美国耐甲氧西林金黄色葡萄球菌感染治疗临床治疗指南(一)

美国感染病学会（IDSA）制订了治疗耐甲氧西林金黄色葡萄球菌（MRSA）患者的循证指南。该指南用于指导MRSA感染患者的治疗。该指南就多种与MRSA疾病相关的临床症状的治疗进行了论述,包括：皮肤和软组织感染（SSTI）、菌血症和感染性心内膜炎、肺炎、骨和关节感染、中枢神经系统（CNS）感染等。该指南重点介绍了关于万古霉素用量及监测,以及对万古霉素低敏的耐甲氧西林金黄色葡萄球菌菌株感染的治疗方案及治疗失败的处置。

Cancer risk in primary sclerosing cholangitis: Epidemiology,prevention, and surveillance strategies

Primary sclerosing cholangitis(PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra-and/or extrahepatic biliary ducts. While its features and disease course can be variable,most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly,PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma,hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.

Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist

Despite improvements in endoscopic technologies and accessories, development of advanced endoscopy fellowship programs, and advances in ancillary imaging techniques, biliary cannulation in endoscopic retrograde cholangiopancreatography(ERCP) can still be unsuccessful in up to 20% of patients, even in referral centers. Once cannulation has been deemed to be difficult, the risk of post-ERCP pancreatitis and technical failure inherently increases. A number of factors, including endoscopist experience and patient anatomy, have been associated with difficult biliary cannulation, but predicting a case of difficult cannulation a priori is often not possible. Numerous techniques such as pancreatic guidewire and stenting, early pre-cut, and rendezvous may be employed when standard approaches fail. Data regarding the rate of success and adverse events of these techniques have been variable, though most studies suggest that pancreatic duct stenting generally reduces the rate of post-ERCP pancreatitis in instances of difficult biliary cannulation. Here we provide a review on difficult biliary cannulation and discuss how the choice of which techniques to employ and how to best employ them should be individualized and take into account the skill of the endoscopist, the disorder being treated, the anatomy of the patient, and the available biomedical literature.

Role of endoscopy in the management of primary sclerosing cholangitis

Primary sclerosing cholangitis(PSC) is a rare but prominent fibroinflammatory cholangiopathy which can affect individuals of essentially any age. It carries a median survival of 15-20 years, regardless of age at diagnosis, and is a foremost risk factor for cholangiocarcinoma. Given the chronic and progressive nature of PSC, its inherent risk for biliary tract and other complications, and the paucity of effective pharmacotherapies, endoscopy plays a major role in the care of many patients with this disorder. In this review, we discuss the endoscopic management of PSC, including established and evolving approaches to the diagnosis and treatment of its benign as well as malignant sequelae. Owing to the rarity of PSC and dearth of high-quality evidence, we propose pragmatic approaches based on both currently available data and expert opinion.

Place of technosphere inhaled insulin in treatment of diabetes

Technosphere insulin(TI), Afrezza, is a powder form of short-acting regular insulin taken by oral inhalation with meals. Action of TI peaks after approximately 40-60 min and lasts for 2-3 h. TI is slightly less effective than subcutaneous insulin aspart, with mean hemoglobin A1c(Hb A1c) reduction of 0.21% and 0.4%, respectively. When compared with technosphere inhaled placebo, the decrease in HbA 1c levels was 0.8% and 0.4% with TI and placebo, respectively. Compared with insulin aspart, TI is associated with lower risk of late postprandial hypoglycemia and weight gain. Apart from hypoglycemia, cough is the most common adverse effect of TI reported by 24%-33% of patients vs 2% with insulin aspart. TI is contraindicated in patients with asthma and chronic obstructive pulmonary disease. While TI is an attractive option of prandial insulin, its use is limited by frequent occurrence of cough, need for periodic monitoring of pulmonary function, and lack of long-term safety data. Candidates for use of TI are patients having frequent hypoglycemia while using short-acting subcutaneous insulin, particularly late postprandial hypoglycemia, patients with needle phobia, and those who cannot tolerate subcutaneous insulin due to skin reactions.

Alcoholic hepatitis: The pivotal role of Kupffer cells

Kupffer cells play a central role in the pathogenesis of alcoholic hepatitis(AH). It is believed that alcohol increases the gut permeability that results in raised levels of serum endotoxins containing lipopolysaccharides(LPS). LPS binds to LPS-binding proteins and presents it to a membrane glycoprotein called CD14, which then activates Kupffer cells via a receptor called tolllike receptor 4. This endotoxin mediated activation of Kupffer cells plays an important role in the inflammatory process resulting in alcoholic hepatitis. There is no effective treatment for AH, although notable progress has been made over the last decade in understanding the underlying mechanism of alcoholic hepatitis. We specifically review the current research on the role of Kupffer cells in the pathogenesis of AH and the treatment strategies. We suggest that the imbalance between the pro-inflammatory and the anti-inflammatory process as well as the increased production of reactive oxygen species eventually lead to hepatocyte injury, the final event of alcoholic hepatitis.

Peroral cholangioscopy:Update on the state-of-the-art

Peroral cholangioscopy(POC)is an endoscopic procedure that allows direct intraductal visualization of the biliary tract.POC has emerged as a vital tool for indeterminate biliary stricture evaluation and treatment of difficult biliary stones.Over several generations of devices,POC has fulfilled additional clinical needs where other diagnostic or therapeutic modalities have been inadequate.With adverse event rates comparable to standard endoscopic retrograde cholangioscopy and unique technical attributes,the role of POC is likely to continue expand.In this frontiers article,we highlight the existing and growing clinical applications of POC as well as areas of ongoing research.

Gastro-gastric intussusception in the setting of a neuroendocrine tumor: A case report

BACKGROUND While in children intussusception is often idiopathic,in adults it is commonly caused by a pathologic condition functioning as a lead point.It is important to note that a variety of pathologic conditions may trigger intussusception,with malignancy being a relatively frequent culprit in adults;this should be considered high on the differential diagnosis during evaluation.CASE SUMMARY This is a case of a 40-year-old female presenting to the emergency department(ED)with three days of acute on chronic,peri-umbilical abdominal pain described as waxing and waning,and pressure-like in nature.Initial computed tomography(CT)of the abdomen and pelvis with contrast in the ED(after her pain had resolved)re-demonstrated a previously noted 13 mm lesion in the gastric antrum but no clear cause of the pain.Endoscopic ultrasound was pursued,and the mass lesion was sampled via fine needle biopsy.Post-procedure the patient experienced another episode of severe pain which prompted a repeat stat CT abdomen and pelvis with contrast;this re-demonstrated the 13 mm antral lesion and in addition was remarkable for a gastro-gastric intussusception.An upper gastrointestinal gastrograffin series was ordered(completed only after the pain had subsided)and showed resolution of the intussusception.Histopathology was consistent with a diagnosis of low-grade neuroendocrine tumor(NET).Surgery was initially deferred during the hospitilization given the low grade pathology of the lesion;however further multidisciplinary discussion between Surgery,Oncology,and Gastroenterology recommended resection given the patient’s recurrent abdominal pain with the NET functioning as a lead point for further intussusception,and the patient thus underwent robotically-assisted wedge resection.CONCLUSION We present a unique case of severe,intermittent,peri-umbilical pain related to gastro-gastric intussusception caused by an antral NET lead point.The case highlights the importance of considering neoplasms as the cause of intussusception in adults and the greater diagnostic yield when imaging is obtained while symptoms(in this case severe,episodic abdominal pain)are most apparent.

Best practices for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis

Acute pancreatitis is of one the most common gastroenterology-related indications for hospital admissions worldwide.With the widespread reliance on endoscopic retrograde cholangiopancreatography(ERCP)for the management of pancreaticobiliary conditions,post-ERCP pancreatitis(PEP)has come to represent an important etiology of acute pancreatitis.Despite many studies aiming to better understand the pathogenesis and prevention of this iatrogenic disorder,findings have been heterogeneous,and considerable variation in clinical practice exists.Herein,we review the literature regarding PEP with the goal to raise awareness of this entity,discuss recent data,and present evidence-based best practices.We believe this manuscript will be useful for gastrointestinal endoscopists as well as other specialists involved in the management of patients with PEP.

Narrow band imaging evaluation of duodenal villi in patients with and without celiac disease:A prospective study

BACKGROUND Duodenal biopsies are commonly obtained during esophagogastroduodenoscopy(EGD) but are very often histopathologically normal. Therefore, a more strategic method for evaluating the duodenal mucosa and avoiding unnecessary biopsies is needed.AIM To examine the clinical utility of narrow band imaging(NBI) for evaluating duodenal villous morphology.METHODS We performed a prospective cohort study of adult patients at Mayo Clinic Rochester from 2013-2014 who were referred for EGD with duodenal biopsies. A staff endoscopist scored, in real-time, the NBI-based appearance of duodenal villi into one of three categories(normal, partial villous atrophy, or complete villous atrophy), captured ≥ 2 representative duodenal NBI images, and obtained mucosal biopsies therein. Images were then scored by an advanced endoscopist and gastroenterology fellow, and biopsies(gold standard) by a pathologist, in a masked fashion using the same three-category classification. Performing endoscopist, advanced endoscopist, and fellow NBI scores were compared to histopathology to calculate performance characteristics [sensitivity, specificity,positive and negative, negative predictive value(NPV), and accuracy]. Inter-rater agreement was assessed with Cohen's kappa.RESULTS112 patients were included. The most common referring indications were dyspepsia(47%), nausea(23%), and suspected celiac disease(14%). Duodenal histopathology scores were: 84% normal, 11% partial atrophy, and 5% complete atrophy. Performing endoscopist NBI scores were 79% normal, 14% partial atrophy, and 6% complete atrophy compared to 91%, 5%, and 4% and 70%, 24%,and 6% for advanced endoscopist and fellow, respectively. NBI performed favorably for all raters, with a notably high(92%-100%) NPV. NBI score agreement was best between performing endoscopist and fellow(κ = 0.65).CONCLUSION NBI facilitates accurate, non-invasive evaluation of duodenal villi. Its high NPV renders it especially useful for foregoing biopsies of histopathologically normal duodenal mucosa.

Association between recognizing dementia as a mental illness and dementia knowledge among elderly Chinese Americans

AIM: To investigate whether older Chinese Americans perceive dementia as a mental illness and the relationship between such perception and their general understanding of dementia remains unclear. Our study aims to understand this relationship and its future implication on improving dementia literacy among ethnic minorities.METHODS: Elderly Chinese American participants from the Greater Los Angeles were asked to complete an 11-item dementia questionnaire, following a community health seminar. Cross-sectional survey data was analyzed using standard statistical methods.RESULTS: The questionnaire received an 88.3% response rate. Among 316 responders, only 28.8%(n = 91) of elderly Chinese Americans identified dementia as a mental illness, and 71.2%(n = 225) did not recognize its mental disease origin. Furthermore, in comparison between these two groups, the first group demonstrated significantly higher level of baseline knowledge of the disease.CONCLUSION: This study reveals that only approximately 1 out of 4 older Chinese Americans recognized dementia as a mental illness, consistent with previous studies on Asian Americans. Our study however showed that when dementia was being perceived as a mental illness, such perception was associated with a higher level of baseline dementia understanding. The current study suggested the potential of improving older Chinese Americans dementia literacy by increasing awareness of its mental illness origin.

Foreign object ingestion and esophageal food impaction:An update and review on endoscopic management

Foreign body ingestion encompasses both foreign object ingestion(FOI) and esophageal food impaction(EFI) and represents a common and clinically significant scenario among patients of all ages. The immediate risk to the patient ranges from negligible to life-threatening, depending on the ingested substance,its location, patient fitness, and time to appropriate therapy. This article reviews the FOI and EFI literature and highlights important considerations and implications for pediatric and adult patients as well as their providers. Where published literature is insufficient to provide evidence-based guidance, expert opinion is included to supplement the content of this comprehensive review.

Large polyps:Pearls for the referring and receiving endoscopist

Polyps are precursors to colorectal cancer,the third most common cancer in the United States.Large polyps,i.e.,,those with a size≥20 mm,are more likely to harbor cancer.Colonic polyps can be removed through various techniques,with the goal to completely resect and prevent colorectal cancer;however,the management of large polyps can be relatively complex and challenging.Such polyps are generally more difficult to remove en bloc with conventional methods,and depending on level of expertise,may consequently be resected piecemeal,leading to an increased rate of incomplete removal and thus polyp recurrence.To effectively manage large polyps,endoscopists should be able to:(1)Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal;(2)Determine the optimal resection technique(e.g.,snare polypectomy,endoscopic mucosal resection,endoscopic submucosal dissection,etc.);and(3)Recognize when to refer to colleagues with greater expertise.This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps.

Atherosclerotic cardiovascular disease in inflammatory bowel disease:The role of chronic inflammation

Inflammatory bowel disease(IBD)causes systemic vascular inflammation.The increased risk of venous as well as arterial thromboembolic phenomena in IBD is well established.More recently,a relationship between IBD and atherosclerotic cardiovascular disease(ASCVD)has been postulated.Systemic inflammatory diseases,such as rheumatoid arthritis and systemic lupus erythematosus,have well characterized cardiac pathologies and treatments that focus on prevention of disease associated ASCVD.The impact of chronic inflammation on ASCVD in IBD remains poorly characterized.This manuscript aims to review and summarize the current literature pertaining to IBD and ASCVD with respect to its pathophysiology and impact of medications in order to encourage further research that can improve understanding and help develop clinical recommendations for prevention and management of ASCVD in patients with IBD.

Place of sodium-glucose co-transporter type 2 inhibitors for treatment of type 2 diabetes

Inhibitors of sodium-glucose co-transporter type 2(SGLT2), such as canagliflozin and dapagliflozin, are recently approved for treatment of type 2 diabetes. These agents lower blood glucose mainly by increasing urinary glucose excretion. Compared with placebo, SGLT2 inhibitors reduce hemoglobin A1c(Hb A1c) levels by an average of 0.5%-0.8% when used as monotherapy or add-on therapy. Advantages of this drug class include modest weight loss of approximately 2 kg, low risk of hypoglycemia, and decrease blood pressure of approximately 4 mm Hg systolic and 2 mm Hg diastolic. These characteristics make these agents potential add-on therapy in patients with Hb A1 c levels close to 7%-8.0%, particularly if these patients are obese, hypertensive, and/or prone for hypoglycemia. Meanwhile, these drugs are limited by high frequency of genital mycotic infections. Less common adverse effects include urinary tract infections, hypotension, dizziness, and worsening renal function. SGLT2 inhibitors should be used with caution in the elderly because of increased adverse effects, and should not be used in chronic kidney disease due to decreased or lack of efficacy and nephrotoxicity. Overall, SGLT2 inhibitors are useful addition for treatment of select groups of patients with type 2 diabetes,but their efficacy and safety need to be established in long-term clinical trials.

Colonoscopic management of diverticular disease

Diverticula are the most common incidental finding during routine colonoscopy,and their prevalence increases with patient age.The term“diverticular disease”encompasses the range of clinical manifestations and complications that can occur with colonic diverticula,including diverticular bleeding,diverticulitisassociated strictures,and acute diverticulitis.Colonoscopy is a vital tool in the diagnosis and management of diverticular disease and can be useful in a variety of regards.In this editorial,we concisely delineate the current approach to and practices in colonoscopic management of diverticular disease.In particular,we discuss treatment options for diverticular bleeding,propose consideration of colonic stenting as a bridge to surgery in patients with diverticulitis-associated strictures,and the need for diagnostic colonoscopy following an episode of acute diverticulitis in order to rule out underlying conditions such as colonic malignancy or inflammatory bowel disease.In addition,we offer practical tips for performing safe and successful colonoscopy in patients with dense diverticulosis coli.

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound(EUS)is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease.Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy,EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events.In this review,we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses,hepatic parenchymal disease,portal hypertension,esophageal and other varices,and indeterminate biliary strictures.

Geoepidemiologic variation in outcomes of primary sclerosing cholangitis

Primary sclerosing cholangitis(PSC)is a chronic,progressive,hepatobiliary disease characterized by inflammation and fibrosis of the intra-and extra-hepatic bile ducts.Its natural history is one that generally progresses towards cirrhosis,liver failure,cholangiocarcinoma,and ultimately disease-related death,with a median liver transplantation-free survival time of approximately 15-20 years.However,despite its lethal nature,PSC remains a heterogenous disease with significant variability in outcomes amongst different regions of the world.There are also many regions where the outcomes of PSC have not been studied,limiting the overall understanding of this disease worldwide.In this review,we present the geoepidemiologic variations in outcomes of PSC,with a focus on survival pre-and post-liver transplantation as well as the concurrence of inflammatory bowel disease and hepatobiliary neoplasia.

Lost Immune Markers for Major Affective Disorders: Could They Help Screen Airline Pilots?

In the 1980s it was discovered that quantitative IgG titers for antibodies directed against the hu-man-obligate DNA viruses were reliably and reproducibly correlated negatively with mood in in-dividuals with major affective disorders. This knowledge was lost to confirmation bias and uncontrolled studies that only looked at Epstein-Barr virus antibodies. The latter led to a long American fad of misdiagnosing major affective disorders as a “chronic Epstein-Barr virus syndrome.” This misdiagnosis even became part of the American popular culture during the 1980s. In light of fatal airline crashes intentionally caused by pilots, the antiviral IgG titers should be revisited as a means of screening pilots for current dysphoria or mania/hypomania due to major affective disorders.

Gastrostomy tubes: Fundamentals, periprocedural considerations, and best practices

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition,decompression,and medication administration.Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events(AEs).Appropriate indications,contraindications,ethical considerations,and comorbidities of patients referred for gastrostomy placement should be weighed and balanced.Additionally,endoscopist should consider either a transoral or transabdominal approach is appropriate,and radiologic or surgical gastrostomy tube placement is needed.However,medical history,physical examination,and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs.