, the potential benefi ts of preoperative colonic stenting cannot be realised with a technical success rate of 70% and a perforation rate of 13%, as was predicted several years ago. Can these numbers be improved? One possibility is for endoscopists to be assisted by interventional radiologists because they excel at guidewire manipulation. Guidewire passage across the obstruction is the rate-limiting step for successful colonic Da vi d M M ar tin /S cie nc e Ph ot o Li br ar y

Todd H. Baron

Papers

Stenotrophomonas (Xanthomonas) maltophilia infection in necrotizing pancreatitis.

Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: a retrospective analysis

Endoscopic pancreaticoduodenostomy for treatment of pancreatic duct disconnection because of severe acute pancreatitis.

Peroral cholangioscopy facilitates targeted tissue acquisition in patients with suspected cholangiocarcinoma.

Stenting for acute malignant colonic obstruction: a bridge to nowhere?