Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

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BackgroundIt is unclear whether plastic or metal stents are more suitable for preoperative biliary decompression in pancreatic cancer. The objective of this study was to compare the rate of endoscopic reinterventions in patients with pancreatic cancer undergoing plastic or self-expandable metal stent (SEMS) placements for preoperative biliary decompression.MethodsThis was a retrospective study of all patients with obstructive jaundice secondary to pancreatic head cancer who underwent their index endoscopic retrograde cholangiopancreatography (ERCP) and all follow-up biliary stent placements at our center before undergoing pancreaticoduodenectomy. Plastic or SEMS were placed at ERCP for biliary decompression. The main outcome measure was to compare the rate of endoscopic reinterventions between the plastic and SEMS cohorts.Results29 patients who underwent pancreaticoduodenectomy had preoperative biliary stent placement (18 plastic, 11 SEMS) at our center. Whereas none of the 11 patients who underwent SEMS placement had stent dysfunction, 7 of 18 (39%) patients with plastic stents required endoscopic reintervention before surgery (P = 0.02). Reinterventions were due to cholangitis (n = 1) or persistent elevation in serum bilirubin levels (n = 6). Two patients with SEMS underwent EUS-guided fine-needle aspiration after ERCP, which yielded a positive diagnosis of cancer in all cases; SEMS did not impair visualization of the tumor mass at EUS. Pancreaticoduodenectomy was undertaken successfully in all 29 patients and the presence of a SEMS did not interfere with biliary anastomosis. On univariate logistic regression, only SEMS placement was associated with less need for endoscopic reintervention (P = 0.02).ConclusionsSEMS are superior to plastic stents for preoperative biliary decompression in pancreatic cancer.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-010-1552-6) contains supplementary material, which is available to authorized users.

Purpose Both stroke and chronic atrial fibrillation (AF) are common in dialysis patients, but uncertainty exists in the incidence of new strokes and the risk conferred by chronic AF. Methods A cohort of dually-eligible (Medicare & Medicaid) incident dialysis patients was constructed. Medicare claims were used to determine the onset of chronic AF, which was specifically treated as a time-dependent covariate. Cox proportional hazards models were used to model time to stroke. Results Of 56,734 patients studied, 5629 (9.9%) developed chronic AF. There were 22.8 ischemic and 5.0 hemorrhagic strokes per 1000 patient-years, a ratio of approximately 4.5:1. Chronic AF was independently associated with time to ischemic (HR 1.26, 99% CI’s 1.06 – 1.49, P = 0.0005), but not hemorrhagic, stroke. Race was strongly associated with hemorrhagic stroke: African-Americans (HR 1.46, 99% CI’s 1.08 – 1.96), Hispanics (HR 1.64, 99% CI’s 1.16 – 2.31), and others (HR 1.76, 99% CI’s 1.16 – 2.78) had higher rates than did Caucasians (P < 0.001 for all). Conclusions Chronic AF has a significant, but modest, association with ischemic stroke. Race/ethnicity is strongly associated with hemorrhagic strokes. The proportion of strokes due to hemorrhage is much higher than in the general population.

Background Few studies have evaluated the impact of biliary stents on EUS-guided FNA. Aim To compare diagnostic yield of EUS-FNA in patients with or without biliary stents. Design Retrospective study. Setting Tertiary referral center. Patients Patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years. Main Outcome Measures The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis. Results Of 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1–3] vs 2 [IQR = 1–4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1–4] vs 2 [IQR = 1–4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001). Limitations Retrospective study. Conclusions The presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA.

Purpose: Addition of carboplatin (Cb) to anthracycline chemotherapy improves pathologic complete response (pCR), and carboplatin plus taxane regimens also yield encouraging pCR rates in triple-negative breast cancer (TNBC). Aim of the NeoSTOP multisite randomized phase II trial was to assess efficacy of anthracycline-free and anthracycline-containing neoadjuvant carboplatin regimens. Patients and Methods: Patients aged ≥18 years with stage I–III TNBC were randomized (1:1) to receive either paclitaxel (P) weekly × 12 plus carboplatin AUC6 every 21 days × 4 followed by doxorubicin/cyclophosphamide (AC) every 14 days × 4 (CbP → AC, arm A), or carboplatin AUC6 + docetaxel (D) every 21 days × 6 (CbD, arm B). Stromal tumor-infiltrating lymphocytes (sTIL) were assessed. Primary endpoint was pCR in breast and axilla. Other endpoints included residual cancer burden (RCB), toxicity, cost, and event-free (EFS) and overall survival (OS). Results: One hundred patients were randomized; arm A (n = 48) or arm B (n = 52). pCR was 54% [95% confidence interval (CI), 40%–69%] in arm A and 54% (95% CI, 40%–68%) in arm B. RCB 0+I rate was 67% in both arms. Median sTIL density was numerically higher in those with pCR compared with those with residual disease (20% vs. 5%; P = 0.25). At median follow-up of 38 months, EFS and OS were similar in the two arms. Grade 3/4 adverse events were more common in arm A compared with arm B, with the most notable differences in neutropenia (60% vs. 8%; P &lt; 0.001) and febrile neutropenia (19% vs. 0%; P &lt; 0.001). There was one treatment-related death (arm A) due to acute leukemia. Mean treatment cost was lower for arm B compared with arm A (P = 0.02). Conclusions: The two-drug CbD regimen yielded pCR, RCB 0+I, and survival rates similar to the four-drug regimen of CbP → AC, but with a more favorable toxicity profile and lower treatment-associated cost.

Objective Benign Paroxysmal Positional Vertigo (BPPV) has been linked to comorbidities like diabetes and hypertension. However, the relationship between type 2 diabetes (DM) and BPPV is unclear. The purpose of this retrospective study was to examine the relationship between DM and BPPV in the presence of known contributors like age, gender and hypertension. Methods A retrospective review of the records of 3933 individuals was categorized by the specific vestibular diagnosis and for the presence of type 2 DM and hypertension. As the prevalence of BPPV was higher in people with type 2 DM compared to those without DM, multivariable logistic regressions were used to identify variables predictive of BPPV. The relationship between type 2 DM, hypertension and BPPV was analyzed using mediation analysis. Results BPPV was seen in 46% of individuals with type 2 DM, compared to 37% of individuals without DM (p<0.001). Forty two percent of the association between type 2 DM and BPPV was mediated by hypertension, and supported hypertension as a complete mediator in the relationship between type 2 DM and BPPV. Conclusions Hypertension may provide the mediating pathway by which diabetes affects the vestibular system. Individuals with complaints of dizziness, with comorbidities including hypertension and diabetes, may benefit from a screening for BPPV.

Background and objectives Stroke is common in patients undergoing long-term dialysis, but the implications for mortality after stroke in these patients are not fully understood.Design, setting, participants, & measurements A large cohort of dually-eligible (Medicare and Medicaid) patients initiating dialysis from 2000 to 2005 and surviving the first 90 days was constructed. Medicare claims were used to ascertain ischemic and hemorrhagic strokes occurring after 90-day survival. A semi-Markov model with additive hazard extension was generated to estimate the association between stroke and mortality, to calculate years of life lost after a stroke, and to determine whether race was associated with differential survival after stroke.Results The cohort consisted of 69,371 individuals representing .112,000 person-years of follow-up. Mean age6SD was 60.8615.5 years. There were 21.1 (99% confidence interval [99% CI], 20.0 to 22.3) ischemic strokes and 4.7 (99% CI, 4.2 to 5.3) hemorrhagic strokes after cohort entry per 1000 patient-years. At 30 days, mortality was 17.9% for ischemic stroke and 53.4% for hemorrhagic stroke. The adjusted hazard ratio (AHR) depended on time since entry into the cohort; for patients who experienced a stroke at 1 year after cohort entry, for example, the AHR of hemorrhagic stroke for mortality was 25.4 (99% CI, 22.4 to 28.4) at 1 week, 9.9 (99% CI, 8.4 to 11.6) at 3 months, 5.9 (99% CI, 5.0 to 7.0) at 6 months, and 1.8 (99% CI, 1.5 to 2.1) at 24 months. The corresponding AHRs for ischemic stroke were 11.7 (99% CI, 10.2 to 13.1) at 1 week, 6.6 (99% CI, 6.4 to 6.7) at 3 months, and 4.7 (99% CI, 4.5 to 4.9) at 6 months, remaining significantly .1.0 even at 48 months. Median months of life lost were 40.7 for hemorrhagic stroke and 34.6 for ischemic stroke. For both stroke types, mortality did not differ by race.Conclusions Dialysis recipients have high mortality after a stroke with corresponding decrements in remaining years of life. Poststroke mortality does not differ by race.