Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study.

BACKGROUND AND AIMS: The need for transpapillary drainage (TPD) in patients undergoing transmural drainage (TMD) of pancreatic fluid collections (PFCs) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TMD versus combined (TMD and TPD) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS: This is a retrospective review of 375 consecutive patients with PFCs who underwent EUS-guided TMD from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TMD and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS: A total of 375 patients underwent EUS-guided TMD of PFCs, of which 174 were pseudocysts. TMD alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success was as follows: TMD, 92 (97%) versus CD, 35 (44%) (P = .0001). There was no difference in adverse events between the TMD (15%) and CD (14%) cohorts (P = .23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TMD and 201 days (interquartile range, 150-493 days) (P = .37). There was no difference in LT symptomatic resolution (TMD, 69% vs CD, 62%; P = .61) or LT radiologic resolution (TMD, 71% vs CD, 67%; P = .79). TPD attempt was negatively associated with LT radiologic resolution of pseudocyst (odds ratio, 0.11; 95% confidence interval, 0.02-0.8; P = .03). CONCLUSIONS: TPD has no benefit on treatment outcomes in patients undergoing EUS-guided TMD of pancreatic pseudocysts and negatively affects LT resolution of PFCs.

Gastrointestinal symptoms in morbid obesity.

BACKGROUND: Several reports have shown an increased prevalence of gastrointestinal (GI) symptoms in obese subjects in community-based studies. To better understand the role of the GI tract in obesity, and because there are limited clinic-based studies, we documented the prevalence of upper and lower GI symptoms in morbidly obese individuals in a clinic setting. OBJECTIVE: The aim of our study was to compare the prevalence of GI symptoms in morbidly obese individuals in a weight management clinic with non-obese individuals with similar comorbidities as morbidly obese individuals in an Internal Medicine clinic. METHODS: Class II and III obese patients BMI >35 kg/m(2) (N = 114) and 182 non-obese patients (BMI <25 kg/m(2)) completed the GI symptoms survey between August 2011 and April 2012 were included in this study. The survey included 24 items pertaining to upper and lower GI symptoms. The participants rated the frequency of symptoms as absent (never, rarely) or present (occasionally, frequently). The symptoms were clustered into five categories: oral symptoms, dysphagia, gastroesophageal reflux, abdominal pain, and bowel habits. Responses to each symptom cluster were compared between obese group and normal weight groups using logistic regression. RESULTS: Of the 24 items, 18 had a higher frequency in the obese group (p < 0.005 for each). After adjusting for age and gender, the obese patients were more likely to have upper GI symptoms: any oral symptom (OR = 2.3, p = 0.0013), dysphagia (OR 2.9, p = 0.0006), and any gastroesophageal reflux (OR 3.8, p < 0.0001). Similarly, the obese patients were more likely to have lower GI symptoms: any abdominal pain (OR = 1.7, p = 0.042) and altered bowel habits (OR = 2.8, p < 0.0001). CONCLUSION: These observations suggest a statistically significant increase in frequency of both upper and lower GI symptoms in morbidly obese patients when compared to non-obese subjects.

Feasibility of accessing data in hospitalized patients to support diagnosis of malnutrition by the Academy-A.S.P.E.N. malnutrition consensus recommended clinical characteristics.

BACKGROUND: The feasibility of accessing data in hospitalized patients to support a malnutrition diagnosis using the new Academy of Nutrition and Dietetics-American Society for Parenteral and Enteral Nutrition (AND-A.S.P.E.N.) consensus recommended clinical characteristics of malnutrition is largely unknown. We sought to characterize baseline practice to guide the development of appropriate interventions for implementation of the recommended approach. MATERIALS AND METHODS: A cross-sectional survey was conducted of 262 consecutive adults who were referred for dietitian or nutrition support team assessments at 2 tertiary teaching hospitals in Pennsylvania. The availability of data to support the proposed AND-A.S.P.E.N. approach and the resulting malnutrition diagnoses were examined. RESULTS: Mean ± SD age was 58.2 ± 17.1 years, and half were female. Food intake history was available for 76%, weight history for 67%, and physical examination for loss of fat and muscle mass for 94% and for edema for 84%. Hand-grip strength was not available. The prevalence of malnutrition among the patients referred for nutrition assessment was 6.7% moderate, 7.6% severe with acute illness; 12.2% moderate, 11% severe with chronic illness; and 0.8% moderate, 0.4% severe with social circumstances. Decline in typical food intake and weight loss were the most commonly used clinical characteristics. CONCLUSION: Data could generally be accessed to support the AND-A.S.P.E.N. consensus clinical characteristics for malnutrition diagnosis, but further testing in multiple care settings is needed before these observations may be generalized. Training in assessment methods and dissemination of the necessary tools will be necessary for full implementation.

Surveillance of chronic kidney disease around the world: tracking and reining in a global problem.

In recent years, there has been a general recognition of the importance of tackling noncommunicable chronic diseases throughout the world and not just in developed nations. Chronic kidney disease (CKD) is increasingly recognized as a public health threat, based on its high prevalence, rising incidence, associated complications, and cost. It is imperative that nations develop screening and surveillance programs related to CKD. This article provides a global perspective on existing and emerging CKD surveillance efforts. A variety of programs are described, ranging from cross-sectional screening studies to determine CKD prevalence; targeted screening of high-risk populations presenting for voluntary testing; to more systematic surveillance within the scope of integrated health care systems in many developed nations. The choice of surveillance programs for many countries will depend on available resources and competing health care priorities. Integration with surveillance programs for other major chronic diseases such as diabetes, hypertension, and obesity is highly desirable and could be a key to the prevention of CKD. Finally, we propose the model of integrated health systems as one that is perhaps best suited to systematic, longitudinal surveillance of many chronic diseases, a model based on a national electronic health care record with linkage across primary care and hospital-based programs. Robust health education efforts and timely dissemination strategies will remain the key to the success of disease surveillance. It is gratifying to note that more and more countries are developing and adopting CKD surveillance programs as part of national disease prevention strategies.