BACKGROUNDCurrent therapeutic techniques for pancreatic pseudocyst include surgical management with a laparoscopic approach or an open surgical procedure, percutaneous catheter drainage and endoscopic drainage. Yet it remains controversial whether different treatment approaches affect inpatient outcome.AIMTo investigate inpatient outcome of different treatment approaches in treating pancreatic pseudocyst.METHODSHere we conducted a retrospective analysis of pancreatic pseudocyst-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. International Classification of Diseases 10 clinical modification and procedure codes are used.RESULTSA total of 7060 patients meeting the above criteria were identified. Our study revealed laparoscopic approach associated with the lowest rate of red blood cell transfusion (P < 0.001), and it had lower short-term complications including acute renal failure (P = 0.01), urinary tract infection (P = 0.01), sepsis (P < 0.001) and acute respiratory failure (P = 0.01). Laparoscopic surgical approach associated with the shortest mean length of stay (P = 0.009), and it had the lowest total charge (P = 0.03). All three modalities have similar inpatient mortality (P = 0.28). The study also revealed that percutaneous drainage associated with more emergent admission (P < 0.001), rural hospital performs the most open surgical drainage (P < 0.001) and patients who received laparoscopic drainage are more likely to be discharged home (P < 0.001).CONCLUSIONLaparoscopic drainage of pancreatic pseudocysts associated with the least short-term complications and had better outcomes comparing to percutaneous and open surgical drainage from 2016 National Inpatient Sample database.

Study design: Retrospective review of prospectively collected data. Objectives: Stress urinary incontinence (SUI) is a cause of significant distress in women with neurogenic bladder dysfunction (NBD) due to spinal cord injury (SCI). Transobturator tape (TOT) has not previously been studied in this select group for cure of SUI. We aim to determine the long-term safety and efficacy of TOT in SCI patients with NBD and SUI. Setting: London, the United Kingdom. Methods: All patients undergoing TOT between 2005 and 2013 were identified (27 patients). All patients had pre-operative videocystometrogram (VCMG) and all had VCMG-proven SUI. Mean follow-up was 5.2 years. Patient-reported leakage, satisfaction, change in bladder management, complications and de novo overactive bladder (OAB) were recorded. Results: Mean age was 56 years (range 30-82) with complete follow-up. Twenty-two patients (81.5%) reported complete dryness from SUI post surgery. One patient (3.7%) reported SUI only when her bladder was very full but was satisfied. Twenty-three patients (85.2%) were happy. Four patients (14.8%) remained wet. Twenty-five patients (92.6%) had no change in bladder management. Two out of five patients (40%) who voided by straining prior to surgery required clean intermittent self-catheterisation (CISC) postoperatively. Two patients (7.4%) developed de novo OAB. No bladder or vaginal injuries, tape erosions or urethral obstruction were seen. Three patients (11.1%) had transient thigh pain. Conclusion: In women with NBD and SUI, TOT should be considered safe and effective with very good medium/long-term outcomes. There may be an increased risk of CISC in women who void by straining pre-operatively. INTRODUCTIONStress urinary incontinence (SUI) in women with neuropathic bladder dysfunction 1 (NBD) can be a major disabling feature. In the general population up to 25% of women are thought to be affected, 2 although among neuropaths the incidence remains unknown.In women with NBD, such as after spinal cord injury (SCI), there are specific additional problems compared with the general population that require consideration. For instance, neuropathic patients may have neurogenic detrusor overactivity (NDO) in association with weakness of the external urethral sphincter or a weak sphincter with an acontractile bladder. Particularly after childbirth, this sphincteric dysfunction may be seen in association with hypermobility or prolapse, which can further complicate management.Following Ulmsten's original description 3 in 1996 of a synthetic polypropylene tension-free vaginal tape placed at a mid-urethral level in retropubic fashion, our unit was the first to study the success of this procedure in neuropathic patients. 4,5 This showed success comparable to non-neuropaths in both short and long term with few complications. The aim of this study was to present the first series of long-term safety and efficacy outcomes of placement of mid-urethral synthetic transobturator tapes (TOT) in patients with urodynamically confirmed SUI and NBD du...

The association between endothelial dysfunction and late onset hypogonadism (LOH) in patients with vasculogenic erectile dysfunction (ED) is not yet well settled. Our objective was to assess the association between LOH and endothelial dysfunction in patients with vasculogenic ED. Throughout 2014-2015 a total of 90 men were enrolled in this cross-sectional observational study. Of them 60 patients with a clinical diagnosis of ED were further subdivided into two equal groups: patients with vasculogenic ED and LOH (A); patients with vasculogenic ED and euogonadal (B). Thirty age-matched men with no ED or hypogonadism were enrolled as control group (C). All patients were subjected to detailed medical and sexual history, total testosterone (TT), calculated free (FT) and bioavailable testosterone (BT), flow cytometric evaluation for endothelial progenitor cells (EPCs) (CD45negative/CD34positive/CD144positive) and endothelial microparticles (EMPs) (CD45negative/CD144positive/annexin V positive). The mean age ± SD of the three groups A, B and C were 51.3 ± 11.1, 53.6 ± 10.6 and 48.3 ± 5 years, respectively, with insignificant age differences (p = 0.089). The diagnostic criteria of LOH were adapted according to European male aging study, 2010. The means of TT(ng/mL) were 2.32 ± 0.21, 6.43 ± 0.36 and 5.37 ± 0.30 in groups A, B and C, respectively. There were highly significant differences between group A and groups B and C (p < 0.001 for each). The means of EPCs were 0.43 ± 0.070, 0.22 ± 0.05 and 0.032 ± 0.013 in groups A, B and C, respectively. The means of EMPs were 0.15 ± 0.029, 0.056 ±  .013 and 0.014 ± 0.002 in groups A, B and C, respectively. There were significant differences between group C and groups A and B (p < 0.05 for each). This study clearly demonstrated that there is a significant association between LOH and the higher expression of EPCs and EMPs in patients with vasculogenic ED.

BackgroundPrednisolone is considered the cornerstone treatment for severe alcoholic hepatitis (AH). However, its use is limited by the increased risk of infection in an already immunocompromised patient population. Among patients with severe AH, there exists a group of non-responders who do not benefit from prednisolone therapy. Day-4 Lille score is a widely employed prognostic model used to identify this non-responder subgroup. The present study evaluates the prognostic ability of the inflammatory marker, the neutrophil-lymphocyte ratio (NLR), as a stand-alone model and in conjunction with the day-4 Lille score.MethodsWe retrospectively reviewed the electronic medical records of patients diagnosed with AH. Demographic and biochemical data at diagnosis were collected to calculate Maddrey’s discriminant function (MDF) and model for end-stage liver disease (MELD) score upon admission and also on day 4. Receiver operating characteristic (ROC) curves were plotted for day-4 NLR and day-4 Lille score for prediction of 90-day mortality, and optimal cut-off values were determined. Patients were then subcategorized into groups based on the generated optimal cut-off values. Categorization was validated by comparing the mortality rate in each group with the chi-squared test. We then performed a multivariate analysis for prediction of 90-day mortality using day-4 Lille score and day-4 NLR, constructing a new prediction score based on the odds ratio (OR). The ROC curve of the new score was plotted and the area under a curve (AUC) was reported and compared with previously validated scores.ResultsOur analysis demonstrated that both day-4 NLR and Lille score individually predicted 90-day mortality with statistical significance (p: 0.049, p: <0.001, respectively). The ROC analysis of day-4 Lille score for the prediction of 90-day mortality revealed an AUC of 0.819 with an optimal cut-off value of 0.45 (sensitivity: 83.3%, specificity: 76.1%). Day-4 NLR had an AUC of 0.756 with an optimal cut-off value of 12.3 (sensitivity: 66.7%, specificity: 78.1%) The combined day-Lille-NLR model with a cut-off of 0.55 had an AUC of .889, which was higher than day-4 Lille score and NLR independently.ConclusionDay-4 NLR is an easily assessed prognostic model of mortality in alcoholic hepatitis. However, it often underperforms relative to day-4 Lille score. Combining these two models to create a "modified" Lille score adds increased performance characteristics to the prediction of outcomes/mortality. The "modified" Lille score presented in this study can be used to further cut down the number of non-responders who are often forced to undergo costly and potentially harmful treatment courses.

Randomized controlled trials (RCTs) are the cornerstone of evidence-based medicine. However, recent literature has drawn attention to the limitations of using P-value to report statistical significance of outcomes in the clinical trials. We performed this analysis to analyze the strength of the data that supported the American College of Gastroenterology (ACG) guidelines for ‘Management of Crohn’s disease in adults’ using fragility index (FI). We screened all the RCTs referenced in the 2018 ACG guidelines ‘Management of Crohn’s disease in adults’. We calculated the FI and the fragility quotient (FQ) and its correlation with P-value. Data were also collected on the patients lost to follow up, year of publication, sample size, number needed to treat (NNT), science citation index (SCI), presence of blinding and the number of centers in these studies. Of the 91 RCTs cited in this guideline, 32 RCTs met the inclusion criteria. The median values for FI for 32 trials were 3 [interquartile range (IQR) 2–6], FQ 0.026 (IQR 0.012–0.413), P-value 0.010 (IQR 0.001–0.03), lost to follow up 17 (IQR 10–39.5) and sample size 133 (IQR 74.5–281.5). There was statistically significant correlation between FI and P-value (r s –0.86, P <0.001) and sample size (r s 0.56, P = 0.002). There was no correlation found with number lost to follow up, NNT, SCI, year of publication, blinding and number of centers. The majority of the RCTs conducted in the field of Crohn’s disease rely on small number of superior events for statistical significance, thus rendering the validity of their conclusion questionable. At least 18 out of 60 ACG recommendations are based on RCTs in which, number of patients lost to follow up exceeds FI, thus making reported outcomes of the trial weak. We suggest that FI and FQ should be included in clinical trials to better understand if the data are meaningful, beyond a P-value.