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Introduction: Although opioids are widely used for pain management in acute pancreatitis, the impact of opioid use disorder (OUD) on outcomes in patients with acute pancreatitis remains unknown. In the current study, we aimed to evaluate the impact of the OUD on outcomes in patients hospitalized with acute pancreatitis and delineate the trends associated with OUD and acute pancreatitis using a nationally representative sample., Methods: This is a retrospective cohort study of patients with acute pancreatitis using the combined releases of the year 2005-2014 of the National (Nationwide) Inpatient Sample (NIS) database. Patients over the age of 18 years with a principal diagnosis of acute pancreatitis were divided into cohorts of patients with opioid use disorders and those without. The primary measured outcome was in-hospital mortality and secondary outcomes were healthcare utilization measures, including length of stay (LOS) and hospitalization costs., Results: A total of 2 593 831 hospitalizations of acute pancreatitis were included; of which, 37 849 (1.46%) had a secondary diagnosis of OUD. Total acute pancreatitis-related hospitalizations increased from 237 882 in 2005 to 274 006 in 2014. At the same time prevalence of OUD in acute pancreatitis patients also increased from 1 to 2.1%. Patients with OUD had significantly increased mortality as compared to patients without OUD (aOR: 1.4; P < 0.001). At the same time, acute pancreatitis patients with OUD were associated with 1.3 days longer LOS as compared to other acute pancreatitis patients (P < 0.001]. The mean adjusted difference in total hospitalization costs was $2353 (P < 0.001)., Conclusion: OUD is associated with a significant increase in LOS, healthcare utilization cost and in-hospital mortality in patients admitted for acute pancreatitis. Therefore, clinicians should exercise caution in prescribing opioid medications to this high-risk patient population and other modalities such as nonopioid pain medications should be tried as alternatives to opioid analgesics., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: Colorectal cancer (CRC) is the third most common cause of cancer worldwide. Studies have shown a strong association between screening colonoscopy and a reduced risk of death from colorectal cancers. The incidence of poor bowel preparation has been reported in up to 25% cases. We conducted a systematic review and comprehensive meta-analysis to evaluate the effect of patient education using multimedia platforms on adenoma detection rate and adequacy of bowel preparation., Methods: Multiple databases were searched through May 2020 for studies that reported the efficacy of multimedia education (smartphone app and online audio-visual aids) in improving quality of bowel preparation and its effect on adenoma detection rate (ADR). Meta-analysis was performed to determine whether multimedia based patient education (MM) helps improve ADR and bowel preparation quality as compared to controls (CT)., Results: We included 13 randomized controlled trials with a total of 3754 patients. Eight studies reported outcomes on ADR and 12 reported on adequacy of bowel preparation. Overall ADR was higher in patients receiving multimedia based education as compared to CT (risk ratio (RR) 1.25, confidence interval (CI) 1.01-1.56, P = 0.04). A higher proportion of patients receiving multimedia based education achieved adequate bowel preparation (RR 1.2, CI 1.1-1.3, P = 0.001). In patients with mean age over 50 years, ADR was better in MM cohort as compared to controls (RR 1.3, CI 1.1-1.6, P = 0.001)., Conclusion: Pre-colonoscopy patient education using multimedia based platforms seems to improve ADR and the adequacy of bowel preparation., (© 2020 Japan Gastroenterological Endoscopy Society.)

After liver transplantation (LT), the role of ursodeoxycholic acid (UDCA) is not well characterized. We examine the effect of UDCA after LT in the prophylaxis of biliary complications (BCs) in all-comers for LT and the prevention of recurrent primary biliary cholangitis (rPBC) in patients transplanted for PBC. Two authors searched PubMed/MEDLINE and Embase from January 1990 through December 2018 to identify all studies that evaluate the effectiveness of UDCA prophylaxis after LT for BCs in all LT recipients and rPBC after LT in patients transplanted for PBC. Odds ratios (ORs) were calculated for endpoints of the BC study. Pooled recurrence rates were calculated for rPBC. The study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A total of 15 studies were included, comprising 530 patients in the analysis for BCs and 1727 patients in the analysis for rPBC. UDCA was associated with decreased odds of BCs (OR, 0.70; 95% confidence interval [CI], 0.52-0.93; P = 0.01) and biliary stones and sludge (OR, 0.49; 95% CI, 0.24-0.77; P = 0.004). Prophylactic use of UDCA did not affect the odds of biliary stricture. For patients transplanted for PBC, the rate of rPBC was lower with the prophylactic use of UDCA (IR 16.7%; 95% CI, 0.114%-22.0%; I2 = 36.1%) compared with not using prophylactic UDCA (IR 23.1%; 95% CI, 16.9%-29.3%; I2 = 86.7%). UDCA after LT reduces the odds of BC and bile stones and sludge in all-comer LT recipients and reduces or delays the incidence of rPBC in patients transplanted for PBC. UDCA use after LT could be considered in all LT recipients to reduce the odds of BC and may be particularly beneficial for patients transplanted for PBC by reducing the incidence of rPBC., (Copyright © 2020 by the American Association for the Study of Liver Diseases.)

Competing Interests: Competing interests Dr. Adler is a consultant for Boston Scientific.

Background and Aim: Acute on chronic liver failure (ACLF) in patients with cirrhosis has high short-term mortality. Data comparing ACLF admissions to academic centers (AC) and non-academic centers (NAC) are scanty., Methods: National Inpatient Sample (2006-2014) was queried for admissions with cirrhosis and ACLF using the ICD-09 codes, and was stratified to AC or NAC., Results: Of 1,928,764 admissions with cirrhosis (2006-2014), 112,174 (5. 9%) had ACLF. 6.7% of 1,018,568 cirrhosis admissions to AC had ACLF versus 5% of 910,196 admissions to NAC, P < 0.0001. Proportion of ACLF admissions to AC increased from 49% during 2006-2008 to 59% during 2012-2014. In a cohort of 73,630 ACLF admissions (36,615 each to AC and NAC) matched for patient demographics, cirrhosis etiology, number of comorbidities, elective versus emergent admission, ACLF grade, and type of organ failure. In-hospital mortality declined by 7% over the study period, but remained higher in AC (46% vs. 42%, P < 0.001), with 11% increased odds for in-hospital mortality compared to admission to NAC. Further admissions to AC versus NAC had higher median (IQR) length of stay at 13 (6-25) versus 11 (5-20) days, with higher median (IQR) hospital charges: 138,239 (66,772-275,603) versus 116,209 (55,767-232,699) USD, P < 0.001 for both., Conclusion: Patients with ACLF have high in-hospital mortality. Further, this is higher among admissions to AC. Although the in-hospital mortality is improving, strategies are needed on early identification of patients with futility of care for early discussion on goals of care, and optimal utilization of hospital resources among admissions with ACLF.

Objectives: Alcohol-associated liver disease is increasing, especially hospitalizations with acute on chronic liver failure and need for liver transplant. We examined trends in prevalence, inhospital mortality, and resource utilization associated with AALD and ACLF in the young., Methods: The National Inpatient Sample (2006-2014) was queried for hospitalizations with a discharge diagnosis of cirrhosis using the International Classification of Diseases, Ninth Edition, codes. ACLF hospitalization was defined as ≥2 organ failures and stratified by age: young (≤35 years) and older (>35 years)., Results: Of 447,090 AALD admissions (16,126 in young) between 2006 and 2014, ACLF occurred in 29,599 (6.6%), of which 1,143 (7.1%) were in young. Compared with older, admissions in young had more women (35% vs 29%), were obese (11% vs 7.6%), were Hispanics (29% vs 18%), have alcoholic hepatitis (AH) (41% vs 17%), and have ACLF grades 2 or 3 (34% vs 25%), P < 0.001 for all. Between 2006 and 2014, ACLF in AALD among young increased from 2.8% to 5.2%, with an AH proportion from 24% to 42%, P < 0.0001 for both. Young had more complications requiring ventilation (79% vs 76%) and dialysis (32% vs 28%), P < 0.001 for both. Compared with older, ACLF admission in young had longer hospitalization (12 vs 10 days) with higher hospital charges ($127,915 vs $97,511), P < 0.0001 for both, with 20% reduced inhospital mortality (54%-45%), P < 0.001., Discussion: AALD-related hospitalizations are increasing in young in the United States, mainly because of the increasing frequency of AH. Furthermore, this disease burden in young is increasing with a higher frequency of admissions with more severe ACLF and consumption of hospital resources. Studies are needed to develop preventive strategies to reduce burden related to AALD and ACLF in young.

Background: Interval colorectal cancers may be associated with a low serrated polyp detection rate (SDR) and advanced adenoma detection rate (AADR). We aimed to determine the SDR and AADR for endoscopists in a United States multicenter cohort., Methods: We included average-risk screening colonoscopies from five medical centers in the United States. Endoscopists with data on at least 100 average-risk screening colonoscopies were included. We calculated median SDR and AADR for endoscopists with adequate adenoma detection rates (ADRs) > 25 %. We analyzed the relationship between ADR and SDR, and between ADR and AADR using nonparametric Spearman correlation coefficients, scatter plots, and linear regression., Results: We included 3513 screening colonoscopies performed by 26 gastroenterologists. The mean age of patients was 56.8 years (SD 7.4) and 1585 (45 %) were male. All but one endoscopist had an ADR above 25 %. There was a significant positive but modest correlation between ADR and SDR (rho = 0.67, P  < 0.01), and between ADR and AADR (rho = 0.56, P  < 0.01). For endoscopists with an adequate ADR, median (interquartile range) ADR was 43 % (32.0 % - 48.6 %), median SDR was 8.4 % (7.3 % - 11.4 %), and median AADR was 9.3 % (6.4 % - 12.6 %)., Conclusion: A significant percentage of endoscopists have either a low SDR or low AADR despite an adequate ADR, justifying the need for separate SDR and AADR benchmarks. Based on our multicenter cohort, endoscopists with adequate ADRs had a median SDR and median AADR of about 8 % and 9 %, respectively., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Bilateral vs unilateral biliary stenting is used for palliation in malignant biliary obstruction. No clear data is available to compare the efficacy and safety of bilateral biliary stenting over unilateral stenting., Aim: To assess the efficacy and safety of bilateral vs unilateral biliary drainage in inoperable malignant hilar obstruction., Methods: PubMed, Embase, Scopus, and Cochrane databases, as well as secondary sources (bibliographic review of selected articles and major GI proceedings), were searched through January 2019. The primary outcome was the re-intervention rate. Secondary outcomes were a technical success, early and late complications, and stent malfunction rate. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome., Results: A total of 9 studies were included (2 prospective Randomized Controlled Study, 5 retrospective studies, and 2 abstracts), involving 782 patients with malignant hilar obstruction. Bilateral stenting had significantly lower re-intervention rate compared with unilateral drainage (OR = 0.59, 95%CI: 0.40-0.87, P = 0.009). There was no difference in the technical success rate (OR = 0.7, CI: 0.42-1.17, P = 0.17), early complication rate (OR = 1.56, CI: 0.31-7.75, P = 0.59), late complication rate (OR = 0.91, CI: 0.58-1.41, P = 0.56) and stent malfunction (OR = 0.69, CI: 0.42-1.12, P = 0.14) between bilateral and unilateral stenting for malignant hilar biliary strictures., Conclusion: Bilateral biliary drainage had a lower re-intervention rate as compared to unilateral drainage for high grade inoperable malignant biliary strictures, with no significant difference in technical success, and early or late complication rates., Competing Interests: Conflict-of-interest statement: No conflict of interest to declare. No financial support was received for the study.

Background: Periprocedural intravenous hydration is suggested to decrease the risk of post-ERCP pancreatitis (PEP). However, quality of evidence supporting this suggestion remains poor. Here we hypothesized that aggressive hydration(AH) could be an effective preventive measure., Methods: Pubmed, EMBASE, CINAHL, Google Scholar, Clinical Trials. gov, Clinical Key, International Standard Randomized Trial Number registry as well as secondary sources were searched through January 2019 to identify randomized controlled studies comparing AH to standard hydration (SH) for prevention of PEP. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random-effects model. RevMan 5.3 was used for analysis., Results: A total of 9 RCTs, with 2094 patients, were included in the meta-analysis. AH reduced incidence of PEP by 56% compared to SH (OR = 0.44, CI:0.28-0.69; p = 0.0004). The incidence of post-ERCP hyperamylasemia also decreased with AH compared to SH (OR = 0.51; p = 0.001). Length of stay decreased by 1 day with AH (Mean Difference (MD): -0.89 d; p = 0.00002). There was no significant difference in adverse events related to fluid overload between two groups (OR:1.29; p = 0.81) and post-ERCP abdominal pain (OR:0.35; p = 0.17). Numbers of patient to be treated with AH to prevent one episode of PEP was 17. Final results of the meta-analysis were not affected by alternative effect measures or statistical models of heterogeneity., Conclusion: Aggressive hydration is associated with a significantly lower incidence of PEP and it appears to be an effective and safe strategy for the prevention of Post ERCP pancreatitis., (Copyright © 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Benefit of direct-acting antivirals (DAA) for hepatitis C virus (HCV) on clinical outcomes is unclear. We examined temporal trends in liver transplant (LT) listings, receipt of LT, re-LT, and survival between pre-DAA (2009-2012) and DAA era (2013-2016) using UNOS database. Of 32 319 first adult LT, 15 049 (47%) were performed for HCV. Trends on listing, first LT, and of re-LT for HCV showed 23%, 20%, and 21% decrease in DAA compared to pre-DAA era (P < 0.0001). One-year liver graft and patient survival among HCV LT improved in DAA era (90% vs. 86% and 92% vs. 88%, respectively, P < 0.0001). Non-HCV LT showed no improvement in survival (89% vs. 89% and 92% vs. 92.4%, P = NS). On cox regression, compared to non-HCV LTs in DAA era, LT for HCV in pre-DAA era had worse patient survival (HR 1.56 [1.04-2.35]). The outcome was similar when compared to LTs for HCV in DAA era and for non-HCV in pre-DAA era. Burden of HCV-related LT waitlist and LT is declining in DAA era, with improved post-transplant outcomes, more so in later than earlier DAA era. Our findings negate recent Cochrane meta-analysis on DAA therapy and encourage studies to examine HCV clinical outcomes outside LT setting., (© 2019 Steunstichting ESOT.)

Acute-on-chronic liver failure (ACLF) is characterized by multiple organ failure (OF) with high short-term mortality. There is lack of population-based data on trends on etiology specific ACLF related burden. National Inpatient Sample (2006-2014) was queried using ICD-09 codes for admissions with cirrhosis and ACLF (≥2 extrahepatic OF). Of 1,928,764 admissions for cirrhosis between 2006 and 2014, 112,174 (5.9%) had ACLF (4.5%, 1.2%, and 0.2% with ACLF 1, 2, and 3, respectively). The brain was the most common OF in 11.9%, followed by respiratory failure in 7.7%, cardiac failure in 6.3%, and renal failure in 5.6%. ACLF increased by 24% between 2006 and 2014 with a 63% increase in 179,104 patients with nonalcoholic steatohepatitis (NASH) cirrhosis (3.5% to 5.7%); a 28% increase in patients with 429,306 alcoholic cirrhosis (5.6% to 7.2%); a 25% increase in patients with 1,091,053 with other etiologies (5.2% to 6.5%); and no significant change in 229,301 patients with viral hepatitis (VH) (4.0% to 4.1%). In-hospital mortality was higher among ACLF patients compared with patients without ACLF (44% versus 4.7%; P < 0.0001). Each NASH-related ACLF patient compared with other etiologies had a longer mean length of stay (14 versus 12 days), was associated with higher median total charges (US $151,196 versus US $134,597), and had more frequent use of dialysis (45% versus 36%) and longterm care (32% versus 26%; P < 0.0001 for all). Results remained similar in a subgroup analysis after including half of admissions with cryptogenic cirrhosis as NASH. In conclusion, NASH cirrhosis is the most rapidly growing indication for ACLF-related hospitalization and use of hospital resources. In the setting of improved treatment options for chronic hepatitis, the health care burden of chronic viral-related liver disease remains stable. Population-based strategies are needed to reduce the health care burden of cirrhosis, particularly related to NASH., (Copyright © 2019 by the American Association for the Study of Liver Diseases.)

Background: Data on liver transplant (LT) outcomes using deceased donors with heavy drinking (HD) (>2 drinks per day) are scanty., Methods: Using the United Network for Organ Sharing database (2002-2014), we examined outcomes after LT in adults comparing deceased HD donors with non-HD (ND) donors., Results: Of 56 182 first LTs performed in the United States for 10 common indications using deceased donors, 47 882 with available information on alcohol use were analyzed. Of these 47 882 LT recipients, 7298 (15%) were from HD donors, with similar proportion over time (2002-2014, Armitage trend test P = 0.75) and for recipient liver disease etiology (χ P = 0.42). Proportion of liver organ used for LT was lower for HD donors compared with ND donors (63% vs 78%; P < 0.001). Five-year outcomes on first LT comparing 7166 HD donors and 21 498 ND donors matched based on propensity score were similar for liver graft (73.7% vs 73.7%, log rank P = 0.98) and patient survival (77.6% vs 77.0%, P = 0.36). On Cox regression analysis, history of HD in deceased donors did not affect liver graft 1.02 (0.97-1.08) or patient survival 1.03 (0.97-1.09)., Conclusions: Among LT recipients using select liver grafts, history of HD in deceased donors does not impact outcomes after LT.

Background: There is equivocal evidence regarding differences in the clinical course and outcomes of Crohn's disease (CD) among African Americans compared with Caucasian Americans. We sought to analyze whether African Americans with CD are more likely to be hospitalized for CD-related complications when compared with Caucasian Americans with CD., Methods: We conducted a retrospective cohort study including 909 African Americans and Caucasian Americans with CD who were seen at our tertiary care Inflammatory Bowel Disease (IBD) referral center between 2000 and 2013. We calculated the rate of hospitalization for CD-related complications among African Americans and Caucasian Americans separately. Zero-inflated Poisson regression models with robust variance estimates were used to estimate crude and multivariable adjusted rate ratios (RR) for CD-related hospitalizations. Multivariable adjusted models included adjustment for age, sex, duration of CD, smoking and CD therapy., Results: The cumulative rate of CD-related hospital admissions was higher among African American patients compared with Caucasian American patients (395.6/1000 person-years in African Americans vs. 230.4/1000 person-years in Caucasian Americans). Unadjusted and multivariable adjusted rate ratios for CD-related hospitalization comparing African Americans and Caucasian Americans were 1.59 (95% confidence interval [95%CI]: 1.10-2.29; P=0.01) and 1.44 (95%CI: 1.02-2.03; P=0.04), respectively., Conclusions: African Americans with CD followed at a tertiary IBD-referral center had a higher rate for CD-related hospitalizations compared with Caucasian Americans. Future studies should examine whether socioeconomic status and biologic markers of disease status could explain the higher risk observed among African Americans., (© The Author(s) 2016. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University.)

Aim: To study the association between vitamin D level and hospitalization rate in Crohn's disease (CD) patients., Methods: We designed a retrospective cohort study using adult patients (> 19 years) with CD followed for at least one year at our inflammatory bowel disease center. Vitamin D levels were divided into: low mean vitamin D level (< 30 ng/mL) vs appropriate mean vitamin D level (30-100 ng/mL). Generalized Poisson Regression Models (GPR) for Rate Data were used to estimate partially adjusted and fully adjusted incidence rate ratios (IRR) of hospitalization among CD patients. We also examined IRRs for vitamin D level as a continuous variable., Results: Of the 880 CD patients, 196 patients with vitamin D level during the observation period were included. Partially adjusted model demonstrated that CD patients with a low mean vitamin D level were almost twice more likely to be admitted (IRR = 1.76, 95%CI: 1.38-2.24) compared to those with an appropriate vitamin D level. The fully adjusted model confirmed this association (IRR = 1.44, 95%CI: 1.11-1.87). Partially adjusted model with vitamin D level as a continuous variable demonstrated, higher mean vitamin D level was associated with a 3% lower likelihood of admission with every unit (ng/mL) rise in mean vitamin D level (IRR = 0.97, 95%CI: 0.96-0.98). The fully adjusted model confirmed this association (IRR = 0.98, 95%CI: 0.97-0.99)., Conclusion: Normal or adequate vitamin D stores may be protective in the clinical course of CD. However, this role needs to be further characterized and understood., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflicts of interest.

Background & Aims: Pretransplant renal failure is commonly reported to be a poor prognostic indicator affecting survival after liver transplantation (LT). However, whether the impact of renal failure on patient outcome varies according to the aetiology of the underlying liver disease is largely unknown., Methods: We investigated the association between renal failure at the time of LT and patient outcome in patients with alcoholic liver disease (ALD) (n = 6920), non-alcoholic steatohepatitis (NASH) (n = 2956) and hepatitis C (HCV) (n = 14 922) using the United Network for Organ Sharing (UNOS) database between February 2002 and December 2013. A total of 24 798 transplant recipients were included., Results: The presence of renal failure was more frequently seen in patients with ALD (23.95%) and NASH (23.27%) compared to patients with HCV (19.38%) (P < 0.001). In multivariate analysis, renal failure was an independent predictor of poor survival. Renal failure showed detrimental effect on patient survival in the overall series (HR = 1.466, P < 0.0001). Importantly, the impact of renal failure was less marked in patients with ALD (HR = 1.31, P < 0.0001) than in patients with NASH (HR = 1.73, P < 0.0001) or HCV (HR = 1.52, P < 0.0001). Despite a higher model for end-stage liver disease (MELD) score at the time of LT, ALD patients with renal failure had better long-term prognosis than non-ALD patients., Conclusions: Renal failure at the time of LT conferred a lower patient and graft survival post-LT. However, renal failure has less impact on the outcome of patients with ALD than that of patients with non-alcoholic liver disease after LT., Competing Interests: The authors disclose no conflicts., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

An African-American man aged 65 years with multiple malignancies in remission was admitted for small bowel obstruction. He was treated with laparotomy following failure of conservative management. Postoperatively, he developed intra-abdominal bleed, which persisted, despite surgical haematoma evacuation. Further haematological workup revealed isolated prolongation of activated partial thromboplastin time (aPTT) with reduced factor VIII (FVIII) activity and raised FVIII inhibitor titre. Assuming acquired haemophilia A (AHA), FVIII inhibitor bypassing activity and corticosteroids were started with subsequent resolution of the bleeding from the surgical site. The patient remained free of bleeding episodes at 3-month follow-up and the aPTT normalised. This case report highlights the association of surgery with AHA and summarises the treatments with underlying mechanisms., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Porphyrias are a group of metabolic disorders, which result from a specific abnormality in one of the eight enzymes of the heme biosynthetic pathway. These have been subdivided based on the predominant site of enzyme defect into hepatic and erythropoietic types and based on clinical presentation into acute neurovisceral and cutaneous blistering porphyrias. This review focuses on hepatic porphyrias, which include acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), aminolevulinic acid dehydratase deficiency porphyria (ADP), and porphyria cutanea tarda (PCT). Of these, AIP and ADP are classified as acute porphyria, PCT as cutaneous, while VP and HCP present with both acute and cutaneous clinical manifestations. Porphobilinogen levels in a spot urine sample is the initial screening test for the diagnosis of acute hepatic porphyria, and plasma with spot urine porphyrin levels is the initial screening test to approach patients suspected of cutaneous porphyria. Specific biochemical porphyrin profile for each porphyria helps in determining the specific diagnosis. Pain relief and elimination of triggering agents are the initial steps in managing a patient presenting with an acute attack. Intravenous glucose administration terminates the mild episode of acute porphyria, with intravenous hemin needed for management of moderate to severe episodes. Liver transplantation is curative and may be needed for patients with a life-threatening acute porphyria attack or for patients with recurrent acute attacks refractory to prophylactic treatment. Of the cutaneous porphyrias, PCT is the most common and is frequently associated with a combination of multiple susceptibility factors such as alcohol use, smoking, hepatitis C virus infection, HIV infection, estrogen use, and mutations of the hemochromatosis gene. Regular phlebotomy schedule and low-dose hydroxychloroquine are effective and safe treatment options for management of PCT.

In the United States, approximately 240,000 men are diagnosed annually with prostate cancer. Although effective treatment options are available for clinically localized cancer, the potential burdensome co-morbidities and attendant healthcare costs from over diagnosis and over treatment have escalated the discussion and controversy regarding appropriate screening, diagnosis, and optimal management of prostate cancer. Although the lifetime risk of developing prostate cancer is approximately 1 in 6 (~16%), the risk of dying from the disease is only ~2%. The discrepancy between the cancer incidence and lethality has led to widespread scrutiny of prostate cancer patient management, particularly for low-grade, low-stage (indolent) disease. The vast majority of men diagnosed with clinically localized prostate cancer are treated with interventional therapies despite studies demonstrating that even without treatment, prostate cancer-specific mortality is low. A MedLine/PubMed search was performed using PICO format (Patient, Intervention, Comparison and Outcome) identifying all relevant articles. No restrictions were used for publication dates. The terms "Prostate Cancer", "Screening", "Mortality", "Morbidity" yielded 307 results. "Diagnosis", "Prognosis" and "Survival" yielded 1504 results. Further filters were applied to narrow down the results using keywords "Prostate cancer screening guidelines 2014", "Beyond PSA", "NCCN Guidelines prostate", "MRI guided Prostate biopsy" yielding 72, 274, 54 and 568 results respectively. Of these, approximately 137 articles were found relevant and were reviewed. References from the reviewed articles were included in the final article.

Coronary fistulas are anomalous shunts from a coronary artery to a cardiac chamber or great vessel, bypassing the myocardial circulation. A 42-year-old Asian man with no significant history of cardiac disease presented with exertional chest discomfort in the form of chest tightness over the precordial area. The patient had no cardiac risk factors, but given the duration and persistence of symptoms, we did a stress echocardiogram. The exercise led to a 'coronary artery steal phenomenon' caused by the coronary fistula, which diverted the blood from the left anterior descending artery to the pulmonary artery thereby producing the ischemic symptoms and ventricular tachycardia. Transcatheter coil embolization was unsuccessful, but the fistula was eventually closed surgically. A repeat stress echocardiogram before discharge was completely normal. We emphasize the need to individualize treatment, taking into consideration all factors in a particular patient.

Background: Menstruation disorders are also responsible for emotional, physical, behavioural and dietary practice changes. These changes affect their normal functioning and social life. The present study was carried out to find the prevalence of menstrual problems among unmarried girls of Chandigarh, India and to compare their knowledge and beliefs regarding menstruation in different sub-groups., Methodology: A community based cross-sectional study was conducted among 744 unmarried females in Rural, Urban and Slum strata of UT Chandigarh, India. Data were collected using a self-administered structured questionnaire on menstruation. Chi-square value was used for testing statistical significance., Results: The mean age of the respondents was 16.84±3.05 years. Maximum respondents (40.9%) were educated up to 10th standard/High school. 448 (60.2%) were aware of menstruation before starting of menarche. Awareness was found to be significantly associated (p=0.02) with age. Socio-economic status and prior knowledge of respondents was also found to be significantly associated (p< 0.001). 61% (454) of the respondents had a regular flow during menses. Normal flow was reported by 70.2 %(522) of the respondents. Dysmenorrhea was found to be the most common problem suffered by 429 (57.7%) respondents., Conclusion: Menstrual hygiene is an issue that needs to be addressed at all levels. A variety of factors are known to affect menstrual behaviors, the most influential ones being economic status. It is essential to design a mechanism to address and for the access of healthy menstrual practices.

Background: In India, female motorized two-wheeler users involved in road traffic accidents account for 70,000 injuries and fatalities annually. Despite federal helmet laws, New Delhi exempted female pillion riders (backseat passengers) from mandatory helmet usage in response to religious and cultural opposition. This study attempts to elucidate factors influencing female pillion riders' helmet usage, hypothesizing religious-based opposition and poor understanding of helmet efficacy., Materials and Methods: A cross-section of female pillion riders in five areas of New Delhi were approached by trained surveyors. Surveys were self-completed (n = 52) or completed with assistance (n = 243). Demographics, helmet use habits, opinions, and media influence data were collected. Data were analyzed using χ(2), Fisher exact test, and multivariable logistic regression., Results: Of 305 women surveyed, 69.8% were Hindus (n = 213), 10.8% Muslims (n = 33), and 10.4% Sikhs (n = 32). More Muslim (33.3%, P = 0.001) and Sikh (25%, P = 0.04) women opposed mandatory helmet use compared with Hindu women (10.6%). There were 66 women who self-reported helmet use, with one woman (Sikh) who abstained from helmets for religious practices (0.9%). The most common reason for helmet disuse was discomfort (n = 40, 36.7%). Most respondents reported media positively influenced helmet use (57.7%)., Conclusions: Despite arguments of infringement on religious rights, women pillions ride without helmets for comfort and appearance purposes primarily. Furthermore, though significantly fewer Sikh and Muslim women support mandatory helmet laws, supporters remain a clear majority in both groups. Most women report media outlets as influential on helmet use, principally television, suggesting that mass media campaigns may improve helmet compliance., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Substance use refers to the use of any psychoactive substance or drug, including licit and illicit drugs, other than when medically indicated. Psychoactive substance use poses a threat to the health, social and economic fabric of families, communities and nations. Chandigarh has more than 0.2 million students from across the country pursuing their courses in higher education institutions. There is a very little information about pattern of drug dependence among the college students of Chandigarh,India., Objectives: To study the prevalence and pattern of substance use among college students of Chandigarh and to study the psycho-social behaviour of youth and perceived reasons for using substances., Material and Methods: A Cross - sectional community based study. A stratified multi-stage random sample design was adopted in study. The study instrument was a questionnaire which was developed by reviewing relevant literature and previously used standardized instruments and protocols including the WHO questionnaire. On the basis of 60% prevalence anticipated on the basis of pilot study, 90% confidence coefficient and 10% permissible error - sample size came out to be 256., Results: Prevalence of substance use was seen in 52.7% students belonging to age group 19 to 21 years. More prevalence of substance use was found among law students (76.2%) followed by the students from Art stream (62.5%). Among the users alcohol was most commonly used (53.5%), followed by smokers (27.3%), tobacco chewers (8.2%), cannabis (6.8%).49% of the users were using substances on daily basis, followed by 23% who using weekly.29.3% of users had father using any substance. Relief from psychological stress (66.0%) followed by easy availability (46.9%) were the most common reasons of substance abuse. that substances use is common among college going male students irrespective of their social demographic characteristics like age [OR 0.76, 95%CI (.443-1.317) religion [OR.859 95%CI (.461-1.598), parental education, occupation and socio-economic status. Therefore, interventions in terms of health education/counselling for reducing substance use among them should be adopted, irrespective of their socio-demographic characteristics. Suggestions: This study suggested some life style related interventions in order to reduce the problem of substance use.There is an utmost need to educate and counsel young students regarding harmful effects of substance use. Health education may be imparted in the school curriculum. Parents should also be educated on discouragement of substance use and on taking proper care of their children.

Background: The 23-hour Observation Unit (OU) is a novel and an effective means for tackling overcrowding in busy Paediatric Emergency Departments (PED) worldwide. However, unexpected hospitalisations in the OU involve transfer of care and they reduce the efficiency of the OU. Hence, we aimed to study the presenting diagnoses which were responsible for the unexpected hospitalisations in a 23-hour OU., Methods and Design: A prospective cohort study Setting: The PED at a tertiary care teaching hospital., Duration: 15th Feb-15th March 2011., Protocol: Consecutive children were triaged at presentation to the PED, according to the WHO paediatric emergency triage algorithm. Those who were transferred to the 23-hour OU, were further followed up for duration of the stay, the hospital course, and the outcome (discharge/hospitalisation)., Results: Three hundred (228 males, 72 females) consecutive children who attended the PED over one month were enrolled. All the children, at presentation, were triaged by the medical intern/s who was/were posted in the PED, and they were crosschecked by a PED consultant. A majority (55%, n=165) of the children were triaged as non-urgent, 32% (n=97) as priority and 13% (n=38) as emergent. Out of the 300 children, 173(58%) were transferred to the 23-hour OU. Of these, 16 (9.1%) required unexpected hospitalisations. The children who required hospitalisations had the following diagnoses: bronchiolitis (4), bronchopneumonia (4), seizure (2), viral hepatitis (2), high fever (1), bronchial asthma (1), severe anaemia (1), and urticaria (1). The mean duration of the stay in the OU was 19 hours for those who needed hospitalisation, as against 13 hours for those who were discharged from the OU., Conclusion: The children with respiratory complaints (bronchiolitis and bronchopneumonia) need frequent monitoring in the 23-hour OU, as they have high hospitalisation rates in the OU.