<strong>Background:</strong><span style="white-space:normal;font-family:;" "=""> Fractional flow reserve (FFR)</span><span style="white-space:normal;font-f...<strong>Background:</strong><span style="white-space:normal;font-family:;" "=""> Fractional flow reserve (FFR)</span><span style="white-space:normal;font-family:;" "="">-</span><span style="white-space:normal;font-family:;" "="">guided interventions</span><span style="white-space:normal;font-family:;" "="">, </span><span style="white-space:normal;font-family:;" "="">though proved to be safe, continue</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">to be a much-underutilized modality in determining treatment strategy, and data is lacking in Indian population. <b>Objective:</b> We aimed to determine the use of FFR-guided PCI and assess the overall impact on treatment decisions and clinical outcomes in patients with acute coronary syndrome (ACS) or chronic coronary syndromes (CCS). <b>Methods:</b> In this single-center retrospective and prospective observational study, FFR had been performed for the evaluation of treatment reclassification and clinical outcomes, as per physician’s clinical practice. <b>Results: </b>Data was obtained for 250 subjects (mean age 60.45 ± 9.6 years) with 324 lesions. The treatment plan based on angiography alone changed in 28% of lesions post-hyperemic FFR. The initial treatment plan based on angiography vs. the final treatment plan post-FFR (>0.80) was medical management 56.5% vs. 66.0%;CABG 11.1% vs.</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">7.7%;and PCI 32.4% vs</span><span style="white-space:normal;font-family:;" "="">.</span><span style="white-space:normal;font-family:;" "=""> 26.2%. In subjects initially assigned to medical management, 14% had changed to PCI, and for subjects initially assigned to PCI, 44% had changed to medical therapy. Receiver operating characteristics (ROC) curve analysis revealed a good correlation between a resting FFR value of <0.87 and hyperemic FFR value of <0.80. The rate of 2-year major adverse cardiovascular events (MACE) was 0.9%. <b>Conclusion: </b>This study supports the use of FFR in determining treatment strategy in ACS or CCS patients with low MACE. Resting FFR value of <0.87 may</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">be an alternative to intracoronary nitroglycerine/adenosine/Nikorandil-induced FFR in predicting positive FFR particularly in hemodynamically unstable patients, and who are intolerant to hyperemic drugs.</span>展开更多
Current new generation stent technology has made remarkable progress in stent design, structure, and component material to improve its performance in reducing stent thrombosis, and restenosis compared to earlier DES a...Current new generation stent technology has made remarkable progress in stent design, structure, and component material to improve its performance in reducing stent thrombosis, and restenosis compared to earlier DES and BMS. Orsiro-Sirolimus eluting stent is new generation ultra-thin strut stent with biodegradable abluminal coating that leaves a polymer free stent after drug release enhances coverage of stent struts and prevents excess neo intimal proliferation. A retrospective data analysis was done to see safety and efficacy of Orsiro in patients treated with ultra-thin DES with Orsiro stents at Sunshine Hospitals, Hyderabad. A total of 331 patients with 525 lesions were treated with 506 Orsiro stents and the major adverse cardiac events (MACE) rate and stent thrombosis (ST) at 2 years’ follow-up were analysed. MACE rate was 1.6% for an average follow-up at 2 years. Out of 2 patients who developed ST, one presented with definite acute stent thrombosis and one with possible, late stent thrombosis and 1.8% non-cardiac death reported during the follow-up. Despite many patients with complex PCI in the ACS subset, Orsiro reduced significant reduction in MACE rate in all spectrum of coronary artery disease patients with excellent acute and long-term results similar to other established FDA-approved current generations stents.展开更多
Introduction: Tetrilimus (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) is a recently-introduced biodegradable-polymer coated everolimus-eluting cobalt-chromium coronary stent system with an ultra-thin stru...Introduction: Tetrilimus (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) is a recently-introduced biodegradable-polymer coated everolimus-eluting cobalt-chromium coronary stent system with an ultra-thin strut thickness. We aimed to evaluate the clinical outcomes with Tetrilimus coronary stents in “real-world” patients with coronary artery disease. Methods: In this retrospective, single-arm, open-label, multi-center registry, all consecutive patients who received Tetrilimus stents between July-2015 and April-2016 at two tertiary-care centers in India were analyzed. Primary endpoint was 30-day incidence of major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, target lesion revascularization, and target vessel revascularization. The Academic Research Consortium (ARC)-defined stent thrombosis was assessed as additional safety endpoint. Results: During the study period, 280 Tetrilimus stents (1.4 ± 0.5 stent/patient) were implanted to treat 252 coronary lesions (1.1 ± 0.3 stent/lesion) in 208 patients (age: 57.5 ± 11.9 years). Of study population, 65.9% were males, 46.6% were hypertensives, 25% were diabetics, 36.5% were alcoholics, 29.3% were smokers, 13.9% were tobacco chewers, 5.3% had previous revascularization, and 45.2% displayed multi-vessel disease. Of treated lesions, 67.5% were complex and 18.7% had total occlusion. Average length and diameter of implanted stents were 25.5 ± 8.8 mm and 2.9 ± 0.3 mm respectively. Subsequently, 30-day MACE were reported in 2 (0.96%) patients;both cases owing to in-hospital cardiac deaths. Events of stent thrombosis or noncardiac death were not reported in any patient. Conclusion: Low MACE rates and absence of stent thrombosis at early 30-day follow-up indicates that Tetrilimus everolimus-eluting stents may have encouraging safety and efficacy in unselected “real-world” patients with coronary artery disease.展开更多
BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct...BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi(PDC)in chronic pancreatitis.POP uses two techniques:Electrohydraulic lithotripsy(EHL)and laser lithotripsy(LL).Data on the safety and efficacy are limited for this procedure.We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP.The secondary aim was to assess pooled rates of technical success,clinical success for the two individual techniques,and adverse event rates.AIM To perform a systematic review and meta-analysis of POP,EHL and LL for management of PDC in chronic pancreatitis.METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed,EMBASE,Cochrane,Google Scholar and Web of Science databases(from 1999 to October 2019)to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP,EHL and LL.The primary outcome assessed involved the pooled technical success and clinical success rate of POP.The secondary outcome included the pooled technical success and clinical success rate for EHL and LL.We also assessed the pooled rate of adverse events for POP,EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP:Hemorrhage,post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP),perforation,abdominal pain,fever and infections.Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain.Randomeffects model was used for analysis.Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics.Publication bias was ascertained,qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTS A total of 16 studies including 383 patients met the inclusion criteria.The technical success rate of POP was 76.4%(95%CI:65.9-84.5;I2=64%)and clinical success rate was 76.8%(95%CI:65.2-85.4;I2=66%).The technical success rate of EHL was 70.3%(95%CI:57.8-80.3;I2=36%)and clinical success rate of EHL was 66.5%(95%CI:55.2-76.2;I2=19%).The technical success rate of LL was 89.3%(95%CI:70.5-96.7;I2=70%)and clinical success rate of LL was 88.2%(95%CI:66.4-96.6;I2=77%).The incidence of pooled adverse events for POP was 14.9%(95%CI:9.2-23.2;I2=49%),for EHL was 11.2%(95%CI:5.9-20.3;I2=15%)and for LL was 13.1%(95%CI:6.3-25.4;I2=31%).Subgroup analysis of adverse events showed rates of PEP at 7%(95%CI:3.5-13.6;I2=38%),fever at 3.7%(95%CI:2-6.9;I2=0),abdominal pain at 4.7%(95%CI:2.7-7.8;I2=0),perforation at 4.3%(95%CI:2.1-8.4;I2=0),hemorrhage at 3.4%(95%CI:1.7-6.6;I2=0)and no mortality.There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSION Our study highlights the high technical and clinical success rates for POP,EHL and LL.POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.展开更多
Acute pancreatitis is a necro-inflammatory disease of the exocrine pancreas that is characterized by inappropriate activation of zymogens, infiltration of the pancreas by inflammatory cells, and destruction of the pan...Acute pancreatitis is a necro-inflammatory disease of the exocrine pancreas that is characterized by inappropriate activation of zymogens, infiltration of the pancreas by inflammatory cells, and destruction of the pancreatic exocrine cells. Acute pancreatitis can progress to a severe life-threatening disease. Currently there is no pharmacotherapy to prevent or treat acute pancreatitis. One of the more common factors associated with acute pancreatitis is alcohol abuse. Although commonly associated with pancreatitis alcohol alone is unable to cause pancreatitis. Instead, it appears that alcohol and its metabolic by-products predispose the pancreas to damage from agents that normally do not cause pancreatitis, or to more severe disease from agents that normally cause mild pancreatic damage. Over the last 10 to 20 years, a tremendous amount of work has defined a number of alcohol-mediated biochemical changes in pancreatic cells. Among these changes are: Sustained levels of intracellular calcium, activation of the mitochondrial permeability transition pore, endoplasmic reticulum stress, impairment in autophagy, alteration in the activity of transcriptional activators, and colocalization of lysosomal and pancreatic digestive enzymes. Elucidation of these changes has led to a deeper understanding of the mechanisms by which ethanol predisposes acinar cells to damage. This greater understanding has revealed a number of promising targets for therapeutic intervention. It is hoped that further investigation of these targets will lead to the development of pharmacotherapy that is effective in treating and preventing the progression of acute pancreatitis.展开更多
AIM:To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy. METHODS:Only EUS and EUS-FNA studies confirmed by surgery or with appropriate fo...AIM:To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy. METHODS:Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 × 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights. RESULTS:Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI:82.9-86.4) to 88.0% (95% CI:85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI:83.2-85.9) to 96.4% (95% CI:95.3-97.4). The P forchi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSION:EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.展开更多
AIM To investigate indications and outcomes of endoscopic retrograde cholangiopancreatography(ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk...AIM To investigate indications and outcomes of endoscopic retrograde cholangiopancreatography(ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events.METHODS We performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017.RESULTS A total of 6,505 patients from 15 studies were analyzed(male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58%(95%CI: 2.77-6.75%, I^2 = 85.9%), post-ERCP pancreatitis(PEP) in 3.68%(95%CI: 1.83-6.00%, I^2 = 89.5%), cholangitis in 1.93%(95%CI: 0.63-3.71%, I^2 = 87.1%) and perforation in 0.00%(95%CI: 0.00-0.23%, I^2 = 37.8%). Six studies were used for comparison of ERCPrelated complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63(95%CI: 1.27-2.09, I2 = 65%): higher rates of hemorrhage with OR of 2.05(95%CI: 1.62-2.58, I^2 = 2.1%) and PEP with OR of 1.33(95%CI: 1.04-1.70, I2=65%), but similar cholangitis rates with OR of 1.23(95%CI: 0.67-2.26, I^2 = 44.3%).CONCLUSION There is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.展开更多
AIMTo determine the association between cirrhosis and ischemic stroke in a large nationally representative sample. METHODSA retrospective cross-sectional study of all hospitalized patients during 2012 and 2013 in the ...AIMTo determine the association between cirrhosis and ischemic stroke in a large nationally representative sample. METHODSA retrospective cross-sectional study of all hospitalized patients during 2012 and 2013 in the United States was performed using the National Inpatient Sample database. Hospitalizations with acute stroke, cirrhosis and other risk factors were identified using ICD-9-CM codes. RESULTSThere were a total of 72082638 hospitalizations in the United States during the years 2012 and 2013. After excluding hospitalizations with missing demographic variables, that there were a total of 1175210 (1.6%) out of these were for acute ischemic stroke. Cirrhosis was present among 5605 (0.4%) cases of ischemic stroke. Mean age among the cirrhotic and non-cirrhotic groups with ischemic stroke were 66.4 and 70.5 years, respectively. Prevalence of risk factors among the two groups was also calculated. After adjusting for various known risk factors the odds of having an ischemic stroke (OR = 0.28, P CONCLUSIONOur study suggests that in a large, nationally representative sample of the United States population, cirrhosis is associated with a lower likelihood of stroke.展开更多
Alcohol abuse is commonly associated with the development of both acute and chronic pancreatitis. Despite this close association, the fact that only a small percentage of human beings who abuse alcohol develop pancrea...Alcohol abuse is commonly associated with the development of both acute and chronic pancreatitis. Despite this close association, the fact that only a small percentage of human beings who abuse alcohol develop pancreatitis indicates that alcohol abuse alone is not sufficient to initiate clinical pancreatitis. This contention is further supported by the fact that administration of ethanol to experimental animals does not cause pancreatitis. Because of these findings, it is widely believed that ethanol sensitizes the pancreas to injury and additional factors trigger the development of overt pancreatitis. How ethanol sensitizes the pancreas to pancreatitis is not entirely known. Numerous studies have demonstrated that ethanol and its metabolites have a number of deleterious effects on acinar cells. Important acinar cells properties that are affected by ethanol include: calcium signaling, secretion of zymogens, autophagy, cellular regeneration, the unfolded protein response, and mitochondrial membrane integrity. In addition to the actions of ethanol on acinar cells, it is apparent that ethanol also affects pancreatic stellatecells. Pancreatic stellate cells have a critical role in normal tissue repair and the pathologic fibrotic response. Given that ethanol and its metabolites affect so many pancreatic functions, and that all of these effects occur simultaneously, it is likely that none of these effects is "THE" effect. Instead, it is most likely that the cumulative effect of ethanol on the pancreas predisposes the organ to pancreatitis. The focus of this article is to highlight some of the important mechanisms by which ethanol alters pancreatic functions and may predispose the pancreas to disease.展开更多
Background: The biodegradable polymer-coated sirolimus-eluting coro-nary stent (SES) system for the treatment of coronary artery disease (CAD) has been implanted in a real-world patient population. Aim: The present st...Background: The biodegradable polymer-coated sirolimus-eluting coro-nary stent (SES) system for the treatment of coronary artery disease (CAD) has been implanted in a real-world patient population. Aim: The present study was designed to evaluate the safety and performance of MetaforTM sirolimus- eluting coronary stent (SES) system in consecutive patients with CAD in a real-world patient population. Methods: All the consecutive 251 patients who underwent percutaneous coronary interventions with the use of Metafor sirolimus-eluting stents were included in this study. Patients were clinically/tele- phonically followed-up at one-year from August 2015 to August 2016. We observed and analyzed major adverse cardiac event (MACE) defined as the aggregate of cardiac death, myocardial infarction (MI), and any target lesion revascularization (TLR) at one-year. Also, stent thrombosis (ST) was observed at one-year patients follow-up. Results: We collected and analyzed the data for 251 patients. Out of 251 participants, 191 (76.1%) were males, 95 (37.8%) patients had diabetes, 117 (46.6%) had ST-segment-elevation myocardial infarction (STEMI), and 134 (53.4%) had hypertension. Mean patient age was 56.35 ± 11.23 years. A total of 295 lesions were treated, out of which 13.6% of the lesions were the long lesion of ≥40 mm. At one-year, MACE occurred in 4 (1.6%) of 251 patients, consisting of 2 (0.8%) cardiac deaths, 2 (0.8%) MI, and 0 (0%) TLR. Stent thrombosis was reported in one patient (0.4%). Conclusions: This retrospective data demonstrated excellent safety and performance of Metafor SES in a “real-world” consecutive CAD patient, indicating low rates of MACE and ST at one-year follow-up.展开更多
文摘<strong>Background:</strong><span style="white-space:normal;font-family:;" "=""> Fractional flow reserve (FFR)</span><span style="white-space:normal;font-family:;" "="">-</span><span style="white-space:normal;font-family:;" "="">guided interventions</span><span style="white-space:normal;font-family:;" "="">, </span><span style="white-space:normal;font-family:;" "="">though proved to be safe, continue</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">to be a much-underutilized modality in determining treatment strategy, and data is lacking in Indian population. <b>Objective:</b> We aimed to determine the use of FFR-guided PCI and assess the overall impact on treatment decisions and clinical outcomes in patients with acute coronary syndrome (ACS) or chronic coronary syndromes (CCS). <b>Methods:</b> In this single-center retrospective and prospective observational study, FFR had been performed for the evaluation of treatment reclassification and clinical outcomes, as per physician’s clinical practice. <b>Results: </b>Data was obtained for 250 subjects (mean age 60.45 ± 9.6 years) with 324 lesions. The treatment plan based on angiography alone changed in 28% of lesions post-hyperemic FFR. The initial treatment plan based on angiography vs. the final treatment plan post-FFR (>0.80) was medical management 56.5% vs. 66.0%;CABG 11.1% vs.</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">7.7%;and PCI 32.4% vs</span><span style="white-space:normal;font-family:;" "="">.</span><span style="white-space:normal;font-family:;" "=""> 26.2%. In subjects initially assigned to medical management, 14% had changed to PCI, and for subjects initially assigned to PCI, 44% had changed to medical therapy. Receiver operating characteristics (ROC) curve analysis revealed a good correlation between a resting FFR value of <0.87 and hyperemic FFR value of <0.80. The rate of 2-year major adverse cardiovascular events (MACE) was 0.9%. <b>Conclusion: </b>This study supports the use of FFR in determining treatment strategy in ACS or CCS patients with low MACE. Resting FFR value of <0.87 may</span><span style="white-space:normal;font-family:;" "=""> </span><span style="white-space:normal;font-family:;" "="">be an alternative to intracoronary nitroglycerine/adenosine/Nikorandil-induced FFR in predicting positive FFR particularly in hemodynamically unstable patients, and who are intolerant to hyperemic drugs.</span>
文摘Current new generation stent technology has made remarkable progress in stent design, structure, and component material to improve its performance in reducing stent thrombosis, and restenosis compared to earlier DES and BMS. Orsiro-Sirolimus eluting stent is new generation ultra-thin strut stent with biodegradable abluminal coating that leaves a polymer free stent after drug release enhances coverage of stent struts and prevents excess neo intimal proliferation. A retrospective data analysis was done to see safety and efficacy of Orsiro in patients treated with ultra-thin DES with Orsiro stents at Sunshine Hospitals, Hyderabad. A total of 331 patients with 525 lesions were treated with 506 Orsiro stents and the major adverse cardiac events (MACE) rate and stent thrombosis (ST) at 2 years’ follow-up were analysed. MACE rate was 1.6% for an average follow-up at 2 years. Out of 2 patients who developed ST, one presented with definite acute stent thrombosis and one with possible, late stent thrombosis and 1.8% non-cardiac death reported during the follow-up. Despite many patients with complex PCI in the ACS subset, Orsiro reduced significant reduction in MACE rate in all spectrum of coronary artery disease patients with excellent acute and long-term results similar to other established FDA-approved current generations stents.
文摘Introduction: Tetrilimus (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) is a recently-introduced biodegradable-polymer coated everolimus-eluting cobalt-chromium coronary stent system with an ultra-thin strut thickness. We aimed to evaluate the clinical outcomes with Tetrilimus coronary stents in “real-world” patients with coronary artery disease. Methods: In this retrospective, single-arm, open-label, multi-center registry, all consecutive patients who received Tetrilimus stents between July-2015 and April-2016 at two tertiary-care centers in India were analyzed. Primary endpoint was 30-day incidence of major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, target lesion revascularization, and target vessel revascularization. The Academic Research Consortium (ARC)-defined stent thrombosis was assessed as additional safety endpoint. Results: During the study period, 280 Tetrilimus stents (1.4 ± 0.5 stent/patient) were implanted to treat 252 coronary lesions (1.1 ± 0.3 stent/lesion) in 208 patients (age: 57.5 ± 11.9 years). Of study population, 65.9% were males, 46.6% were hypertensives, 25% were diabetics, 36.5% were alcoholics, 29.3% were smokers, 13.9% were tobacco chewers, 5.3% had previous revascularization, and 45.2% displayed multi-vessel disease. Of treated lesions, 67.5% were complex and 18.7% had total occlusion. Average length and diameter of implanted stents were 25.5 ± 8.8 mm and 2.9 ± 0.3 mm respectively. Subsequently, 30-day MACE were reported in 2 (0.96%) patients;both cases owing to in-hospital cardiac deaths. Events of stent thrombosis or noncardiac death were not reported in any patient. Conclusion: Low MACE rates and absence of stent thrombosis at early 30-day follow-up indicates that Tetrilimus everolimus-eluting stents may have encouraging safety and efficacy in unselected “real-world” patients with coronary artery disease.
文摘BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi(PDC)in chronic pancreatitis.POP uses two techniques:Electrohydraulic lithotripsy(EHL)and laser lithotripsy(LL).Data on the safety and efficacy are limited for this procedure.We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP.The secondary aim was to assess pooled rates of technical success,clinical success for the two individual techniques,and adverse event rates.AIM To perform a systematic review and meta-analysis of POP,EHL and LL for management of PDC in chronic pancreatitis.METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed,EMBASE,Cochrane,Google Scholar and Web of Science databases(from 1999 to October 2019)to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP,EHL and LL.The primary outcome assessed involved the pooled technical success and clinical success rate of POP.The secondary outcome included the pooled technical success and clinical success rate for EHL and LL.We also assessed the pooled rate of adverse events for POP,EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP:Hemorrhage,post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP),perforation,abdominal pain,fever and infections.Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain.Randomeffects model was used for analysis.Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics.Publication bias was ascertained,qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTS A total of 16 studies including 383 patients met the inclusion criteria.The technical success rate of POP was 76.4%(95%CI:65.9-84.5;I2=64%)and clinical success rate was 76.8%(95%CI:65.2-85.4;I2=66%).The technical success rate of EHL was 70.3%(95%CI:57.8-80.3;I2=36%)and clinical success rate of EHL was 66.5%(95%CI:55.2-76.2;I2=19%).The technical success rate of LL was 89.3%(95%CI:70.5-96.7;I2=70%)and clinical success rate of LL was 88.2%(95%CI:66.4-96.6;I2=77%).The incidence of pooled adverse events for POP was 14.9%(95%CI:9.2-23.2;I2=49%),for EHL was 11.2%(95%CI:5.9-20.3;I2=15%)and for LL was 13.1%(95%CI:6.3-25.4;I2=31%).Subgroup analysis of adverse events showed rates of PEP at 7%(95%CI:3.5-13.6;I2=38%),fever at 3.7%(95%CI:2-6.9;I2=0),abdominal pain at 4.7%(95%CI:2.7-7.8;I2=0),perforation at 4.3%(95%CI:2.1-8.4;I2=0),hemorrhage at 3.4%(95%CI:1.7-6.6;I2=0)and no mortality.There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSION Our study highlights the high technical and clinical success rates for POP,EHL and LL.POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.
基金Supported by Funds from the University of Nebraska Department of Internal Medicine,the Fred and Pamela Buffett Cancer Center,and the Nebraska Research Initiative(to Clemens DL)by NIH,NIAAA grant AA020818(to Arkfeld CK)
文摘Acute pancreatitis is a necro-inflammatory disease of the exocrine pancreas that is characterized by inappropriate activation of zymogens, infiltration of the pancreas by inflammatory cells, and destruction of the pancreatic exocrine cells. Acute pancreatitis can progress to a severe life-threatening disease. Currently there is no pharmacotherapy to prevent or treat acute pancreatitis. One of the more common factors associated with acute pancreatitis is alcohol abuse. Although commonly associated with pancreatitis alcohol alone is unable to cause pancreatitis. Instead, it appears that alcohol and its metabolic by-products predispose the pancreas to damage from agents that normally do not cause pancreatitis, or to more severe disease from agents that normally cause mild pancreatic damage. Over the last 10 to 20 years, a tremendous amount of work has defined a number of alcohol-mediated biochemical changes in pancreatic cells. Among these changes are: Sustained levels of intracellular calcium, activation of the mitochondrial permeability transition pore, endoplasmic reticulum stress, impairment in autophagy, alteration in the activity of transcriptional activators, and colocalization of lysosomal and pancreatic digestive enzymes. Elucidation of these changes has led to a deeper understanding of the mechanisms by which ethanol predisposes acinar cells to damage. This greater understanding has revealed a number of promising targets for therapeutic intervention. It is hoped that further investigation of these targets will lead to the development of pharmacotherapy that is effective in treating and preventing the progression of acute pancreatitis.
文摘AIM:To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy. METHODS:Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 × 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights. RESULTS:Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI:82.9-86.4) to 88.0% (95% CI:85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI:83.2-85.9) to 96.4% (95% CI:95.3-97.4). The P forchi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. CONCLUSION:EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.
文摘AIM To investigate indications and outcomes of endoscopic retrograde cholangiopancreatography(ERCP) in cirrhotics, especially adverse events. Patients with cirrhosis undergoing ERCP are believed to have increased risk. However, there is a paucity of literature describing the indications and outcomes of ERCP procedures in patients with cirrhosis, especially focusing on adverse events.METHODS We performed a systematic appraisal of major literature databases, including PubMed and EMBASE, with a manual search of literature from their inception until April 2017.RESULTS A total of 6,505 patients from 15 studies were analyzed(male ratio 59%, mean age 59 years), 11% with alcoholic and 89% with non-alcoholic cirrhosis, with 56.2% Child-Pugh class A, and 43.8% class B or C. Indications for ERCP included choledocholithiasis 60.9%, biliary strictures 26.2%, gallstone pancreatitis 21.1% and cholangitis 15.5%. Types of interventions included endoscopic sphincterotomy 52.7%, biliary stenting 16.7% and biliary dilation 4.6%. Individual adverse events included hemorrhage in 4.58%(95%CI: 2.77-6.75%, I^2 = 85.9%), post-ERCP pancreatitis(PEP) in 3.68%(95%CI: 1.83-6.00%, I^2 = 89.5%), cholangitis in 1.93%(95%CI: 0.63-3.71%, I^2 = 87.1%) and perforation in 0.00%(95%CI: 0.00-0.23%, I^2 = 37.8%). Six studies were used for comparison of ERCPrelated complications in cirrhosis vs non-cirrhosis, which showed higher overall rates of complications in cirrhosis patients with pooled OR of 1.63(95%CI: 1.27-2.09, I2 = 65%): higher rates of hemorrhage with OR of 2.05(95%CI: 1.62-2.58, I^2 = 2.1%) and PEP with OR of 1.33(95%CI: 1.04-1.70, I2=65%), but similar cholangitis rates with OR of 1.23(95%CI: 0.67-2.26, I^2 = 44.3%).CONCLUSION There is an overall higher rate of adverse events related to ERCP in patients with cirrhosis, especially hemorrhage and PEP. A thorough risk/benefit assessment should be performed prior to undertaking ERCP in patients with cirrhosis.
文摘AIMTo determine the association between cirrhosis and ischemic stroke in a large nationally representative sample. METHODSA retrospective cross-sectional study of all hospitalized patients during 2012 and 2013 in the United States was performed using the National Inpatient Sample database. Hospitalizations with acute stroke, cirrhosis and other risk factors were identified using ICD-9-CM codes. RESULTSThere were a total of 72082638 hospitalizations in the United States during the years 2012 and 2013. After excluding hospitalizations with missing demographic variables, that there were a total of 1175210 (1.6%) out of these were for acute ischemic stroke. Cirrhosis was present among 5605 (0.4%) cases of ischemic stroke. Mean age among the cirrhotic and non-cirrhotic groups with ischemic stroke were 66.4 and 70.5 years, respectively. Prevalence of risk factors among the two groups was also calculated. After adjusting for various known risk factors the odds of having an ischemic stroke (OR = 0.28, P CONCLUSIONOur study suggests that in a large, nationally representative sample of the United States population, cirrhosis is associated with a lower likelihood of stroke.
文摘Alcohol abuse is commonly associated with the development of both acute and chronic pancreatitis. Despite this close association, the fact that only a small percentage of human beings who abuse alcohol develop pancreatitis indicates that alcohol abuse alone is not sufficient to initiate clinical pancreatitis. This contention is further supported by the fact that administration of ethanol to experimental animals does not cause pancreatitis. Because of these findings, it is widely believed that ethanol sensitizes the pancreas to injury and additional factors trigger the development of overt pancreatitis. How ethanol sensitizes the pancreas to pancreatitis is not entirely known. Numerous studies have demonstrated that ethanol and its metabolites have a number of deleterious effects on acinar cells. Important acinar cells properties that are affected by ethanol include: calcium signaling, secretion of zymogens, autophagy, cellular regeneration, the unfolded protein response, and mitochondrial membrane integrity. In addition to the actions of ethanol on acinar cells, it is apparent that ethanol also affects pancreatic stellatecells. Pancreatic stellate cells have a critical role in normal tissue repair and the pathologic fibrotic response. Given that ethanol and its metabolites affect so many pancreatic functions, and that all of these effects occur simultaneously, it is likely that none of these effects is "THE" effect. Instead, it is most likely that the cumulative effect of ethanol on the pancreas predisposes the organ to pancreatitis. The focus of this article is to highlight some of the important mechanisms by which ethanol alters pancreatic functions and may predispose the pancreas to disease.
文摘Background: The biodegradable polymer-coated sirolimus-eluting coro-nary stent (SES) system for the treatment of coronary artery disease (CAD) has been implanted in a real-world patient population. Aim: The present study was designed to evaluate the safety and performance of MetaforTM sirolimus- eluting coronary stent (SES) system in consecutive patients with CAD in a real-world patient population. Methods: All the consecutive 251 patients who underwent percutaneous coronary interventions with the use of Metafor sirolimus-eluting stents were included in this study. Patients were clinically/tele- phonically followed-up at one-year from August 2015 to August 2016. We observed and analyzed major adverse cardiac event (MACE) defined as the aggregate of cardiac death, myocardial infarction (MI), and any target lesion revascularization (TLR) at one-year. Also, stent thrombosis (ST) was observed at one-year patients follow-up. Results: We collected and analyzed the data for 251 patients. Out of 251 participants, 191 (76.1%) were males, 95 (37.8%) patients had diabetes, 117 (46.6%) had ST-segment-elevation myocardial infarction (STEMI), and 134 (53.4%) had hypertension. Mean patient age was 56.35 ± 11.23 years. A total of 295 lesions were treated, out of which 13.6% of the lesions were the long lesion of ≥40 mm. At one-year, MACE occurred in 4 (1.6%) of 251 patients, consisting of 2 (0.8%) cardiac deaths, 2 (0.8%) MI, and 0 (0%) TLR. Stent thrombosis was reported in one patient (0.4%). Conclusions: This retrospective data demonstrated excellent safety and performance of Metafor SES in a “real-world” consecutive CAD patient, indicating low rates of MACE and ST at one-year follow-up.
