A Systematic Approach to Pregnancy-Specific Liver Disorders.

Consultation for liver disease during pregnancy is challenging for both the hepatologist and gynecologist, as normal physiologic changes during pregnancy can mimic chronic liver disease. Pregnancy-specific liver disorders are leading causes of abnormal liver function tests during pregnancy. Moreover, up to 3% of all pregnant women in developed countries experience liver diseases nonspecific to pregnancy. When severe, pregnancy-specific liver disorders are associated with significant morbidity and mortality for both the mother and the fetus. The main factors that determine maternal prognosis are the type of liver disease; degree of impaired synthetic, metabolic, and excretory liver function; and timing of delivery. This article focuses on a systematic approach to diagnosing and managing pregnancy-specific liver disorders, which includes understanding normal findings in pregnancy, excluding liver diseases nonspecific to pregnancy, factoring in trimester status, and using clinical clues to make a diagnosis and provide treatment in a timely fashion.

Enhanced Recovery in Mild Acute Pancreatitis: A Randomized Controlled Trial.

OBJECTIVES: Acute pancreatitis (AP) is a leading cause of hospitalization for a gastrointestinal illness in the United States. We hypothesized that enhanced recovery approaches may lead to earlier time to refeeding in patients with AP. METHODS: We performed a double-blind, randomized controlled trial of patients admitted with mild AP from July 2016 to April 2017 at a tertiary medical center. Participants were randomly assigned to receive either enhanced recovery consisting of nonopioid analgesia, patient-directed oral intake, and early ambulation versus standard treatment with opioid analgesia and physician-directed diet. Primary study end point was time to oral refeeding on an intent-to-treat basis. Secondary end points included differences in pancreatitis activity scores, morphine equivalents, length of stay, and 30-day readmissions. RESULTS: Forty-six participants enrolled. Median age was 53.1 years, and 54.3% were female. There was significant reduction in time to successful oral refeeding in the enhanced recovery versus standard treatment group (median, 13.8 vs 124.8 hours, P < 0.001). Pancreatitis activity scores trended lower at 48 to 96 hours among patients assigned to enhanced recovery (mean, 43.6 vs. 58.9, P = 0.32). No differences found in length of stay or 30-day readmissions. CONCLUSION: In this randomized controlled trial, enhanced recovery was safe and effective in promoting earlier time to refeeding in patients hospitalized with AP.

Patient Preferences for Management of Cystic Neoplasms of the Pancreas: A Cross-Sectional Survey Study.

OBJECTIVE: The aim of this study was to determine how patient anxiety, knowledge, and cancer worry influence preferences for management of pancreatic cysts. METHODS: We performed a prospective, cross-sectional study using a disease-specific survey instrument. We included patients older than 18 years who were diagnosed with a pancreatic cyst. A telephone survey instrument was developed to assess baseline anxiety using the Hospital Anxiety and Depression Scale (HADS), knowledge regarding pancreatic cysts, cancer worry, and patient preferences using a standard gamble. RESULTS: Of the 100 studied participants (median age, 65 years; 72% women), median Hospital Anxiety and Depression Scale score was 4 (normal range). In terms of knowledge, 96% of the patients were not aware of their specific cyst type, and 58% were unaware of the possibility of any cyst-related malignancy. Overall, 8% of respondents had some degree of cancer worry. Respondents were more willing to undergo magnetic resonance imaging surveillance compared with endoscopic ultrasound or surgery. Knowledge of cyst type was a significant predictor of willingness to undergo invasive testing. CONCLUSIONS: There is a significant gap in patient knowledge with respect to pancreatic cysts. Greater emphasis on patient education can help patients make informed decisions regarding cyst management.

Permanent Pacemaker Implantation Early After Cardiac Surgery: A Descriptive Study of Pacemaker Utility After One Year of Follow-Up.

BACKGROUND: Complete heart block (CHB) is a common complication of cardiac surgery, which may resolve spontaneously. The optimal number of days to wait for resolution of CHB prior to proceeding with a permanent pacemaker (PPM) and the long-term utility of PPMs placed in this setting remain uncertain. METHODS AND RESULTS: This was a retrospective cohort study, which included members of Kaiser Permanente Northern California who had cardiac surgery, a PPM placed within 30 days after surgery, and one year of follow-up time. Chart review was performed to determine the frequency of ventricular pacing at each PPM interrogation visit up to one year after surgery. A PPM was categorized as underutilized at the time of an interrogation if none of the following were present: underlying rhythm <40 bpm, persistent CHB, or >1% ventricular pacing. The study included 247 patients with a mean time from cardiac surgery to PPM of 6.5 days. In 33 cases (13%), underutilized status was confirmed. The time from surgery to PPM implant was significantly higher in the underutilized group (8.1 ± 4.2 days vs. 6.2 ± 4.2 days, p = 0.003). CONCLUSIONS: The majority of PPMs placed early after cardiac surgery are not underutilized. In this retrospective, observational study, longer delay from surgery to PPM implantation was not associated with a greater likelihood that the PPM would be utilized long term. A prospective study is required to determine optimal timing of PPM implantation in this setting.