BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral an...BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral and non-viral etiologies are treated by traditional ARDS protocols that recommend 12-16 hours of prone position ventilation(PPV)with neuromuscular blocking agents(NMBA)and a trial of inhaled vasodilators(IVd)if oxygenation does not improve.However,debate on the efficacy of adjuncts to PPV and low tidal volume ventilation persists and evidence about the benefits of IVd/NMBA in COVID ARDS is sparse.In our multi-center retrospective review,we evaluated the impact of PPV,IVd,and NMBA on outcomes and lung mechanics in COVID ARDS patients with moderate to severe ARDS.AIM To evaluate the impact of PPV used alone or in combination with pulmonary IVd and/or NMBA in mechanically ventilated patients with moderate to severe ARDS during the COVID-19 pandemic.METHODS A retrospective study at two tertiary academic medical centers compared outcomes between COVID ARDS patients receiving PPV and patients in the supine position.PPV patients were divided based on concurrent use of ARDS adjunct therapies resulting in four subgroups:(1)PPV alone;(2)PPV and IVd;(3)PPV and NMBA;and(4)PPV,IVd,and NMBA.Primary outcomes were hospital and intensive care unit(ICU)length of stay(LOS),mortality,and venovenous extracorporeal membrane oxygenation(VV-ECMO)status.Secondary outcomes included changes in lung mechanics at 24-hour intervals for 7 days.RESULTS Total 114 patients were included in this study.Baseline respiratory parameters and Sequential Organ Failure Assessment scores were significantly worse in the PPV group.ICU LOS and LOS were significantly longer for patients who were proned,but no mortality benefit or difference in VV-ECMO status was found.Among the subgroups,no difference in primary outcomes were found.In the secondary analysis,PPV was associated with a significant improvement in arterial oxygen partial pressure(PaO_(2))/fractional inspired oxygen(FiO_(2))(P/F)ratio from day 1 to day 4(P<0.05)and higher driving pressures day 5 to day 7(P<0.05).The combination of PPV and IVd together resulted in improvements in P/F ratio from day 1 to day 7 and plateau pressure on day 4 and day 6(P<0.05).PPV with NMBA was not associated with improvements in any of the secondary outcomes.The use of all three rescue therapies together resulted in improvements in lung compliance on day 2(P<0.05)but no other improvements.CONCLUSION In mechanically ventilated patients diagnosed with moderate to severe COVID ARDS,PPV and PPV with the addition of IVd produced a significant and sustained increase in P/F ratio.The combination of PPV,IVd and NMBA improved compliance however this did not reach significance.Mortality and LOS did not improve with adjunct therapies.Further research is warranted to determine the efficacy of these therapies alone and in combination in the treatment of COVID ARDS.展开更多
BACKGROUND Ulcerative colitis(UC)increases the risk of colorectal dysplasia.While colectomy was once standard,advances in polypectomy,endoscopic mucosal resection(EMR),endoscopic submucosal dissection(ESD),and endosco...BACKGROUND Ulcerative colitis(UC)increases the risk of colorectal dysplasia.While colectomy was once standard,advances in polypectomy,endoscopic mucosal resection(EMR),endoscopic submucosal dissection(ESD),and endoscopic full-thickness resection(EFTR)now allow organ-sparing management in selected cases.AIM To summarize current evidence on the feasibility,safety,and outcomes of these techniques in UC-associated neoplasia.METHODS A scoping review was conducted using PubMed and EMBASE(1975-May 2025)with the search:(“endoscopic submucosal dissection”/exp OR“endoscopic mucosal resection”OR“full thickness resection”OR“polypectomy”)AND(“ulcerative colitis”/exp OR“ulcerative colitis”OR“pouch”).Screening followed PRISMA guidelines.Eligible studies included those reporting outcomes,feasibility,or novel techniques in the endoscopic management of UC-associated dysplasia.RESULTS Of 1075 identified records,754 were screened after duplicate removal,and 48 studies were included.Polypectomy was safe and effective for well-demarcated,lifting lesions without adjacent dysplasia.EMR has excellent outcomes for small,polypoid,or right-sided lesions that demonstrated adequate lifting.ESD is ind icated for flat,large,non-polypoid,or fibrotic lesions,particularly in the left colon.ESD achieved en bloc resection in 88%-100%and R0 resection in 73%-96%of cases.The overall complication rate with ESD was approximately 2%-10%,primarily bleeding or perforation.Local recurrence occurred in 0%-6.8%,and metachronous lesions developed in up to 31%of cases over follow-up durations of up to 15 years.Surgical intervention after ESD was required in 10%-20%of patients,typically for non-curative resection or new lesions.Submucosal fibrosis,a common obstacle in UC,limited lifting and increased procedural difficulty.Adjunctive strategies-such as water pressure-assisted dissection,pocket-creation method,self-assembling peptide injectables,and traction systems-enhanced technical success.EFTR,though limited to case series,was effective for non-lifting or anatomically complex lesions,particularly in post-surgical or pouch anatomy,but carried higher procedural risk including rare but serious adverse events.CONCLUSION Endoscopic resection offers a spectrum of curative,minimally invasive options for managing dysplasia in UC.EMR remains appropriate for simple,lifting lesions,while ESD and EFTR broaden the therapeutic landscape for complex or fibrotic pathology.Lesion morphology,lifting characteristics,and operator experience should guide technique selection.Long-term outcomes are favorable with appropriate surveillance,though the risk of metachronous neoplasia necessitates continued monitoring.展开更多
The incidence of hepatocellular carcinoma(HCC)has been steadily rising,und-erscoring the need for a clear,stage-specific treatment approach.The Barcelona Clinic Liver Cancer(BCLC)staging system remains the most widely...The incidence of hepatocellular carcinoma(HCC)has been steadily rising,und-erscoring the need for a clear,stage-specific treatment approach.The Barcelona Clinic Liver Cancer(BCLC)staging system remains the most widely used frame-work for classifying HCC and guiding therapy.Among its classifications,the intermediate stage(BCLC-B)encompasses a highly heterogeneous patient popu-lation,with varying degrees of tumor burden and liver function.Traditionally,transarterial chemoembolization has been the standard treatment for this stage,based on earlier evidence.However,recent studies suggest that a subset of BCLC-B patients-particularly those with localized disease-may benefit more from liver resection.This review summarizes current treatment paradigms for BCLC-B HCC,explores emerging subclassifications within this group,and highlights evolving guidelines that support the selective use of surgery in appropriately chosen patients.展开更多
BACKGROUND There is widespread debate about the impact of metabolically healthy obesity(MHO)on cardiovascular outcomes.However,studies have not exclusively examined the impact of MHO on cardiovascular outcomes in the ...BACKGROUND There is widespread debate about the impact of metabolically healthy obesity(MHO)on cardiovascular outcomes.However,studies have not exclusively examined the impact of MHO on cardiovascular outcomes in the postmeno-pausal population.AIM To explore the prevalence of MHO and its relationship with hospitalization outcomes,including major adverse cardiac or cerebrovascular events(MACCE),in postmenopausal women.METHODS We extracted data from the National Inpatient Sample 2020 database using International Classification of Disease,Tenth Revision,Clinical Modification codes for all admissions of postmenopausal women.We excluded patients with diabetes,hypertension,and hyperlipidemia to obtain metabolically healthy patients and then identified patients with obesity to create obese and non-obese cohorts.We used a 1:1 propensity score matching method to match patients with and without MHO based on age,and then we did a multivariable regression analysis for in-hospital MACCE.RESULTS In 2020,1304185 metabolically healthy postmenopausal women were admitted;148250(11.4%)had MHO.After propensity score matching for age,a statistically significant difference was observed in overall MACCE[odds ratio(OR):1.08,95%confidence interval(CI):1.01-1.16,P=0.028]among MHO and non-MHO cohorts,especially in patients of African-American ethnicity(OR:1.23,95%CI:1.01-1.49,P=0.035)and the lowermost income quartile(OR:1.24,95%CI:1.06-1.44,P=0.007).CONCLUSION Postmenopausal patients with MHO are at risk of MACCE,especially black patients and those with lower incomes.Larger prospective studies can demystify MHO’s impact on cardiovascular outcomes among postmenopausal women.展开更多
BACKGROUND Cardiopulmonary changes in noncirrhotic portal hypertension(NCPH)are poorly understood.AIM To investigate cardiopulmonary changes using transthoracic echocardiography(TTE)in NCPH and their correlation with ...BACKGROUND Cardiopulmonary changes in noncirrhotic portal hypertension(NCPH)are poorly understood.AIM To investigate cardiopulmonary changes using transthoracic echocardiography(TTE)in NCPH and their correlation with clinical features.METHODS Prospective cohort including 10 preclinical NCPH[without portal hypertension(PH)]and 32 NCPH subjects who underwent TTE with agitated saline injection and comprehensive clinical evaluation were assessed.PH was defined by presence of either varices,ascites or portosystemic shunting.Intrapulmonary vascular dilatation(IPVD)is defined as appearance of microbubbles in the left atrium after three heartbeats.Right ventricular systolic pressure(RVSP)>38 mmHg was used to identify possible porto-pulmonary hypertension.Cardiomyopathy is defined using cirrhotic cardiomyopathy consortium criteria.RESULTS Among 42 subjects,17(40%)had IPVD,4(9.5%)had RVSP>38 mmHg,and 6(14%)had cardiomyopathy.Aspartate aminotransferase to alanine aminotransferase(AST/ALT)(1.3 vs 1,P=0.04)and liver stiffness measurement(LSM)(12.4 kPa vs 7.1 kPa,P=0.03)were higher in those with IPVD.Presence of either LSM>10 or AST/ALT>1.2 aided in identifying subjects with IPVD-sensitivity,specificity,and accuracy of 76%.RVSP correlated with oxygen saturation(r=-0.33),and free right hepatic vein pressure(r=0.43).Those with PH had higher left atrial volume(LAV)(62 mL vs 48 mL,P<0.01),and LAV index(LAVI)(35 m^(2) vs 23 m^(2),P<0.01)compared to those without PH.Total bile acids,especially primary bile acids positively correlated with LAV(r=0.36),and LAVI(r=0.41).CONCLUSION Similar to cirrhotic patients,cardiopulmonary changes are prevalent in NCPH,especially among those with PH.In NCPH,cardiopulmonary changes occur despite preserved synthetic function,suggesting the NCPH model's value in understanding cardiopulmonary dysfunction in liver disease.展开更多
BACKGROUND Coronavirus disease 2019(COVID-19)has been shown to increase the risk of stroke.However,the prevalence and risk of recurrent stroke in COVID-19 patients with prior stroke/transient ischemic attack(TIA),as w...BACKGROUND Coronavirus disease 2019(COVID-19)has been shown to increase the risk of stroke.However,the prevalence and risk of recurrent stroke in COVID-19 patients with prior stroke/transient ischemic attack(TIA),as well as its impact on mor-tality,are not established.AIM To evaluate the impact of COVID-19 on in-hospital mortality,length of stay,and healthcare costs in patients with recurrent strokes.METHODS We identified admissions of recurrent stroke(current acute ischemic stroke admissions with at least one prior TIA or stroke)in patients with and without COVID-19 using ICD-10-CM codes using the National Inpatient Sample(2020).We analyzed the impact of COVID-19 on mortality following recurrent stroke admissions by subgroups.RESULTS Of 97455 admissions with recurrent stroke,2140(2.2%)belonged to the COVID-19-positive group.The COVID-19-positive group had a higher prevalence of diabetes and chronic kidney disease vs the COVID-19 negative group(P<0.001).Among the subgroups,patients aged>65 years,patients aged 45–64 years,Asians,Hispanics,whites,and blacks in the COVID-19 positive group had higher rates of all-cause mortality than the COVID-19 negative group(P<0.01).Higher odds of in-hospital mortality were seen in the group aged 45-64(OR:8.40,95%CI:4.18-16.91)vs the group aged>65(OR:7.04,95%CI:5.24-9.44),males(OR:7.82,95%CI:5.38-11.35)compared to females(OR:6.15,95%CI:4.12-9.18),and in Hispanics(OR:15.47,95%CI:7.61-31.44)and Asians/Pacific Islanders(OR:14.93,95%CI:7.22-30.87)compared to blacks(OR:5.73,95%CI:3.08-10.68),and whites(OR:5.54,95%CI:3.79-8.09).CONCLUSION The study highlights the increased risk of all-cause in-hospital mortality in recurrent stroke patients with COVID-19,with a more pronounced increase in middle-aged patients,males,Hispanics,or Asians.展开更多
Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic...Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic challenge. Primary cardiac tumors are rare and usually benign, whereas most cardiac tumors result from metastases, commonly originating from malignancies in the breast, lung, or melanoma. Aim: This report highlights the importance of distinguishing various cardiac masses based on clinical presentations, clinical courses, and radiological features. Case Presentation: We describe two cases of cardiac masses with unique and diverse clinical features. Each case posed significant diagnostic challenges due to their distinct presentations and clinical progressions. Conclusion: These cases underscore the importance of considering both benign and metastatic origins in the differential diagnosis of intracavitary cardiac masses. Accurate differentiation between thrombi and tumors is crucial for appropriate management and treatment.展开更多
BACKGROUND Short bowel syndrome(SBS)hospitalizations are often complicated with sepsis.There is a significant paucity of data on adult SBS hospitalizations in the United States and across the globe.AIM To assess trend...BACKGROUND Short bowel syndrome(SBS)hospitalizations are often complicated with sepsis.There is a significant paucity of data on adult SBS hospitalizations in the United States and across the globe.AIM To assess trends and outcomes of SBS hospitalizations complicated by sepsis in the United States.METHODS The National Inpatient Sample was utilized to identify all adult SBS hospitalizations between 2005-2014.The study cohort was further divided based on the presence or absence of sepsis.Trends were identified,and hospitalization characteristics and clinical outcomes were compared.Predictors of mortality for SBS hospitalizations complicated with sepsis were assessed.RESULTS Of 247097 SBS hospitalizations,21.7%were complicated by sepsis.Septic SBS hospitalizations had a rising trend of hospitalizations from 20.8%in 2005 to 23.5%in 2014(P trend<0.0001).Compared to non-septic SBS hospitalizations,septic SBS hospitalizations had a higher proportion of males(32.8%vs 29.3%,P<0.0001),patients in the 35-49(45.9%vs 42.5%,P<0.0001)and 50-64(32.1%vs 31.1%,P<0.0001)age groups,and ethnic minorities,i.e.,Blacks(12.4%vs 11.3%,P<0.0001)and Hispanics(6.7%vs 5.5%,P<0.0001).Furthermore,septic SBS hospitalizations had a higher proportion of patients with intestinal transplantation(0.33%vs 0.22%,P<0.0001),inpatient mortality(8.5%vs 1.4%,P<0.0001),and mean length of stay(16.1 d vs 7.7 d,P<0.0001)compared to the non-sepsis cohort.A younger age,female gender,White race,and presence of comorbidities such as anemia and depression were identified to be independent predictors of inpatient mortality for septic SBS hospitalizations.CONCLUSION Septic SBS hospitalizations had a rising trend between 2005-2014 and were associated with higher inpatient mortality compared to non-septic SBS hospitalizations.展开更多
Immune checkpoint inhibitors(ICIs) are monoclonal antibodies that target downregulators of the anti-cancer immune response: Cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand programmed ...Immune checkpoint inhibitors(ICIs) are monoclonal antibodies that target downregulators of the anti-cancer immune response: Cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand programmed death-ligand 1.ICIs have revolutionized the treatment of a variety of malignancies. However,many immune-related adverse events have also been described which mainly occurs as the immune system becomes less suppressed, affecting various organs including the gastrointestinal tract and causing diarrhea and colitis. The incidence of immune-mediated colitis(IMC) ranges from 1%-25% depending on the type of ICI and if used in combination. Endoscopically and histologically there is a significant overlap between IMC and inflammatory bowel disease,however more neutrophilic inflammation without chronic inflammation is usually present in IMC. Corticosteroids are recommended for grade 2 or more severe colitis while holding the immunotherapy. About one third to two thirds of patients are steroid refractory and benefit from infliximab. Recently vedolizumab has been found to be efficacious in steroid and infliximab refractory cases. While in grade 4 colitis, the immunotherapy is permanently discontinued, the decision is controversial in grade 3 colitis.展开更多
The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of...The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of colon cancer patients and 25% of rectal cancer patients and should be prevented. Strategies to prevent colon or rectal cancer local recurrence and peritoneal metastases include cytoreductive surgery and hyperthermic perioperative chemotherapy (HIPEC). These strategies can be used at the time of primary colon or rectal cancer resection if the HIPEC is available. At institutions where HIPEC is not available with the treatment of primary malignancy, a proactive second-look surgery is recommended. Several phase II studies strongly support the proactive approach. If peritoneal metastases were treated along with the primary colon resection, 5-year survival was seen and these results were superior to the results of treatment after peritoneal metastases had developed as recurrence. Also, prophylactic HIPEC improved survival with T3/T4 mucinous or signet ring colon cancers. A second-look has been shown to be effective in two published manuscripts. Unpublished data from MedStar Washington Cancer Institute also produced favorable date. Rectal cancer with peritoneal metastases may not be so effectively treated. There are both credits and debits of this proactive approach. Selection factors should be reviewed by the multidisciplinary team for individualized management of patients with or at high risk for peritoneal metastases.展开更多
Vitamin D through its active form 1a-25-dihydroxyvtamin D[1,25(OH)2D]is a secosteroid hormone that plays a key role in mineral metabolism.Recent years have witnessed a significant scientific interest on vitamin D and ...Vitamin D through its active form 1a-25-dihydroxyvtamin D[1,25(OH)2D]is a secosteroid hormone that plays a key role in mineral metabolism.Recent years have witnessed a significant scientific interest on vitamin D and expanded its actions to include immune modulation,cell differentiation and proliferation and inflammation regulation.As our understanding of the many functions of vitamin D has grown,the presence of vitamin D deficiency has become one of the most prevalent micronutrient deficiencies worldwide.Concomitantly,non-alcoholic fatty liver disease(NAFLD)has become the most common form of chronic liver disease in western countries.NAFLD and vitamin D deficiency often coexist and epidemiologic evidence has shown that both of these conditions share several cardiometabolic risk factors.In this article we provide an overview of the epidemiology and pathophysiology linking NAFLD and vitamin D deficiency,as well as the available evidence on the clinical utility of vitamin D supplementation in NAFLD.展开更多
Mucosa-associated lymphoid tissue(MALT) lymphoma of the liver is a very rare condition and thus the diag-nosis may be challeng-ing-. The clinical presentation is usually variable, rang-ing- from minimal clinical sympt...Mucosa-associated lymphoid tissue(MALT) lymphoma of the liver is a very rare condition and thus the diag-nosis may be challeng-ing-. The clinical presentation is usually variable, rang-ing- from minimal clinical symptoms to severe end stag-e liver disease. In this paper, we describe the clinicopatholog-ic finding-s in two cases of primary hepatic MALT lymphoma. One case is an 80-year-old female with no underlying- chronic liver disease and the second case is a 30-year-old female with autoimmune hepatitis complicated by MALT lymphoma. In both specimens, there was diffuse infiltration of atypical B-lymphocytes that were positive for CD20 and CD79 a, but neg-ative for CD5, CD43 and CD10. There were occasional lymphoepithelial lesions involving- the hepatocytes or bile ducts. Polymerase chain reaction analysis showed monoclonal immunog-lobulin heavy chain g-ene rearrang-ement in both cases. The first case was treated with surg-ery but developed pulmonary recurrence a year after complete resection but went into remission following- treatment with rituximab. A second recurrence occurred in the rig-ht parotid g-land 7 years later, which was treated with idelalisib. The second case was effectively treated with rituximab. To our knowledg-e, the second case is the first reported case linked to autoimmune hepatitis.展开更多
腹膜癌是一种预后较差的恶性肿瘤,肿瘤来源较广泛,开展规范化治疗对腹膜癌患者至关重要。腹膜表面肿瘤协作组国际联盟(Peritoneal Surface Oncology Group International,PSOGI)制订了腹膜癌临床指南,本文为国际腹膜癌治疗指南中文版,...腹膜癌是一种预后较差的恶性肿瘤,肿瘤来源较广泛,开展规范化治疗对腹膜癌患者至关重要。腹膜表面肿瘤协作组国际联盟(Peritoneal Surface Oncology Group International,PSOGI)制订了腹膜癌临床指南,本文为国际腹膜癌治疗指南中文版,该指南共分四部分:术前评估、腹膜癌手术、腹膜癌化疗及临床路径。其中,术前评估主要包括术前CT检查、预后评估模型、诊断性腹腔镜探查、腹膜癌指数及细胞减灭程度评分;腹膜癌治疗原则是以肿瘤细胞减灭术(cytoreductive surgery,CRS)和围手术期化疗为核心的综合治疗,但完全CRS是患者获得长期生存的关键;腹膜癌化疗主要包括围手术期化疗及区域性化疗。最后,本指南概述了腹膜癌的临床路径。经PSOGI执行委员会秘书长许可,发表该指南中文版。展开更多
Intracerebral hemorrhage(ICH) remains the second-most common form of stroke with high morbidity and mortality.ICH can be divided into two pathophysiological stages:an acute primary phase,including hematoma volume expa...Intracerebral hemorrhage(ICH) remains the second-most common form of stroke with high morbidity and mortality.ICH can be divided into two pathophysiological stages:an acute primary phase,including hematoma volume expansion,and a subacute secondary phase consisting of blood-brain barrier disruption and perihematomal edema expansion.To date,all major trials for ICH have targeted the primary phase with therapies designed to reduce hematoma expansion through blood pressure control,surgical evacuation,and hemostasis.However,none of these trials has resulted in improved clinical outcomes.Magnesium is a ubiquitous element that also plays roles in vasodilation,hemostasis,and blood-brain barrier preservation.Animal models have highlighted potential therapeutic roles for magnesium in neurological diseases specifically targeting these pathophysiological mechanisms.Retrospective studies have also demonstrated inverse associations between admission magnesium levels and hematoma volume,hematoma expansion,and clinical outcome in patients with ICH.These associations,coupled with the multifactorial role of magnesium that targets both primary and secondary phases of ICH,suggest that magnesium may be a viable target of study in future ICH studies.展开更多
BACKGROUND Herbal supplements(HS)for weight loss are perceived to be“safe”and“natural”,as advertised in ads,however,hepatotoxicity can be associated with consumption of some HS.Use of HS may be missed,as the patie...BACKGROUND Herbal supplements(HS)for weight loss are perceived to be“safe”and“natural”,as advertised in ads,however,hepatotoxicity can be associated with consumption of some HS.Use of HS may be missed,as the patient may not report these unless specifically asked about these products,since they are often not thought of as medications with potential side effects or interaction potential.CASE SUMMARY We reported a case of a 21-year-old female with morbid obesity who presented with abdominal pain for 1 wk associated with nausea,vomiting,anorexia and myalgias.She denied smoking tobacco,drinking alcohol,usage of illicit drugs,hormonal contraceptives,or energy drinks.There was no significant past medical or family illnesses.Her laboratory workup revealed acute liver failure.The workup for possible etiologies of acute liver failure was unremarkable.She was using a weight loss herbal supplement“Garcinia cambogia”for 4 wks.This case demonstrates the association of acute liver failure with Garcinia cambogia.CONCLUSION Medical reconciliation of HS should be performed in patients with suspected acute liver failure and early discontinuation of HS can prevent further progression of drug induced hepatoxicity.展开更多
Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,p...Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,pruritis,and malaise,a triad that develops secondary to obstruction,which often occurs late in the course of the disease process.The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis,staging,and management of patients with pancreatic cancer.Endoscopic retrograde cholangiopancreatography(ERCP)-guided diagnosis(with brush cytology,serial pancreatic juice aspiration cytologic examination technique,or biliary biopsy)and therapeutic interventions such as pancreatobiliary decompression,intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management.In this review,we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.展开更多
Patient with atrial fibrillation(AF) are at risk of developing stroke with the left atrial appendage(LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increa...Patient with atrial fibrillation(AF) are at risk of developing stroke with the left atrial appendage(LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF,some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion(LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device.Watchman is the most common and only Food and Drug Administration(FDA)approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism.However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.展开更多
The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There h...The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There have been a number of clinically-relevant advances in diabetes, obesity, and metabolic syndrome emanating from gastroenterological research. Gastric emptying is a significant factor in the development of upper gastrointestinal symptoms. However, it is not the only mechanism whereby such symptoms occur in patients with diabetes. Disorders of intrinsic pacing are involved in the control of stomach motility in patients with gastroparesis; on the other hand, there is limited impact of glycemic control on gastric emptying in patients with established diabetic gastroparesis. Upper gastrointestinal functions related to emptying and satiations are significantly associated with weight gain in obesity. Medications used in the treatment of diabetes or metabolic syndrome, particularly those related to pancreatic hormones and incretins affect upper gastrointestinal tract function and reduce hyperglycemia and facilitate weight loss. The degree of gastric emptying delay is significantly correlated with the weight loss in response to liraglutide, a glucagonlike peptide-1 analog. Network meta-analysis shows that liraglutide is one of the two most efficacious medical treatments of obesity, the other being the combination treatment phentermine-topiramate. Interventional therapies for the joint management of obesity and diabetes mellitus include newer endoscopic procedures, which require long-term follow-up and bariatric surgical procedure for which long-term follow up shows advantages for individuals with diabetes. Newer bariatric procedures are presently undergoing clinical evaluation. On the horizon, combination therapies, in part directed at gastrointestinal functions, appear promising for these indications. Ongoing and future gastroenterological research when translated to care of individuals with diabetes mellitus should provide additional options to improve their clinical outcomes.展开更多
文摘BACKGROUND A major cause of mortality in the coronavirus disease 2019(COVID-19)pandemic was acute respiratory distress syndrome(ARDS).Currently,moderate to severe ARDS induced by COVID-19(COVID ARDS)and other viral and non-viral etiologies are treated by traditional ARDS protocols that recommend 12-16 hours of prone position ventilation(PPV)with neuromuscular blocking agents(NMBA)and a trial of inhaled vasodilators(IVd)if oxygenation does not improve.However,debate on the efficacy of adjuncts to PPV and low tidal volume ventilation persists and evidence about the benefits of IVd/NMBA in COVID ARDS is sparse.In our multi-center retrospective review,we evaluated the impact of PPV,IVd,and NMBA on outcomes and lung mechanics in COVID ARDS patients with moderate to severe ARDS.AIM To evaluate the impact of PPV used alone or in combination with pulmonary IVd and/or NMBA in mechanically ventilated patients with moderate to severe ARDS during the COVID-19 pandemic.METHODS A retrospective study at two tertiary academic medical centers compared outcomes between COVID ARDS patients receiving PPV and patients in the supine position.PPV patients were divided based on concurrent use of ARDS adjunct therapies resulting in four subgroups:(1)PPV alone;(2)PPV and IVd;(3)PPV and NMBA;and(4)PPV,IVd,and NMBA.Primary outcomes were hospital and intensive care unit(ICU)length of stay(LOS),mortality,and venovenous extracorporeal membrane oxygenation(VV-ECMO)status.Secondary outcomes included changes in lung mechanics at 24-hour intervals for 7 days.RESULTS Total 114 patients were included in this study.Baseline respiratory parameters and Sequential Organ Failure Assessment scores were significantly worse in the PPV group.ICU LOS and LOS were significantly longer for patients who were proned,but no mortality benefit or difference in VV-ECMO status was found.Among the subgroups,no difference in primary outcomes were found.In the secondary analysis,PPV was associated with a significant improvement in arterial oxygen partial pressure(PaO_(2))/fractional inspired oxygen(FiO_(2))(P/F)ratio from day 1 to day 4(P<0.05)and higher driving pressures day 5 to day 7(P<0.05).The combination of PPV and IVd together resulted in improvements in P/F ratio from day 1 to day 7 and plateau pressure on day 4 and day 6(P<0.05).PPV with NMBA was not associated with improvements in any of the secondary outcomes.The use of all three rescue therapies together resulted in improvements in lung compliance on day 2(P<0.05)but no other improvements.CONCLUSION In mechanically ventilated patients diagnosed with moderate to severe COVID ARDS,PPV and PPV with the addition of IVd produced a significant and sustained increase in P/F ratio.The combination of PPV,IVd and NMBA improved compliance however this did not reach significance.Mortality and LOS did not improve with adjunct therapies.Further research is warranted to determine the efficacy of these therapies alone and in combination in the treatment of COVID ARDS.
文摘BACKGROUND Ulcerative colitis(UC)increases the risk of colorectal dysplasia.While colectomy was once standard,advances in polypectomy,endoscopic mucosal resection(EMR),endoscopic submucosal dissection(ESD),and endoscopic full-thickness resection(EFTR)now allow organ-sparing management in selected cases.AIM To summarize current evidence on the feasibility,safety,and outcomes of these techniques in UC-associated neoplasia.METHODS A scoping review was conducted using PubMed and EMBASE(1975-May 2025)with the search:(“endoscopic submucosal dissection”/exp OR“endoscopic mucosal resection”OR“full thickness resection”OR“polypectomy”)AND(“ulcerative colitis”/exp OR“ulcerative colitis”OR“pouch”).Screening followed PRISMA guidelines.Eligible studies included those reporting outcomes,feasibility,or novel techniques in the endoscopic management of UC-associated dysplasia.RESULTS Of 1075 identified records,754 were screened after duplicate removal,and 48 studies were included.Polypectomy was safe and effective for well-demarcated,lifting lesions without adjacent dysplasia.EMR has excellent outcomes for small,polypoid,or right-sided lesions that demonstrated adequate lifting.ESD is ind icated for flat,large,non-polypoid,or fibrotic lesions,particularly in the left colon.ESD achieved en bloc resection in 88%-100%and R0 resection in 73%-96%of cases.The overall complication rate with ESD was approximately 2%-10%,primarily bleeding or perforation.Local recurrence occurred in 0%-6.8%,and metachronous lesions developed in up to 31%of cases over follow-up durations of up to 15 years.Surgical intervention after ESD was required in 10%-20%of patients,typically for non-curative resection or new lesions.Submucosal fibrosis,a common obstacle in UC,limited lifting and increased procedural difficulty.Adjunctive strategies-such as water pressure-assisted dissection,pocket-creation method,self-assembling peptide injectables,and traction systems-enhanced technical success.EFTR,though limited to case series,was effective for non-lifting or anatomically complex lesions,particularly in post-surgical or pouch anatomy,but carried higher procedural risk including rare but serious adverse events.CONCLUSION Endoscopic resection offers a spectrum of curative,minimally invasive options for managing dysplasia in UC.EMR remains appropriate for simple,lifting lesions,while ESD and EFTR broaden the therapeutic landscape for complex or fibrotic pathology.Lesion morphology,lifting characteristics,and operator experience should guide technique selection.Long-term outcomes are favorable with appropriate surveillance,though the risk of metachronous neoplasia necessitates continued monitoring.
文摘The incidence of hepatocellular carcinoma(HCC)has been steadily rising,und-erscoring the need for a clear,stage-specific treatment approach.The Barcelona Clinic Liver Cancer(BCLC)staging system remains the most widely used frame-work for classifying HCC and guiding therapy.Among its classifications,the intermediate stage(BCLC-B)encompasses a highly heterogeneous patient popu-lation,with varying degrees of tumor burden and liver function.Traditionally,transarterial chemoembolization has been the standard treatment for this stage,based on earlier evidence.However,recent studies suggest that a subset of BCLC-B patients-particularly those with localized disease-may benefit more from liver resection.This review summarizes current treatment paradigms for BCLC-B HCC,explores emerging subclassifications within this group,and highlights evolving guidelines that support the selective use of surgery in appropriately chosen patients.
文摘BACKGROUND There is widespread debate about the impact of metabolically healthy obesity(MHO)on cardiovascular outcomes.However,studies have not exclusively examined the impact of MHO on cardiovascular outcomes in the postmeno-pausal population.AIM To explore the prevalence of MHO and its relationship with hospitalization outcomes,including major adverse cardiac or cerebrovascular events(MACCE),in postmenopausal women.METHODS We extracted data from the National Inpatient Sample 2020 database using International Classification of Disease,Tenth Revision,Clinical Modification codes for all admissions of postmenopausal women.We excluded patients with diabetes,hypertension,and hyperlipidemia to obtain metabolically healthy patients and then identified patients with obesity to create obese and non-obese cohorts.We used a 1:1 propensity score matching method to match patients with and without MHO based on age,and then we did a multivariable regression analysis for in-hospital MACCE.RESULTS In 2020,1304185 metabolically healthy postmenopausal women were admitted;148250(11.4%)had MHO.After propensity score matching for age,a statistically significant difference was observed in overall MACCE[odds ratio(OR):1.08,95%confidence interval(CI):1.01-1.16,P=0.028]among MHO and non-MHO cohorts,especially in patients of African-American ethnicity(OR:1.23,95%CI:1.01-1.49,P=0.035)and the lowermost income quartile(OR:1.24,95%CI:1.06-1.44,P=0.007).CONCLUSION Postmenopausal patients with MHO are at risk of MACCE,especially black patients and those with lower incomes.Larger prospective studies can demystify MHO’s impact on cardiovascular outcomes among postmenopausal women.
基金Supported by Division of Intramural Research Program at National Institute of Diabetes and Digestive and Kidney Diseases,No.1ZIADK075008。
文摘BACKGROUND Cardiopulmonary changes in noncirrhotic portal hypertension(NCPH)are poorly understood.AIM To investigate cardiopulmonary changes using transthoracic echocardiography(TTE)in NCPH and their correlation with clinical features.METHODS Prospective cohort including 10 preclinical NCPH[without portal hypertension(PH)]and 32 NCPH subjects who underwent TTE with agitated saline injection and comprehensive clinical evaluation were assessed.PH was defined by presence of either varices,ascites or portosystemic shunting.Intrapulmonary vascular dilatation(IPVD)is defined as appearance of microbubbles in the left atrium after three heartbeats.Right ventricular systolic pressure(RVSP)>38 mmHg was used to identify possible porto-pulmonary hypertension.Cardiomyopathy is defined using cirrhotic cardiomyopathy consortium criteria.RESULTS Among 42 subjects,17(40%)had IPVD,4(9.5%)had RVSP>38 mmHg,and 6(14%)had cardiomyopathy.Aspartate aminotransferase to alanine aminotransferase(AST/ALT)(1.3 vs 1,P=0.04)and liver stiffness measurement(LSM)(12.4 kPa vs 7.1 kPa,P=0.03)were higher in those with IPVD.Presence of either LSM>10 or AST/ALT>1.2 aided in identifying subjects with IPVD-sensitivity,specificity,and accuracy of 76%.RVSP correlated with oxygen saturation(r=-0.33),and free right hepatic vein pressure(r=0.43).Those with PH had higher left atrial volume(LAV)(62 mL vs 48 mL,P<0.01),and LAV index(LAVI)(35 m^(2) vs 23 m^(2),P<0.01)compared to those without PH.Total bile acids,especially primary bile acids positively correlated with LAV(r=0.36),and LAVI(r=0.41).CONCLUSION Similar to cirrhotic patients,cardiopulmonary changes are prevalent in NCPH,especially among those with PH.In NCPH,cardiopulmonary changes occur despite preserved synthetic function,suggesting the NCPH model's value in understanding cardiopulmonary dysfunction in liver disease.
文摘BACKGROUND Coronavirus disease 2019(COVID-19)has been shown to increase the risk of stroke.However,the prevalence and risk of recurrent stroke in COVID-19 patients with prior stroke/transient ischemic attack(TIA),as well as its impact on mor-tality,are not established.AIM To evaluate the impact of COVID-19 on in-hospital mortality,length of stay,and healthcare costs in patients with recurrent strokes.METHODS We identified admissions of recurrent stroke(current acute ischemic stroke admissions with at least one prior TIA or stroke)in patients with and without COVID-19 using ICD-10-CM codes using the National Inpatient Sample(2020).We analyzed the impact of COVID-19 on mortality following recurrent stroke admissions by subgroups.RESULTS Of 97455 admissions with recurrent stroke,2140(2.2%)belonged to the COVID-19-positive group.The COVID-19-positive group had a higher prevalence of diabetes and chronic kidney disease vs the COVID-19 negative group(P<0.001).Among the subgroups,patients aged>65 years,patients aged 45–64 years,Asians,Hispanics,whites,and blacks in the COVID-19 positive group had higher rates of all-cause mortality than the COVID-19 negative group(P<0.01).Higher odds of in-hospital mortality were seen in the group aged 45-64(OR:8.40,95%CI:4.18-16.91)vs the group aged>65(OR:7.04,95%CI:5.24-9.44),males(OR:7.82,95%CI:5.38-11.35)compared to females(OR:6.15,95%CI:4.12-9.18),and in Hispanics(OR:15.47,95%CI:7.61-31.44)and Asians/Pacific Islanders(OR:14.93,95%CI:7.22-30.87)compared to blacks(OR:5.73,95%CI:3.08-10.68),and whites(OR:5.54,95%CI:3.79-8.09).CONCLUSION The study highlights the increased risk of all-cause in-hospital mortality in recurrent stroke patients with COVID-19,with a more pronounced increase in middle-aged patients,males,Hispanics,or Asians.
文摘Background: The differential diagnosis for intracavitary cardiac masses is limited, typically including vegetations, tumors, or thrombi. Cardiac thrombi can often mimic cardiac tumors on imaging, creating a diagnostic challenge. Primary cardiac tumors are rare and usually benign, whereas most cardiac tumors result from metastases, commonly originating from malignancies in the breast, lung, or melanoma. Aim: This report highlights the importance of distinguishing various cardiac masses based on clinical presentations, clinical courses, and radiological features. Case Presentation: We describe two cases of cardiac masses with unique and diverse clinical features. Each case posed significant diagnostic challenges due to their distinct presentations and clinical progressions. Conclusion: These cases underscore the importance of considering both benign and metastatic origins in the differential diagnosis of intracavitary cardiac masses. Accurate differentiation between thrombi and tumors is crucial for appropriate management and treatment.
文摘BACKGROUND Short bowel syndrome(SBS)hospitalizations are often complicated with sepsis.There is a significant paucity of data on adult SBS hospitalizations in the United States and across the globe.AIM To assess trends and outcomes of SBS hospitalizations complicated by sepsis in the United States.METHODS The National Inpatient Sample was utilized to identify all adult SBS hospitalizations between 2005-2014.The study cohort was further divided based on the presence or absence of sepsis.Trends were identified,and hospitalization characteristics and clinical outcomes were compared.Predictors of mortality for SBS hospitalizations complicated with sepsis were assessed.RESULTS Of 247097 SBS hospitalizations,21.7%were complicated by sepsis.Septic SBS hospitalizations had a rising trend of hospitalizations from 20.8%in 2005 to 23.5%in 2014(P trend<0.0001).Compared to non-septic SBS hospitalizations,septic SBS hospitalizations had a higher proportion of males(32.8%vs 29.3%,P<0.0001),patients in the 35-49(45.9%vs 42.5%,P<0.0001)and 50-64(32.1%vs 31.1%,P<0.0001)age groups,and ethnic minorities,i.e.,Blacks(12.4%vs 11.3%,P<0.0001)and Hispanics(6.7%vs 5.5%,P<0.0001).Furthermore,septic SBS hospitalizations had a higher proportion of patients with intestinal transplantation(0.33%vs 0.22%,P<0.0001),inpatient mortality(8.5%vs 1.4%,P<0.0001),and mean length of stay(16.1 d vs 7.7 d,P<0.0001)compared to the non-sepsis cohort.A younger age,female gender,White race,and presence of comorbidities such as anemia and depression were identified to be independent predictors of inpatient mortality for septic SBS hospitalizations.CONCLUSION Septic SBS hospitalizations had a rising trend between 2005-2014 and were associated with higher inpatient mortality compared to non-septic SBS hospitalizations.
文摘Immune checkpoint inhibitors(ICIs) are monoclonal antibodies that target downregulators of the anti-cancer immune response: Cytotoxic T-lymphocyte antigen-4, programmed cell death protein-1, and its ligand programmed death-ligand 1.ICIs have revolutionized the treatment of a variety of malignancies. However,many immune-related adverse events have also been described which mainly occurs as the immune system becomes less suppressed, affecting various organs including the gastrointestinal tract and causing diarrhea and colitis. The incidence of immune-mediated colitis(IMC) ranges from 1%-25% depending on the type of ICI and if used in combination. Endoscopically and histologically there is a significant overlap between IMC and inflammatory bowel disease,however more neutrophilic inflammation without chronic inflammation is usually present in IMC. Corticosteroids are recommended for grade 2 or more severe colitis while holding the immunotherapy. About one third to two thirds of patients are steroid refractory and benefit from infliximab. Recently vedolizumab has been found to be efficacious in steroid and infliximab refractory cases. While in grade 4 colitis, the immunotherapy is permanently discontinued, the decision is controversial in grade 3 colitis.
文摘The prevention of a disease process has always been superior to the treatment of the same disease throughout the history of medicine and surgery. Local recurrence and peritoneal metastases occur in approximately 8% of colon cancer patients and 25% of rectal cancer patients and should be prevented. Strategies to prevent colon or rectal cancer local recurrence and peritoneal metastases include cytoreductive surgery and hyperthermic perioperative chemotherapy (HIPEC). These strategies can be used at the time of primary colon or rectal cancer resection if the HIPEC is available. At institutions where HIPEC is not available with the treatment of primary malignancy, a proactive second-look surgery is recommended. Several phase II studies strongly support the proactive approach. If peritoneal metastases were treated along with the primary colon resection, 5-year survival was seen and these results were superior to the results of treatment after peritoneal metastases had developed as recurrence. Also, prophylactic HIPEC improved survival with T3/T4 mucinous or signet ring colon cancers. A second-look has been shown to be effective in two published manuscripts. Unpublished data from MedStar Washington Cancer Institute also produced favorable date. Rectal cancer with peritoneal metastases may not be so effectively treated. There are both credits and debits of this proactive approach. Selection factors should be reviewed by the multidisciplinary team for individualized management of patients with or at high risk for peritoneal metastases.
文摘Vitamin D through its active form 1a-25-dihydroxyvtamin D[1,25(OH)2D]is a secosteroid hormone that plays a key role in mineral metabolism.Recent years have witnessed a significant scientific interest on vitamin D and expanded its actions to include immune modulation,cell differentiation and proliferation and inflammation regulation.As our understanding of the many functions of vitamin D has grown,the presence of vitamin D deficiency has become one of the most prevalent micronutrient deficiencies worldwide.Concomitantly,non-alcoholic fatty liver disease(NAFLD)has become the most common form of chronic liver disease in western countries.NAFLD and vitamin D deficiency often coexist and epidemiologic evidence has shown that both of these conditions share several cardiometabolic risk factors.In this article we provide an overview of the epidemiology and pathophysiology linking NAFLD and vitamin D deficiency,as well as the available evidence on the clinical utility of vitamin D supplementation in NAFLD.
文摘Mucosa-associated lymphoid tissue(MALT) lymphoma of the liver is a very rare condition and thus the diag-nosis may be challeng-ing-. The clinical presentation is usually variable, rang-ing- from minimal clinical symptoms to severe end stag-e liver disease. In this paper, we describe the clinicopatholog-ic finding-s in two cases of primary hepatic MALT lymphoma. One case is an 80-year-old female with no underlying- chronic liver disease and the second case is a 30-year-old female with autoimmune hepatitis complicated by MALT lymphoma. In both specimens, there was diffuse infiltration of atypical B-lymphocytes that were positive for CD20 and CD79 a, but neg-ative for CD5, CD43 and CD10. There were occasional lymphoepithelial lesions involving- the hepatocytes or bile ducts. Polymerase chain reaction analysis showed monoclonal immunog-lobulin heavy chain g-ene rearrang-ement in both cases. The first case was treated with surg-ery but developed pulmonary recurrence a year after complete resection but went into remission following- treatment with rituximab. A second recurrence occurred in the rig-ht parotid g-land 7 years later, which was treated with idelalisib. The second case was effectively treated with rituximab. To our knowledg-e, the second case is the first reported case linked to autoimmune hepatitis.
文摘Intracerebral hemorrhage(ICH) remains the second-most common form of stroke with high morbidity and mortality.ICH can be divided into two pathophysiological stages:an acute primary phase,including hematoma volume expansion,and a subacute secondary phase consisting of blood-brain barrier disruption and perihematomal edema expansion.To date,all major trials for ICH have targeted the primary phase with therapies designed to reduce hematoma expansion through blood pressure control,surgical evacuation,and hemostasis.However,none of these trials has resulted in improved clinical outcomes.Magnesium is a ubiquitous element that also plays roles in vasodilation,hemostasis,and blood-brain barrier preservation.Animal models have highlighted potential therapeutic roles for magnesium in neurological diseases specifically targeting these pathophysiological mechanisms.Retrospective studies have also demonstrated inverse associations between admission magnesium levels and hematoma volume,hematoma expansion,and clinical outcome in patients with ICH.These associations,coupled with the multifactorial role of magnesium that targets both primary and secondary phases of ICH,suggest that magnesium may be a viable target of study in future ICH studies.
文摘BACKGROUND Herbal supplements(HS)for weight loss are perceived to be“safe”and“natural”,as advertised in ads,however,hepatotoxicity can be associated with consumption of some HS.Use of HS may be missed,as the patient may not report these unless specifically asked about these products,since they are often not thought of as medications with potential side effects or interaction potential.CASE SUMMARY We reported a case of a 21-year-old female with morbid obesity who presented with abdominal pain for 1 wk associated with nausea,vomiting,anorexia and myalgias.She denied smoking tobacco,drinking alcohol,usage of illicit drugs,hormonal contraceptives,or energy drinks.There was no significant past medical or family illnesses.Her laboratory workup revealed acute liver failure.The workup for possible etiologies of acute liver failure was unremarkable.She was using a weight loss herbal supplement“Garcinia cambogia”for 4 wks.This case demonstrates the association of acute liver failure with Garcinia cambogia.CONCLUSION Medical reconciliation of HS should be performed in patients with suspected acute liver failure and early discontinuation of HS can prevent further progression of drug induced hepatoxicity.
文摘Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9%in the United States.At presentation,the majority of patients have painless jaundice,pruritis,and malaise,a triad that develops secondary to obstruction,which often occurs late in the course of the disease process.The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis,staging,and management of patients with pancreatic cancer.Endoscopic retrograde cholangiopancreatography(ERCP)-guided diagnosis(with brush cytology,serial pancreatic juice aspiration cytologic examination technique,or biliary biopsy)and therapeutic interventions such as pancreatobiliary decompression,intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management.In this review,we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.
文摘Patient with atrial fibrillation(AF) are at risk of developing stroke with the left atrial appendage(LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF,some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion(LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device.Watchman is the most common and only Food and Drug Administration(FDA)approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism.However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.
基金Supported by the grant from National Institutes of Health,No.R01-DK67071
文摘The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There have been a number of clinically-relevant advances in diabetes, obesity, and metabolic syndrome emanating from gastroenterological research. Gastric emptying is a significant factor in the development of upper gastrointestinal symptoms. However, it is not the only mechanism whereby such symptoms occur in patients with diabetes. Disorders of intrinsic pacing are involved in the control of stomach motility in patients with gastroparesis; on the other hand, there is limited impact of glycemic control on gastric emptying in patients with established diabetic gastroparesis. Upper gastrointestinal functions related to emptying and satiations are significantly associated with weight gain in obesity. Medications used in the treatment of diabetes or metabolic syndrome, particularly those related to pancreatic hormones and incretins affect upper gastrointestinal tract function and reduce hyperglycemia and facilitate weight loss. The degree of gastric emptying delay is significantly correlated with the weight loss in response to liraglutide, a glucagonlike peptide-1 analog. Network meta-analysis shows that liraglutide is one of the two most efficacious medical treatments of obesity, the other being the combination treatment phentermine-topiramate. Interventional therapies for the joint management of obesity and diabetes mellitus include newer endoscopic procedures, which require long-term follow-up and bariatric surgical procedure for which long-term follow up shows advantages for individuals with diabetes. Newer bariatric procedures are presently undergoing clinical evaluation. On the horizon, combination therapies, in part directed at gastrointestinal functions, appear promising for these indications. Ongoing and future gastroenterological research when translated to care of individuals with diabetes mellitus should provide additional options to improve their clinical outcomes.
