Contemporary nationwide trends in major adverse cardiovascular events in young cannabis users without concomitant tobacco,alcohol,cocaine use

BACKGROUND Cannabis use has increased among young individuals in recent years.Although dependent cannabis use disorder(CUD)has been associated with various cardiac events,its effects on young adults without concurrent substance use remain understudied.AIM To examine trends in hospitalizations for major adverse cardiac and cerebrovascular events(MACCE)in this cohort.METHODSWe used the National Inpatient Sample(2016-2019)to identify hospitalized young individuals(18-44 years),excluding those with concurrent substance usage(tobacco,alcohol,and cocaine).They were divided into CUD+and CUD-.Using International Classification of Diseases-10 codes,we examined the trends in MACCE hospitalizations,including all-cause mortality(ACM),acute myocardial infarction(AMI),cardiac arrest(CA),and acuteischemic stroke(AIS).RESULTSOf 27.4 million hospitalizations among young adults without concurrent substance abuse,4.2%(1.1 million)hadco-existent CUD.In CUD+group,hospitalization rates for MACCE(1.71%vs 1.35%),AMI(0.86%vs 0.54%),CA(0.27%vs 0.24%),and AIS(0.49%vs 0.35%)were higher than in CUD-group(P<0.001).However,rate of ACMhospitalizations was lower in CUD+group(0.30%vs 0.44%).From 2016 to 2019,CUD+group experienced arelative rise of 5%in MACCE and 20%in AMI hospitalizations,compared to 22%and 36%increases in CUDgroup(P<0.05).The CUD+group had a 13%relative decrease in ACM hospitalizations,compared to a 10%relative rise in CUD-group(P<0.05).However,when adjusted for confounders,MACCE odds among CUD+cohort remain comparable between 2016 and 2019.CONCLUSIONThe CUD+group had higher rates of MACCE,but the rising trends were more apparent in the CUD-group overtime.Interestingly,the CUD+group had lower ACM rates than the CUD-group.

Impact of D-dimer on in-hospital mortality following aortic dissection:A systematic review and meta-analysis

BACKGROUND The utility of D-dimer(DD)as a biomarker for acute aortic dissection(AD)is recognized.Yet,its predictive value for in-hospital mortality remains uncertain and subject to conflicting evidence.AIM To conduct a meta-analysis of AD-related in-hospital mortality(ADIM)with elevated DD levels.METHODS We searched PubMed,Scopus,Embase,and Google Scholar for AD and ADIM literature through May 2022.Heterogeneity was assessed using I2 statistics and effect size(hazard or odds ratio)analysis with random-effects models.Sample size,study type,and patients’mean age were used for subgroup analysis.The significance threshold was P<0.05.RESULTS Thirteen studies(3628 patients)were included in our study.The pooled prevalence of ADIM was 20%(95%CI:15%-25%).Despite comparable demographic characteristics and comorbidities,elevated DD values were associated with higher ADIM risk(unadjusted effect size:1.94,95%CI:1.34-2.8;adjusted effect size:1.12,95%CI:1.05-1.19,P<0.01).Studies involving patients with a mean age of<60 years exhibited an increased mortality risk(effect size:1.43,95%CI:1.23-1.67,P<0.01),whereas no significant difference was observed in studies with a mean age>60 years.Prospective and larger sample size studies(n>250)demonstrated a heightened likelihood of ADIM associated with elevated DD levels(effect size:2.57,95%CI:1.30-5.08,P<0.01 vs effect size:1.05,95%CI:1.00-1.11,P=0.05,respectively).CONCLUSION Our meta-analysis shows elevated DD increases in-hospital mortality risk in AD patients,highlighting the need for larger,prospective studies to improve risk prediction models.

Lean body mass index is a marker of advanced tumor features in patients with hepatocellular carcinoma

BACKGROUND Obesity is an independent risk factor for the development of hepatocellular carcinoma(HCC)and may influence its outcomes.However,after diagnosis of HCC,like other malignancies,the obesity paradox may exist where higher body mass index(BMI)may in fact confer a survival benefit.This is frequently observed in patients with advanced HCC and cirrhosis,who often present late with advanced tumor features and cancer related weight loss.AIM To explore the relationship between BMI and survival in patients with cirrhosis and HCC.METHODS This is a retrospective cohort study of over 2500 patients diagnosed with HCC between 2009-2019 at two United States academic medical centers.Patient and tumor characteristics were extracted manually from medical records of each institutions'cancer registries.Patients were stratified according to BMI classes:<25 kg/m^(2)(lean),25-29.9 kg/m^(2)(overweight),and>30 kg/m^(2)(obese).Patient and tumor characteristics were compared according to BMI classification.We performed an overall survival analysis using Kaplan Meier by the three BMI classes and after adjusting for Milan criteria.A multivariable Cox regression model was then used to assess known risk factors for survival in patients with cirrhosis and HCC.RESULTS A total of 2548 patients with HCC were included in the analysis of which 11.2%(n=286)were classified as noncirrhotic.The three main BMI categories:Lean(n=754),overweight(n=861),and obese(n=933)represented 29.6%,33.8%,and 36.6%of the total population overall.Within each BMI class,the non-cirrhotic patients accounted for 15%(n=100),12%(n=94),and 11%(n=92),respectively.Underweight patients with a BMI<18.5 kg/m^(2)(n=52)were included in the lean cohort.Of the obese cohort,42%(n=396)had a BMI≥35 kg/m^(2).Out of 2262 patients with cirrhosis and HCC,654(29%)were lean,767(34%)were overweight,and 841(37%)were obese.The three BMI classes did not differ by age,MELD,or Child-Pugh class.Chronic hepatitis C was the dominant etiology in lean compared to the overweight and obese patients(71%,62%,49%,P<0.001).Lean patients had significantly larger tumors compared to the other two BMI classes(5.1 vs 4.2 vs 4.2 cm,P<0.001),were more likely outside Milan(56%vs 48%vs 47%,P<0.001),and less likely to undergo transplantation(9%vs 18%vs 18%,P<0.001).While both tumor size(P<0.0001)and elevated alpha fetoprotein(P<0.0001)were associated with worse survival by regression analysis,lean BMI was not(P=0.36).CONCLUSION Lean patients with cirrhosis and HCC present with larger tumors and are more often outside Milan criteria,reflecting cancer related cachexia from delayed diagnosis.Access to care for hepatitis C virus therapy and liver transplantation confer a survival benefit,but not overweight or obese BMI classifications.

Recurrent stroke admissions with vs without COVID-19 and associated in-hospital mortality: A United States nationwide analysis, 2020

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.

Association of cannabis use disorder with atrial fibrillation in young men without concomitant tobacco use:Insights from nationwide propensity matched analysis

BACKGROUND Recent data are inconclusive regarding the risk of arrhythmias among young cannabis users.Furthermore,many young adults use both cannabis and tobacco,which could add a residual confounding effect on outcomes.So,we studied young men who have cannabis use disorder(CUD)excluding tobacco use disorder(TUD)to understand their independent association with atrial fibrillation(AF)and related outcomes.AIM To study the association of CUD with AF and related outcomes.METHODS We used weighted discharge records from National Inpatient Sample(2019)to assess the baseline characteristics and mortality rates for AF-related hospitalizations in young(18-44 years)men in 1:1 propensity-matched CUD+vs CUD-cohorts without TUD.RESULTS Propensity matched CUD+and CUD-cohorts consisted of 108495 young men in each arm.Our analysis showed an increased incidence of AF in black population with CUD.In addition,the CUD+cohort had lower rates of hyperlipidemia(6.4%vs 6.9%),hypertension(5.3%vs 6.3%),obesity(9.1%vs 10.9%),alcohol abuse(15.5%vs 16.9%),but had higher rates of anxiety(24.3%vs 18.4%)and chronic obstructive pulmonary disease(COPD)(9.8%vs 9.4%)compared to CUD-cohort.After adjustment with covariates including other substance abuse,a non-significant association was found between CUD+cohort and AF related hospitalizations(odd ratio:1.27,95%confidence interval:0.91-1.78,P=0.15).CONCLUSION Among hospitalized young men,the CUD+cohort had a higher prevalence of anxiety and COPD,and slightly higher proportion of black patients.Although there were higher odds of AF hospitalizations in CUD+cohort without TUD,the association was statistically non-significant.The subgroup analysis showed higher rates of AF in black patients.Large-scale prospective studies are required to evaluate long-term effects of CUD on AF risk and prognosis without TUD and concomitant substance abuse.

Predictors of double balloon endoscopy outcomes in the evaluation of gastrointestinal bleeding

AIM:To identify patients' characteristics associated with double balloon endoscopy(DBE)outcomes in investigation of obscure gastrointestinal bleeding(OGIB).METHODS:Retrospective study performed at an academic tertiary referral center.Evaluated endpoints were clinical factors associated with no diagnostic yield or non-therapeutic intervention of DBE performed for OGIB evaluation.RESULTS:We included fifty-five DBE between August 2010 and April 2012.The mean age of the sample was 67 with 32 males(58.2%).Twenty-four DBE had no diagnostic yield and 30 DBE did not require therapy.Non-diagnostic yield was associated with performing two or more DBE studies in one day [odds ratio(OR):13.72,P=0.008],absence of blood transfusions within a year of the DBE(OR:7.16,P=0.03)and absence of ulcers or arteriovenous malformations(AVMs)on prior esophagogastroduodenoscopy(EGD)or colonoscopy(OR:19.30,P=0.033).Non-therapeutic DBE was associated with performing two or more DBE per day(OR:18.579,P=0.007),gastrointestinal bleeding episode within a week of the DBE(OR:11.48,P=0.003),fewer blood transfusion requirements prior to DBE(OR:4.55,P=0.036)and absence of ulcers or AVMs on prior EGD or colonoscopy(OR:8.47,P=0.027).CONCLUSION:Predictors of DBE yield and therapeutic intervention on DBE include blood transfusion requirements,previous endoscopic findings and possibly endoscopist fatigue.

Impact of recipient functional status on 1-year liver transplant outcomes

BACKGROUND The Karnofsky Performance Status(KPS)scale has been widely validated for clinical practice for over 60 years.AIM To examine the extent to which poor pre-transplant functional status,assessed using the KPS scale,is associated with increased risk of mortality and/or graft failure at 1-year post-transplantation.METHODS This study included 38278 United States adults who underwent first,non-urgent,liver-only transplantation from 2005 to 2014(Scientific Registry of Transplant Recipients).Functional impairment/disability was categorized as severe,moderate,or none/normal.Analyses were conducted using multivariableadjusted Cox survival regression models.RESULTS The median age was 56 years,31%were women,median pre-transplant Model for End-Stage for Liver Disease score was 18.Functional impairment was present in 70%;one-quarter of the sample was severely disabled.After controlling for key recipient and donor factors,moderately and severely disabled patients had a 1-year mortality rate of 1.32[confidence interval(CI):1.21-1.44]and 1.73(95%CI:1.56-1.91)compared to patients with no impairment,respectively.Subjects with moderate and severe disability also had a multivariable-adjusted 1-year graft failure rate of 1.13(CI:1.02-1.24)and 1.16(CI:1.02-1.31),respectively.CONCLUSION Pre-transplant functional status is a useful prognostic indicator for 1-year posttransplant patient and graft survival.

Evaluation of clinical outcomes in an interdisciplinary abdominal pain clinic: A retrospective, exploratory review

BACKGROUND Pediatric functional gastrointestinal disorders(FGIDs)are common and wellaccepted to be etiologically complex in terms of the contribution of biological,psychological,and social factors to symptom presentations.Nonetheless,despite its documented benefits,interdisciplinary treatment,designed to address all of these factors,for pediatric FGIDs remains rare.The current study hypothesized that the majority of pediatric patients seen in an interdisciplinary abdominal pain clinic(APC)would demonstrate clinical resolution of symptoms during the study period and that specific psychosocial variables would be significantly predictive of GI symptom improvement.AIM To evaluate outcomes with interdisciplinary treatment in pediatric patients with pain-related FGIDs and identify patient characteristics that predicted clinical outcomes.METHODS Participants were 392 children,ages 8-18[M=13.8;standard deviation(SD)=2.7],seen between August 1,2013 and June 15,2016 in an interdisciplinary APC housed within the Division of Gastroenterology in a medium-sized Midwestern children's hospital.To be eligible,patients had to be 8 years of age or older and have had abdominal pain for≥8 wk at the time of initial evaluation.Medical and psychosocial data collected as part of standard of care were retrospectively reviewed and analyzed in the context of the observational study.Logistic regression was used to model odds of reporting vs never reporting improvement,as well as to differentiate rapid from slower improvers.RESULTS Nearly 70%of patients followed during the study period achieved resolution on at least one of the employed outcome indices.Among those who achieved resolution during follow up,43%to 49%did so by the first follow up(i.e.,within roughly 2 mo after initial evaluation and initiation of interdisciplinary treatment).Patient age,sleep,ease of relaxation,and depression all significantly predicted the likelihood of resolution.More specifically,the odds of clinical resolution were 14%to 16%lower per additional year of patient age(P<0.001 to P=0.016).The odds of resolution were 28%to 42%lower per 1-standard deviation(SD)increase on a pediatric sleep measure(P=0.006 to P<0.040).Additionally,odds of clinical resolution were 58%lower per 1-SD increase on parent-reported measure of depression(P=0.006),and doubled in cases where parents agreed that their children found it easy to relax(P=0.045).Furthermore,sleep predicted the rapidity of clinical resolution;that is,the odds of achieving resolution by the first follow up visit were 47%to 60%lower per 1-SD increase on the pediatric sleep measure(P=0.002).CONCLUSION Outcomes for youth with FGIDs may be significantly improved by paying specific attention to sleep,ensuring adequate skills for relaxation,and screening of and referral for treatment of comorbid depression.

Timing of percutaneous endoscopic gastrostomy tube placement in post-stroke patients does not impact mortality, complications, or outcomes

BACKGROUND Percutaneous Endoscopic Gastrostomy(PEG)tubes are often placed for dysphagia following a stroke in order to maintain sufficient caloric intake.The 2011 ASGE guidelines recommend delaying PEG tube placement for two weeks,as half of patients with dysphagia improve within 2 wk.There are few studies comparing outcomes based on timing of PEG tube placement,and there is increasing demand for early PEG tube placement to meet requirements for timely discharge to rehab and skilled nursing facilities.AIM To assess the safety of early(≤7 d post stroke)vs late(>7 d post stroke)PEG tube placement and evaluate whether pre-procedural risk factors could predict mortality or complications.METHODS We performed a retrospective study of patients undergoing PEG tube placement for dysphagia following a stroke at two hospitals in Saint Louis,MO between January 2011 and December 2017.Patients were identified by keyword search of endoscopy reports.Mortality,peri-procedural complication rates,and post-procedural complication rates were compared in both groups.Predictors of morbidity and mortality such as protein-calorie malnutrition,presence of an independent cardiovascular risk equivalent,and presence of Systemic inflammatory response syndrome(SIRS)criteria or documented infection were evaluated by multivariate logistic regression.RESULTS 154 patients had a PEG tube placed for dysphagia following a stroke,92 in the late group and 62 in the early group.There were 32 observed deaths,with 8 occurring within 30 d of the procedure.There was an increase in peri-procedural and post-procedural complications with delayed PEG placement which was not statistically significant.Hospital length of stay was significantly less in patients with early PEG tube placement(12.9 vs 22.34 d,P<0.001).Protein calorie malnutrition,presence of SIRS criteria and/or documented infection prior to procedure or having a cardiovascular disease risk equivalent did not significantly predict mortality or complications.CONCLUSION Early PEG tube placement following a stroke did not result in a higher rate of mortality or complications and significantly decreased hospital length of stay.Given similar safety outcomes in both groups,early PEG tube placement should be considered in the appropriate patient to potentially reduce length of hospital stay and incurred costs.

老年人志愿活动对认知功能的纵向影响:基于美国健康与退休研究的二次数据分析

目的研究志愿活动与退休老年人认知活动、社会活动和身体活动的关系,以及与其不同时期认知功能的关系。方法资料来源于美国健康与退休研究小组数据中2008年、2012年和2016年的3波数据(n=2862)。使用自我报告问卷评估老年人的年度志愿服务频率(无志愿服务,<100 h和≥100 h),并使用认知状态电话访谈(Telephone Interview for Cognitive Status,TICS)修订版评估老年人的记忆、思维、知识、语言和定位等。应用结构方程模型评估退休老年人志愿活动对其认知功能的长期影响。结果与未参加志愿活动者相比,2012年参加志愿活动的老年人在2008—2012年中等体力活动增加(一年志愿活动少于100h者β=0.19,P<0.001;一年志愿活动至少100 h者β=0.21,P<0.001),社交活动增加(前者β=0.10,P=0.052;后者β=0.12,P=0.018),认知活动增加(一年志愿活动至少100h者β=0.13,P<0.001)。2008年和2012年较高的认知活动水平与随后的研究时间段较高认知功能存在关联(β=0.66,β=0.60,P<0.001)。讨论志愿活动是可人为改变的活动,可以通过增加老年人认知活动来改善老年人的认知功能。

Is Anticoagulation Warranted after Left Atrial Appendage Ligation in Patients at Risk for Stroke after Cardiac Surgery?

Objectives: Left atrial appendage ligation (LAAL) may constitute alternative stroke prophylaxis in patients with atrial fibrillation (AF). Herein we describe the 30-day post discharge outcomes of cardiac surgery patients with elevated stroke risk with or without anticoagulation (AC) following epicardial LAAL. Methods: Data were reviewed for 479 consecutive adult patients who underwent epicardial LAAL from 2014-2019 (median CHA2DS2-VASc score = 4.0). There were 251 and 228 patients discharged with and without AC, respectively, who were followed for 30 days. Patients were matched via 1:1 Propensity Score Matching (PSM;n = 115 per group). Post-discharge outcomes included stroke, bleeding, readmission for cardiac re-intervention, mortality, and a composite endpoint comprised of the aforementioned outcomes. Results: There was no difference in post-discharge stroke incidence regardless of AC (adjusted cumulative incidence (ACI) 0.009 CI [0.001 - 0.043] with AC vs 0.009 CI [0.001 - 0.43] without AC;p = 0.826), post-discharge bleeding (ACI 0.018 CI [0.003 - 0.057] with AC vs 0.009 CI [0.001 - 0.046] without AC;p = 0.738), readmission for cardiac re-intervention (ACI 0.009 CI [0.009 - 0.009] with AC vs 0 CI [NA] without AC;p = 0.340, post-discharge mortality (ACI 0 CI NA with AC vs 0.009 CI [0.001 - 0.046] without AC;p = 0.123, or in the composite outcome (ACI 0.026 CI [0.007 - 0.069] with AC vs 0.027 CI [0.007 - 0.071] without AC;p = 0.824. Conclusion: Cessation of AC in patients with elevated stroke risk following epicardial LAAL during cardiac surgery does not affect stroke rate, mortality, or bleeding incidence up to 30 days post-discharge in this preliminary analysis.

社区参与眼部保健:与社区合作并服务社区

社区参与的保健系统是初级卫生保健的基本要素,也是1978年《阿拉木图宣言》的核心内容,其指出“公民有权力和义务参与个人或集体的医疗保健”。世界上至少有一半人群无法享有全面的卫生保健服务,而社区的参与将会改变这一现状。而社区是由一群不同特征的人组成,他们处于不同生活环境或者不同地理位置,通过一些社会纽带,共同的观念联系在一起。

优化骶尾骨侧位数字化X线摄影的方法学研究

目的:评价曝光辐射剂量及图像后处理2种优化措施对骶尾骨侧位数字化X线摄影影像质量的影响。方法:利用等效体模和矩形波测试卡选取适用于临床优化的曝光条件。37例患者每例均先后使用该优化的曝光条件和设备默认的曝光条件,摄取骶尾骨侧位的初级图像共74幅,比较2次曝光所测得的毫安秒值和剂量面积乘积的统计学差异。分别使用设备自带的图像后处理软件包中的默认参数与优化参数对所有初级图像进行后处理,得到最终图像共148幅。由2位高年资放射科医师参照欧共体标准对最终图像的影像质量进行主观评价。结果:优化曝光条件下测得的辐射剂量较默认曝光条件显著降低(P<0.01)。2种不同的曝光条件对最终图像的影像质量没有显著性影响(P=0.13),而2种不同的图像后处理参数则显著地影响了最终图像的影像质量(P<0.01)。结论:数字化骶尾骨侧位摄影检查中,可在一定范围内减低辐射剂量,同时依靠图像后处理软件的优化,同样能得到满足诊断要求的高质量图像。

East meets West:ethnic differences in epidemiology and clinical behaviors of lung cancer between East Asians and Caucasians

Lung cancer is the leading cause of cancer death worldwide,with large variation of the incidence and mortality across regions.Although the mortality of lung cancer has been decreasing,or steady in the US,it has been increasing in Asia for the past two decades.Smoking is the leading cause of lung cancer,and other risk factors such as indoor coal burning,cooking fumes,and infections may play important roles in the development of lung cancer among Asian never smoking women.The median age of diagnosis in Asian patients with lung cancer is generally younger than Caucasian patients,particularly among never-smokers.Asians and Caucasians may have different genetic susceptibilities to lung cancer,as evidenced from candidate polymorphisms and genome-wide association studies.Recent epidemiologic studies and clinical trials have shown consistently that Asian ethnicity is a favorable prognostic factor for overall survival in non-small cell lung cancer(NSCLC),independent of smoking status.Compared with Caucasian patients with NSCLC,East Asian patients have a much higher prevalence of epidermal growth factor receptor(EGFR) mutation(approximately 30% vs.7%,predominantly among patients with adenocarcinoma and never-smokers),a lower prevalence of K-Ras mutation(less than 10% vs.18%,predominantly among patients with adenocarcinoma and smokers),and higher proportion of patients who are responsive to EGFR tyrosine kinase inhibitors.The ethnic differences in epidemiology and clinical behaviors should be taken into account when conducting global clinical trials that include different ethnic populations.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Prevalence and dietetic management of mild gastrointestinal disorders in milk-fed infants

AIM: To assess the prevalence of mild gastrointestinal disorders in milk-fed infants in paediatric practice, and to evaluate the effectiveness and satisfaction with dietetic treatment.METHODS: A cross-sectional epidemiological study was first carried out. A total of 285 paediatricians included 3487 children seen during a period of one week. In a second phase an observational, prospective and multicentre study was conducted and 2069 milk-fed infants with mild gastrointestinal disorders (colic, constipation, regurgitation and diarrhoea) were included. There was a baseline visit (start of treatment) and a final visit four weeks later. The effectiveness of the various Novalac formulas, as well as the satisfaction of the parents/tutors and paediatricians with the dietetic treatment were assessed at the final visit.RESULTS: The prevalence of mild gastrointestinal disorders was 27.8% of all paediatrician consultations (9.2%, 7.8%, 6.1% and 4.6% in relation to colic, constipation, regurgitation and diarrhoea, respectively). The several Novalac adapted milk formulas resolved 88.4% of the mild gastrointestinal disorders. Depending on the type of disorder, differences in response rate were observed. The highest effectiveness was recorded with respect to diarrhoea (92.6%), followed by constipation (91.6%), colic (87.6%) and regurgitation (81%). Overall, 91% of the paediatricians and 88.8% of the parents/tutors were satisfied or very satisfied with the Novalac adapted milk formulas.CONCLUSION: Mild gastrointestinal disorders show a high prevalence in paediatric practice. The Novalac adapted milk formulas have been shown to be effective in treating mild gastrointestinal disorders in milk-fed infants in the context of routine clinical practice.

Epidemiology and natural history of hepatitis C virus infection

Hepatitis C virus(HCV)affects 130-210 million people worldwide and is one of the major risk factors for hepatocellular carcinoma.Globally,at least one third of hepatocellular carcinoma cases are attributed to HCV infection,and 350000 people died from HCV related diseases per year.There is a great geographical variation of HCV infection globally,with risk factors for the HCV infection differing in various countries.The progression of chronic hepatitis C to end-stage liver disease also varies in different study populations.A long-term follow-up cohort enrolling participants with asymptomatic HCV infection is essential for elucidating the natural history of HCV-caused hepatocellular carcinoma,and for exploring potential seromarkers that have high predictability for risk of hepatocellular carcinoma.However,prospective cohorts comprising individuals with HCV infection are still uncommon.The risk evaluation of viral load elevation and associated liver disease/cancer in HCV(REVEAL-HCV)study has followed a cohort of 1095 residents seropositive for antibodies against hepatitis C virus living in seven townships in Taiwan for more than fifteen years.Most of them have acquired HCV infection through iatrogenic transmission routes.As the participants in the REVEALHCV study rarely receive antiviral therapies,it provides a unique opportunity to study the natural history of chronic HCV infection.In this review,the prevalence,risk factors and natural history of HCV infection are comprehensively reviewed.The study cohort,data collection,and findings on liver disease progression of the REVEAL-HCV study are described.

Reversibility of diabetes mellitus: Narrative review of the evidence

The global disease burden of diabetes mellitus is high. It is well-established that prediabetes is reversible but it is unclear whether diabetes is reversible once it has been diagnosed. The objective of this narrative review is to review the evidence of reversibility of diabetes me-llitus and stimulate interest in prolonged remission as a treatment target. The current evidence for bariatric surgery is stronger than intensive medical management and the evidence is stronger for type 2 diabetes pa-tients compared with type 1 diabetes patients. It is also unclear whether non obese diabetes patients would benefit from such interventions and the duration of diabetes before diabetes become irreversible. Further research is needed in this area especially with regards to the subgroup of diabetes patient who will benefit from these interventions and the long term safety and efficacy remains unknown especially with intensive me-dical management.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

Perioperative challenges in management of diabetic patients undergoing non-cardiac surgery

Prediabetes and diabetes are important disease processes which have several perioperative implications.About one third of the United States population is considered to have prediabetes.The prevalence in surgical patients is even higher.This is due to the associated micro and macrovascular complications of diabetes that result in the need for subsequent surgical procedures.A careful preoperative evaluation of diabetic patients and patients at risk for prediabetes is essential to reduce perioperative mortality and morbidity.This preoperative evaluation involves an optimization of preoperative comorbidities.It also includes optimization of antidiabetic medication regimens,as the avoidance of unintentional hypoglycemic and hyperglycemic episodes during the perioperative period is crucial.The focus of the perioperative management is to ensure euglycemia and thus improve postoperative outcomes.Therefore,prolonged preoperative fasting should be avoided and close monitoring of blood glucose should be initiated and continued throughout surgery.This can be accomplished with either analysis in blood gas samples,venous phlebotomy or point-of-care testing.Although capillary and arterial whole blood glucose do not meet standard guidelines for glucose testing,they can still be used to guide insulin dosing in the operating room.Intraoperative glycemic control goals may vary slightly in different protocols but overall the guidelines suggest a glucose range in the operating room should be between 140 mg/dL to 180 mg/dL.When hyperglycemia is detected in the operating room,blood glucose management may be initiated with subcutaneous rapid-acting insulin,with intravenous infusion or boluses of regular insulin.Fluid and electrolyte management are other perioperative challenges.Notably diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic state are the two most serious acute metabolic complications of diabetes that must be recognized early and treated.