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Zika virus is an emerging infection transmitted in multiple ways. In 2016 we assessed the level of knowledge about Zika virus transmission in an underserved, predominantly Hispanic, mixed gender population living in suburban New York City, many of whom potentially travel to affected regions. Based on a convenience sample of 147 participants, 134 (91%) were aware of Zika virus transmission by mosquitoes; 116 (79%) knew about transmission from a pregnant female to the fetus; and 89 (61%) were aware of sexual transmission. Age, marital status, education, and native language were unrelated to knowledge (P > 0.10). Women, however, were significantly more likely than men to know about sexual transmission (P = 0.023) and about maternal transmission to the fetus (P = 0.044). Travel to Zika virus endemic areas was unrelated to level of knowledge (P = 0.40). Greater awareness of the risk of sexual transmission of Zika virus is needed for at risk populations in the US, especially for males., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aim: To assess the quality of and to critically synthesize the available data on hepatitis C infections in the Middle East and North Africa (MENA) region to map evidence gaps., Methods: We conducted an overview of systematic reviews (SRs) following an a priori developed protocol (CRD42017076736). Our overview followed the preferred reporting items for systematic reviews and meta-analyses guidelines for reporting SRs and abstracts and did not receive any funding. Two independent reviewers systematically searched MEDLINE and conducted a multistage screening of the identified articles. Out of 5758 identified articles, 37 SRs of hepatitis C virus (HCV) infection in populations living in 20 countries in the MENA region published between 2008 and 2016 were included in our overview. The nine primary outcomes of interest were HCV antibody (anti-) prevalences and incidences in different at-risk populations; the HCV viremic (RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population (GP); the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. The conflicts of interest declared by the authors of the SRs were also extracted. Good quality outcomes reported by the SRs were defined as having the population, outcome, study time and setting defined as recommended by the PICOTS framework and a sample size > 100., Results: We included SRs reporting HCV outcomes with different levels of quality and precision. A substantial proportion of them synthesized data from mixed populations at differing levels of risk for acquiring HCV or at different HCV infection stages (recent and prior HCV transmissions). They also synthesized the data over long periods of time ( e.g ., two decades). Anti-HCV prevalence in the GP varied widely in the MENA region from 0.1% (study dates not reported) in the United Arab Emirates to 2.1%-13.5% (2003-2006) in Pakistan and 14.7% (2008) in Egypt. Data were not identified for Bahrain, Jordan, or Palestine. Good quality estimates of anti-HCV prevalence in the GP were reported for Algeria, Djibouti, Egypt, Iraq, Morocco, Pakistan, Syria, Sudan, Tunisia, and Yemen. Anti-HCV incidence estimates in the GP were reported only for Egypt (0.8-6.8 per 1000 person-year, 1997-2003). In Egypt, Morocco, and the United Arab Emirates, viremic rates in anti-HCV-positive individuals from the GP were approximately 70%. In the GP, the viremic prevalence varied from 0.7% (2011) in Saudi Arabia to 5.8% (2007-2008) in Pakistan and 10.0% (2008) in Egypt. Anti-HCV prevalence was lower in blood donors than in the GP, ranging from 0.2% (1992-1993) in Algeria to 1.7% (2005) in Yemen. The reporting quality of the outcomes in blood donors was good in the MENA countries, except in Qatar where no time framework was reported for the outcome. Some countries had anti-HCV prevalence estimates for children, transfused patients, contacts of HCV-infected patients, prisoners, sex workers, and men who have sex with men., Conclusion: A substantial proportion of the reported outcomes may not help policymakers to develop micro-elimination strategies with precise HCV infection prevention and treatment programs in the region, as nowcasting HCV epidemiology using these data is potentially difficult. In addition to providing accurate information on HCV epidemiology, outcomes should also demonstrate practical and clinical significance and relevance. Based on the available data, most countries in the region have low to moderate anti-HCV prevalence. To achieve HCV elimination by 2030, up-to-date, good quality data on HCV epidemiology are required for the GP and key populations such as people who inject drugs and men who have sex with men., Competing Interests: Conflict-of-interest statement: The authors have declared that no competing interests exist.

Aims: Much of the diabetes burden is caused by its complications. This cross-sectional study aimed to determine the prevalence and risk factors for diabetic microvascular complications (retinopathy, nephropathy, and neuropathy) in a high-risk population., Methods: We collected information via a structured questionnaire and directly from the patient's record on 1034 adult type 2 diabetic patients who were attending outpatient clinics in Qatar., Results: The mean age of the patients was 55 ± 10 years, and the mean duration of diabetes was 12.4 ± 8.9 years. Forty-five percent had one or more microvascular complications. Shared risk factors for multiplicity and for individual complications included family history, severity and duration of diabetes, and hypertension, but some risk factors were specific for individual microvascular complications. Early age at onset of diabetes was strongly associated with multiplicity of complications ( P = 0.0003)., Conclusions: About half the diabetics in this high-risk population had one or more microvascular complications. Several well-established risk factors were associated with multiplicity and individual microvascular complications, but each separate microvascular complication was linked to a somewhat different constellation of risk factors.

Background & Aims: Improved therapy has substantially increased survival of persons with cystic fibrosis (CF). But the risk of colorectal cancer (CRC) in adults with CF is 5-10 times greater compared to the general population, and 25-30 times greater in CF patients after an organ transplantation. To address this risk, the CF Foundation convened a multi-stakeholder task force to develop CRC screening recommendations., Methods: The 18-member task force consisted of experts including pulmonologists, gastroenterologists, a social worker, nurse coordinator, surgeon, epidemiologist, statistician, CF adult, and a parent. The committee comprised 3 workgroups: Cancer Risk, Transplant, and Procedure and Preparation. A guidelines specialist at the CF Foundation conducted an evidence synthesis February-March 2016 based on PubMed literature searches. Task force members conducted additional independent searches. A total of 1159 articles were retrieved. After initial screening, the committee read 198 articles in full and analyzed 123 articles to develop recommendation statements. An independent decision analysis evaluating the benefits of screening relative to harms and resources required was conducted by the Department of Public Health at Erasmus Medical Center, Netherlands using the Microsimulation Screening Analysis model from the Cancer Innervation and Surveillance Modeling Network. The task force included recommendation statements in the final guideline only if they reached an 80% acceptance threshold., Results: The task force makes 10 CRC screening recommendations that emphasize shared, individualized decision-making and familiarity with CF-specific gastrointestinal challenges. We recommend colonoscopy as the preferred screening method, initiation of screening at age 40 years, 5-year re-screening and 3-year surveillance intervals (unless shorter interval is indicated by individual findings), and a CF-specific intensive bowel preparation. Organ transplant recipients with CF should initiate CRC screening at age 30 years within 2 years of the transplantation because of the additional risk for colon cancer associated with immunosuppression., Conclusions: These recommendations aim to help CF adults, families, primary care physicians, gastroenterologists, and CF and transplantation centers address the issue of CRC screening. They differ from guidelines developed for the general population with respect to the recommended age of screening initiation, screening method, preparation, and the interval for repeat screening and surveillance., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Individuals with cystic fibrosis are at increased risk of colorectal cancer (CRC) compared with the general population, and risk is higher among those who received an organ transplant. We performed a cost-effectiveness analysis to determine optimal CRC screening strategies for patients with cystic fibrosis., Methods: We adjusted the existing Microsimulation Screening Analysis-Colon model to reflect increased CRC risk and lower life expectancy in patients with cystic fibrosis. Modeling was performed separately for individuals who never received an organ transplant and patients who had received an organ transplant. We modeled 76 colonoscopy screening strategies that varied the age range and screening interval. The optimal screening strategy was determined based on a willingness to pay threshold of $100,000 per life-year gained. Sensitivity and supplementary analyses were performed, including fecal immunochemical test (FIT) as an alternative test, earlier ages of transplantation, and increased rates of colonoscopy complications, to assess if optimal screening strategies would change., Results: Colonoscopy every 5 years, starting at an age of 40 years, was the optimal colonoscopy strategy for patients with cystic fibrosis who never received an organ transplant; this strategy prevented 79% of deaths from CRC. Among patients with cystic fibrosis who had received an organ transplant, optimal colonoscopy screening should start at an age of 30 or 35 years, depending on the patient's age at time of transplantation. Annual FIT screening was predicted to be cost-effective for patients with cystic fibrosis. However, the level of accuracy of the FIT in this population is not clear., Conclusions: Using a Microsimulation Screening Analysis-Colon model, we found screening of patients with cystic fibrosis for CRC to be cost effective. Because of the higher risk of CRC in these patients, screening should start at an earlier age with a shorter screening interval. The findings of this study (especially those on FIT screening) may be limited by restricted evidence available for patients with cystic fibrosis., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Individuals with cystic fibrosis are at increased risk of colorectal cancer (CRC) compared to the general population, and risk is higher among those who received an organ transplant. We performed a cost-effectiveness analysis to determine optimal CRC screening strategies for patients with cystic fibrosis., Methods: We adjusted the existing Microsimulation Screening Analysis-Colon microsimulation model to reflect increased CRC risk and lower life expectancy in patients with cystic fibrosis. Modeling was performed separately for individuals who never received an organ transplant and patients who had received an organ transplant. We modeled 76 colonoscopy screening strategies that varied the age range and screening interval. The optimal screening strategy was determined based on a willingness to pay threshold of $100,000 per life-year gained. Sensitivity and supplementary analyses were performed, including fecal immunochemical test (FIT) as an alternative test, earlier ages of transplantation, and increased rates of colonoscopy complications, to assess whether optimal screening strategies would change., Results: Colonoscopy every 5 years, starting at age 40 years, was the optimal colonoscopy strategy for patients with cystic fibrosis who never received an organ transplant; this strategy prevented 79% of deaths from CRC. Among patients with cystic fibrosis who had received an organ transplant, optimal colonoscopy screening should start at an age of 30 or 35 years, depending on the patient's age at time of transplantation. Annual FIT screening was predicted to be cost-effective for patients with cystic fibrosis. However, the level of accuracy of the FIT in population is not clear., Conclusions: Using a Microsimulation Screening Analysis-Colon microsimulation model, we found screening of patients with cystic fibrosis for CRC to be cost-effective. Due to the higher risk in these patients for CRC, screening should start at an earlier age with a shorter screening interval. The findings of this study (especially those on FIT screening) may be limited by restricted evidence available for patients with cystic fibrosis., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Zika virus, an emerging serious infectious disease, is a threat to persons living or travelling to regions where it is currently endemic, and also to contacts of infected individuals. The aim of this study was to assess knowledge about this new public health threat to persons residing in a Middle Eastern country., Methods: We conducted a survey at several international universities in Qatar to assess knowledge and awareness about this disease. An adapted version of the survey was also conducted using online channels from Qatar., Results: The median age of the 446 participants, was 25 years, 280 (63%) were females, and 32% were from Gulf Cooperation Council (GCC) or other Middle East countries. Based upon their knowledge about availability of a vaccine, role of mosquitoes and other modes of transmission, and disease complications, we classified respondent's knowledge as "poor" (66%), "basic" (27%) or "broad" (7%). Forty-five (16%) persons with poor knowledge considered themselves to be well-informed., Conclusions: This report from a sample of persons associated with Middle East educational complex, reveals inadequate knowledge about Zika virus, a serious emerging infectious disease. Although few cases have been reported from the region, future cases are possible, since this area is a transit hub connecting currently infected regions to North America, Europe and Asia. As a preventive measure, an educational program about Zika virus would be valuable, especially for individuals or family members travelling to afflicted regions.

Background: Periodontal disease (PD), now our commonest infectious disorder leads to tooth loss, and has been linked to various systemic diseases, including various types of cancer. The aim of this study is to provide a systematic review and a meta-analysis of the relationship between PD, edentulism, and pancreatic cancer (PC)., Patients and Methods: From an initial review of 327 references we selected eight studies concerning periodontitis or edentulism with sufficient quantitative information to allow us to examine the risk of PC. We used relative risks (RRs), hazard ratios, or odds ratios to measure the association between periodontitis, edentulism, and PC. We employed random effects models to obtain summary risks, and we also provide measures of study differences and possible biases., Results: The summary RR for periodontitis and PC was 1.74 [95% confidence interval (CI) 1.41-2.15] and 1.54 for edentulism (95% CI 1.16-2.05). There was no evidence of heterogeneity for either variable, and no evidence of publication bias. The studies included reports from three continents, suggesting that the association is generalizable. Most of the studies were adjusted for variables thought to be associated with PC, such as gender, smoking, BMI, diabetes, and alcohol., Conclusions: Using meta-analysis, both periodontitis and edentulism appear to be associated with PC, even after adjusting for common risk factors. As yet, the mechanisms linking oral disease and PC are uncertain, but could be related to changes in the oral microbiome-an area of current research., (© The Author 2017. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: To determine optimum measurements for abdominal obesity and to assess the prevalence and determinants of metabolic syndrome in Qatar., Design: National health survey., Setting: Qatar National STEPwise Survey conducted by the Supreme Council of Health during 2012., Participants: 2496 Qatari citizens aged 18-64 representative of the general population., Primary and Secondary Outcome Measures: Measure of obesity (body mass index, waist circumference or waist-to-height ratio) that best identified the presence of at least 2 other factors of metabolic syndrome; cut-off values of waist circumference; frequency of metabolic syndrome., Results: Waist circumference ≥102 for men and ≥94 cm for women was the best predictor of the presence of other determinants of metabolic syndrome (raised blood pressure, fasting blood glucose, triglycerides and reduced high-density lipoprotein cholesterol). Using these values, we identified 28% of Qataris with metabolic syndrome, which is considerably lower than the estimate of 37% calculated using the International Diabetes Federation (IDF) criteria. Restricting the analysis to participants without known elevated blood pressure, elevated blood sugar or diabetes 16.5% would be classified as having metabolic syndrome. In a multivariable logistic regression analysis, the prevalence of metabolic syndrome increased steadily with age (OR=3.40 (95% CI 2.02 to 5.74), OR=5.66 (3.65 to 8.78), OR=10.2 (5.98 to 17.6) and OR=18.2 (7.01 to 47.5) for those in the age group '30-39', '40-49', '50-59', '60-64' vs '18-29'; p<0.0001), decreased with increasing educational attainment (OR=0.61 (0.39 to 0.96) for those who attained 'secondary school or more' compared with 'less than primary school'; p=0.03) and exercise (OR=0.60 (0.42 to 0.86) for those exercising ≥3000 vs <600 MET-min/week; p=0.006) but was not associated with smoking or diet., Conclusions: Waist circumference was the best measure of obesity to combine with other variables to construct a country-specific definition of metabolic syndrome in Qatar. Approximately 28% of adult Qatari citizens satisfy the criteria for metabolic syndrome, which increased significantly with age. Education and physical activity were inversely associated with this syndrome., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: While pancreatic cancer (PC) most often affects older adults, to date, there has been no comprehensive assessment of risk factors among PC patients younger than 60 years., Methods: We defined early-onset PC (EOPC) and very-early-onset PC (VEOPC) as diagnosis of PC in patients younger than 60 and 45 years, respectively. We pooled data from 8 case-control studies, including 1954 patients with EOPC and 3278 age- and sex-matched control subjects. Logistic regression analysis was performed to identify associations with EOPC and VEOPC., Results: Family history of PC, diabetes mellitus, smoking, obesity, and pancreatitis were associated with EOPC. Alcohol use equal to or greater than 26 g daily also was associated with increased risk of EOPC (odds ratio, 1.49; 95% confidence interval, 1.21-1.84), and there appeared to be a dose- and age-dependent effect of alcohol on risk. The point estimate for risk of VEOPC was an odds ratio of 2.18 (95% confidence interval, 1.17-4.09)., Conclusions: The established risk factors for PC, including smoking, diabetes, family history of PC, and obesity, also apply to EOPC. Alcohol intake appeared to have an age-dependent effect; the strongest association was with VEOPC.

Background: The aetiology of pancreatic cancer (PC) has been extensively studied and is the subject of numerous meta-analyses and pooled analyses. We have summarized results from these pooled and meta-analytical studies to estimate the fraction of PCs attributable to each of the identified risk factors., Methods: Using a comprehensive strategy, we retrieved 117 meta-analytical or pooled reports dealing with the association between specific risk factors and PC risk. We combined estimates of relative risk and estimates of exposure to calculate the fraction of PCs caused or prevented by a particular exposure., Results: Tobacco smoking ('strong' evidence) and Helicobacter pylori infection ('moderate' evidence) are the major risk factors associated with PC, with respective estimated population attributable fractions of 11-32% and 4-25%. The major protective factors are history of allergy ('strong' evidence) and increasing fruit or folate intake ('moderate' evidence), with respective population preventable fractions of 3-7% and 0-12%., Conclusions: We summarized results of 117 meta-analytical or pooled data reports dealing with 37 aetiological exposures, to obtain robust information about the suspected causes of PC. By combining these estimates with their prevalences in the population, we calculated population attributable or population preventable fractions. About two-thirds of the major risk factors associated with PC are potentially modifiable, affording a unique opportunity for preventing one of our deadliest cancers., (© The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Objective: To estimate the prevalence of prediabetes in adolescents living in a high-risk country and to detect risk factors associated with this disorder., Design: Survey questionnaire combined with physical measurements and blood sugar determination., Setting: Doha, capital city of Qatar., Participants: A total of 1694 male and female students aged 11-18 years without previously diagnosed diabetes enrolled in four schools., Main Outcome Measure: Blood sugar measurements. Other measured variables included gender, height, weight, abdominal circumference, country of origin, family history of diabetes and frequency of exercise., Results: Using a random blood sugar ≥7.8 mmol/L or a fasting blood sugar ≥5.5 mmol/L as cutpoints, we identified 4.2% of students (56 boys, 15 girls) as probable prediabetics. In a multivariate model, being boys (OR 3.2, 95% CI 1.7-6.2), having a diabetic parent (OR 1.9, 95% CI 1.1-3.2) or having a waist-to-height ratio >0.5 (OR 1.8, 95% CI 1.1-3.0) were significantly associated with being a prediabetic. The parental origin of diabetes had a differential effect upon blood sugar. The mean random blood sugar in students with a maternal inheritance pattern of diabetes was 5.61 mmol/L ± 1.0, compared to 5.39 mmol/L ± 0.89 in students with a paternal inheritance pattern (p = 0.02)., Conclusions: In a country with a high risk of adult diabetes, we identified 4.2% of students aged 11-18 as being prediabetic. Risk factors associated with prediabetes included male gender, family history of diabetes and waist-to-height ratio >0.5.

In order to quantify the risk of pancreatic cancer associated with history of any allergy and specific allergies, to investigate differences in the association with risk according to age, gender, smoking status, or body mass index, and to study the influence of age at onset, we pooled data from 10 case-control studies. In total, there were 3,567 cases and 9,145 controls. Study-specific odds ratios and 95% confidence intervals were calculated by using unconditional logistic regression adjusted for age, gender, smoking status, and body mass index. Between-study heterogeneity was assessed by using the Cochran Q statistic. Study-specific odds ratios were pooled by using a random-effects model. The odds ratio for any allergy was 0.79 (95% confidence interval (CI): 0.62, 1.00) with heterogeneity among studies (P < 0.001). Heterogeneity was attributable to one study; with that study excluded, the pooled odds ratio was 0.73 (95% CI: 0.64, 0.84) (Pheterogeneity = 0.23). Hay fever (odds ratio = 0.74, 95% CI: 0.56, 0.96) and allergy to animals (odds ratio = 0.62, 95% CI: 0.41, 0.94) were related to lower risk, while there was no statistically significant association with other allergies or asthma. There were no major differences among subgroups defined by age, gender, smoking status, or body mass index. Older age at onset of allergies was slightly more protective than earlier age.

Acute pancreatitis is one of the most frequent gastrointestinal causes of hospital admission in the United States. Chronic pancreatitis, although lower in incidence, significantly reduces patients' quality of life. Pancreatic cancer is associated with a high mortality rate and is one of the top 5 causes of death from cancer. The burden of pancreatic disorders is expected to increase over time. The risk and etiology of pancreatitis differ with age and sex, and all pancreatic disorders affect the black population more than any other race. Gallstones are the most common cause of acute pancreatitis, and early cholecystectomy eliminates the risk of future attacks. Alcohol continues to be the single most important risk factor for chronic pancreatitis. Smoking is an independent risk factor for acute and chronic pancreatitis, and its effects could synergize with those of alcohol. Significant risk factors for pancreatic cancer include smoking and non-O blood groups. Alcohol abstinence and smoking cessation can alter the progression of pancreatitis and reduce recurrence; smoking cessation is the most effective strategy to reduce the risk of pancreatic cancer., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Pancreatic cancer affects 44,000 Americans and at least 250,000 individuals worldwide annually. The incidence is slowly increasing after a recent period of decline. Cases are predicted to increase globally because of increased longevity and the widespread adoption of cancer-causing behaviors, such as cigarette smoking, dietary indiscretion, and a global increase in diabetes. Well-known risk factors for pancreatic cancer are advancing age, tobacco smoking, obesity, certain inherited familial disorders, second-hand smoke exposure, chronic pancreatitis, and diabetes. Associations with human immunodeficiency virus, ABO blood group, hepatitis B virus, human immunodeficiency virus, and Helicobacter pylori have also been identified.

Background: Pancreatitis is a known risk factor for pancreatic cancer; however, an unknown fraction of the disease is thought to be a consequence of tumor-related duct obstruction., Patients and Methods: A pooled analysis of a history of pancreatitis and risk of pancreatic cancer was carried out considering the time interval between diagnoses and potential modification by covariates. Adjusted pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated from 10 case-control studies (5048 cases of ductal pancreatic adenocarcinoma and 10,947 controls) taking part in the International Pancreatic Cancer Case-Control Consortium (PanC4)., Results: The association between pancreatitis and pancreatic cancer was nearly three-fold at intervals of >2 years between diagnoses (OR: 2.71, 95% CI: 1.96-3.74) and much stronger at intervals of ≤2 years (OR: 13.56, 95% CI: 8.72-21.90) probably reflecting a combination of reverse causation and antecedent misdiagnosis of pancreas cancer as pancreatitis. The younger (<65 years) pancreatic cancer cases showed stronger associations with previous (>2 years) pancreatitis (OR: 3.91, 95% CI: 2.53-6.04) than the older (≥65 years) cases (OR: 1.68, 95% CI: 1.02-2.76; P value for interaction: 0.006)., Conclusions: Despite a moderately strong association between pancreatitis (diagnosed before >2 years) and pancreatic cancer, the population attributable fraction was estimated at 1.34% (95% CI: 0.612-2.07%), suggesting that a relatively small proportion of pancreatic cancer might be avoided if pancreatitis could be prevented.

Despite their wealth and modern road systems, traffic injury rates in Middle Eastern countries are generally higher than those in Western countries. The authors examined traffic injuries in Qatar during 2000-2010, a period of rapid population growth, focusing on the impact of speed control cameras installed in 2007 on overall injury rates and mortality. During the period 2000-2006, prior to camera installation, the mean (SD) vehicular injury death rate per 100,000 was 19.9±4.1. From 2007 to 2010, the mean (SD) vehicular death rates were significantly lower: 14.7±1.5 (p=0.028). Non-fatal severe injury rates also declined, but mild injury rates increased, perhaps because of increased traffic congestion and improved notification. It is possible that speed cameras decreased speeding enough to affect the death rate, without affecting overall injury rates. These data suggest that in a rapidly growing Middle Eastern country, photo enforcement (speed) cameras can be an important component of traffic control, but other measures will be required for maximum impact.

Background and Aim: Previous studies on the development of pancreatic pseudocysts following acute pancreatitis were monocentric, mostly retrospective, did not fulfil the Atlanta criteria, and featured a mixture of patients with post-acute and chronic pancreatitis. Therefore, the natural course of pancreatic pseudocysts after acute pancreatitis and the reasons for their spontaneous resolution remain unknown., Methods: This prospective study of 369 patients investigated the prognostic factors for development of pancreatic pseudocysts and for their spontaneous resolution after a first episode of acute pancreatitis., Results: On discharge, 124 (34%) patients still had pancreatic fluid collections. The prognostic factor for these fluid collections was severe acute pancreatitis. Follow-up examination 3 and 6 months later showed pancreatic pseudocysts in 36 (10%) patients (30 with and 6 without prior fluid collection), and in 27 (7%) patients (25 with and 2 without pancreatic pseudocyst after 3 months), respectively. The prognostic factors for their development were alcohol abuse and an initial severe course of the disease. Spontaneous complete resolution of the pancreatic pseudocysts occurred in 11 (31%) of the 36 patients. Prognostic factors for the spontaneous resolution were no or mild symptoms (nausea, vomiting, abdominal pain) and a maximal cyst diameter of <4 cm., Conclusions: Patients with a first severe attack of acute pancreatitis and fluid collections at discharge should be checked by ultrasonography for pancreatic pseudocysts 3 months later. In patients with a small pseudocyst and mild symptoms therapy may be postponed for a further 3 months, since spontaneous resolution is possible., (Copyright © 2012 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: Pre-existing polyps, especially large polyps, are known to be the major source for colorectal cancer, but there is limited available information about factors that are associated with polyp size and polyp growth. We aim to determine factors associated with polyp size in different age groups., Methods: Colonoscopy data were prospectively collected from 67 adult gastrointestinal practice sites in the United States between 2002 and 2007 using a computer-generated endoscopic report form. Data were transmitted to and stored in a central data repository, where all asymptomatic white (n = 78352) and black (n = 4289) patients who had a polyp finding on screening colonoscopy were identified. Univariate and multivariate analysis of age, gender, performance site, race, polyp location, number of polyps, and family history as risk factors associated with the size of the largest polyp detected at colonoscopy., Results: In both genders, size of the largest polyp increased progressively with age in all age groups (P < .0001). In subjects ≥ 80 years the relative risk was 1.55 (95% CI, 1.35-1.79) compared to subjects in the youngest age group. With the exception of family history, all study variables were significantly associated with polyp size (P < .0001), with multiple polyps (≥ 2 versus 1) having the strongest risk: 3.41 (95% CI, 3.29-3.54)., Conclusions: In both genders there is a significant increase in polyp size detected during screening colonoscopy with increasing age. Important additional risk factors associated with increasing polyp size are gender, race, polyp location, and number of polyps, with polyp multiplicity being the strongest risk factor. Previous family history of bowel cancer was not a risk factor.

Background and Aims: Correct upper reference limits (URL) of serum liver enzyme activities are used to select individuals in whom further diagnostic procedures for suspected liver disorders are warranted and to compare the prevalence and incidence of increased serum liver enzyme levels within and among populations. We sought to establish URL in a general adult population by not only generating a disease-free population but also further excluding subjects with ultrasonographical diagnosis of hepatic steatosis., Methods: We used data from 4,242 subjects (2,154 women) aged 20-79 years recruited for the population-based Study of Health in Pomerania. A reference population was selected comprising 1,953 subjects (1,129 women). Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and γ-glutamyltransferase (GGT) were measured photometrically., Results: The exclusion of 630 subjects with hepatic steatosis and 20 subjects with equivocal data on liver ultrasound from the reference population predominantly affected the URL for serum ALT and GGT levels in younger age groups. URL for serum ALT, AST and GGT levels were 1.00 μmol/L/s (60 U/L), 0.55 μmol/L/s (33 U/L) and 1.11 μmol/L/s (67 U/L), respectively, in men as well as 0.57 μmol/L/s (34 U/L), μmol/L/s (25 U/L) and μmol/L/s (39 U/L), respectively, in women., Conclusions: URL for serum liver enzyme activities are higher than recommended previously. Creating a reference population for establishing URL for serum liver enzyme activities should include liver ultrasound in order to exclude subjects with subclinical hepatic steatosis., (© 2010 John Wiley & Sons A/S.)

Background: ABO blood type has been associated with various malignancies, including pancreatic cancer. Our aim was to study this association using data from a hospital-based tumour registry., Methods: From the tumour registry, we retrieved data from 15,359 cancer patients treated during 2000-2003 at the European Institute of Oncology (Milan, Italy), with defined ABO blood type. We performed a case-control analysis, comparing the distribution of ABO blood types of patients with each specific form of cancer against that of patients with other forms of cancer. We also reviewed the literature and performed a meta-analysis on the association between ABO blood group and pancreatic cancer., Results: We observed a significantly lower frequency of blood type O in patients with exocrine pancreatic cancer compared to patients with other forms of cancer (29% versus 44%; P<0.001; odds ratio (OR), 0.53; 95% confidence intervals (CI), 0.33-0.83). This association was confirmed by the meta-analysis of seven prior studies (summary relative risk, 0.79; 95% CI, 0.70-0.90). No association was found for endocrine pancreatic cancer or for cancer originating in other organs., Conclusions: Our data suggest that the association between ABO blood group and cancer is limited to exocrine pancreas malignancy., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Acute pancreatitis, chronic pancreatitis and pancreatic cancer are responsible for most of the burden of exocrine pancreatic disease. Glandular damage from recurrent bouts of acute pancreatitis can lead to irreversible changes characteristic of chronic pancreatitis. In recent decades accumulating evidence has defined longstanding pre-existing chronic pancreatitis as a strong risk factor for pancreatic cancer. The lag period between diagnosis of chronic pancreatitis and pancreatic cancer is usually one or two decades: pancreatitis appearing a year or two before the diagnosis of pancreatic cancer is often the result of tumour-related ductal obstruction. The risk of developing pancreatic cancer appears to be highest in rare types of pancreatitis with an early onset, such as hereditary pancreatitis and tropical pancreatitis. Even though there is a strong link between chronic pancreatitis and pancreatic cancer, over a 20 year period only around five percent of patients with chronic pancreatitis will develop pancreatic cancer. Until the development of more sophisticated screening procedures, screening is not recommended for patients with chronic pancreatitis., (2010 Elsevier Ltd. All rights reserved.)

Objectives: High serum creatinine is a well-known unfavorable prognostic parameter in acute pancreatitis. Elevated creatinine at 48 h after admission was recently described as a marker for pancreatic necrosis. As pancreatic necrosis is a serious complication of acute pancreatitis and its identification by a simple single laboratory test would be very helpful, the aim of this study was to test that statement., Methods: In a prospective multicenter study of 462 patients with a first attack of acute pancreatitis, serum creatinine was determined on admission, and at 24 and 48 h thereafter, and compared with the findings of contrast-enhanced computed tomography (CT) performed within 96 h of admission., Results: Pancreatic necrosis was present in 62 (13%) of the patients. Serum creatinine levels (abnormal > or = 2 mg/dl) on admission and after 24 and 48 h were evaluated vs. the presence or absence of pancreatic necrosis. Sensitivity rates varied between 14 and 23%, specificity between 95 and 97%, positive predictive values between 41 and 50%, and negative predictive values between 87 and 89%. Receiver operating characteristic curves revealed an area under the curve of between 0.604 and 0.669., Conclusions: An elevated serum creatinine concentration at any time during the first 48 h of admission is not a marker for pancreatic necrosis in a first attack of acute pancreatitis. If serum creatinine is normal, necrotizing pancreatitis is unlikely, and contrast-enhanced CT need not be performed unless complications occur and/or the patient's condition deteriorates.

Purpose: To investigate risk factors that may be linked to pancreatic cancer., Methods: We designed a multicenter population-based case-control (823 cases, 1679 control patients) study with data collection by using a common protocol and questionnaire. Participating centers were located in Australia, Canada, the Netherlands, and Poland., Results: After adjustment for confounding factors, a positive history of pancreatitis was associated with pancreatic cancer (odds ratio [OR], 4.68; 95% confidence interval [95% CI], 2.23-9.84). The risk was especially high in heavy smokers (OR, 15.4; 95% CI, 3.18-74.9). Patients with diabetes had an increased risk of developing pancreatic cancer (OR, 2.16; 95% CI, 1.60-2.91). The risk was highest in the first year after the development of diabetes (OR, 6.68; 95% CI, 3.56-12.6) and decreased over time. A history of allergy was associated with a reduced risk of pancreas cancer (OR, 0.64; 95% CI, 0.50-0.82)., Conclusions: Patients with newly diagnosed diabetes and patients with pancreatitis, particularly in heavy smokers, have an increased risk for developing pancreatic cancer. In addition to being risk factors, these conditions could be early manifestations of underlying pancreatic cancer. A history of allergy decreases the risk of pancreatic cancer., (2010 Elsevier Inc. All rights reserved.)

Background/aims: Smoking is an established risk factor for chronic pancreatitis (CP). We sought to identify how often and in which CP patients physicians consider smoking to be a risk factor., Methods: We analyzed data on CP patients and controls prospectively enrolled from 19 US centers in the North American Pancreatitis Study-2. We noted each subject's self-reported smoking status and quantified the amount and duration of smoking. We noted whether the enrolling physician (gastroenterologist with specific interest in pancreatology) classified alcohol as the etiology for CP and selected smoking as a risk factor., Results: Among 382/535 (71.4%) CP patients who were self-reported ever smokers, physicians cited smoking as a risk factor in only 173/382 (45.3%). Physicians cited smoking as a risk factor more often among current smokers, when classifying alcohol as CP etiology, and with higher amount and duration of smoking. We observed a wide variability in physician decision to cite smoking as a risk factor. Multivariable regression analysis however confirmed that the association of CP with smoking was independent of physician decision to cite smoking as a risk factor., Conclusions: Physicians often underrecognize smoking as a CP risk factor. Efforts are needed to raise awareness of the association between smoking and CP. and IAP., (Copyright © 2011 S. Karger AG, Basel.)

Background: Helicobacter pylori has been suggested to be involved in pancreatic diseases, namely autoimmune pancreatitis and pancreatic carcinoma. We investigated the presence of conserved sequences of Helicobacter in pancreatic tissue and pancreatic juice from patients with chronic nonautoimmune and autoimmune pancreatitis as well as pancreatic ductal adenocarcinoma (PDAC)., Methods: 35 pancreatic juices collected during routine endoscopic retrograde cholangiopancreatography and 30 pancreatic tissues were studied. Nested PCR was used to detect H. pylori in the isolated DNA samples. In order to exclude a methodological bias, the samples were analyzed blindly in 2 different laboratories using either conventional or LightCycler PCR for H. pylori urease A and 16S ribosomal DNA., Results: In the pancreas of 11 patients with autoimmune pancreatitis, no H. pylori DNA could be detected. Further, in none of the other tissue samples of chronic pancreatitis or PDAC could we detect any Helicobacter sequences. Out of the pancreatic juice samples, none demonstrated either of the 2 Helicobacter gene sequences investigated., Conclusion: Despite good scientific reasoning for an involvement of Helicobacter in pancreatic diseases, a direct infection of the microbial agent seems unlikely. Rather, the pathomechanism must involve molecular mimicry in autoimmune pancreatitis, or the transformation of nitric food constituents to nitrosamines in pancreatic cancer. and IAP., (Copyright © 2010 S. Karger AG, Basel.)

Background and Aims: Over the last decades, Europe has experienced dramatic changes in the geographical variation of liver cirrhosis rates. We attempt to provide a comprehensive analysis of patterns and trends in liver cirrhosis mortality in European countries and regions., Methods: Age-standardized (world standard) liver cirrhosis mortality rates per 100,000 person-years at ages 20-64 for 35 separate countries were computed using the World Health Organization Mortality Database., Results: In the analyzed period (1959-2002), a very strong East-to-West gradient in mortality rates was observed. An increase of the burden of mortality due to liver cirrhosis appeared in Eastern Europe in two specific areas: South-eastern Europe and North-eastern Europe. In the first group of countries, liver cirrhosis mortality was 10-20 times higher than in most other European states, levels never before observed in Europe. In the countries of North-eastern Europe (former Soviet Union countries) liver cirrhosis mortality was characterized by dramatic changes (both positive and negative) in specific periods of time., Conclusions: Despite the fact that the etiology of liver cirrhosis is multifactorial, it seems that alcohol drinking is the factor that best explains the observed patterns in frequency of this disease in Europe. Alcohol control policies in Central and Eastern Europe could lead to an appreciable reduction of premature mortality from liver cirrhosis., (Copyright © 2010 S. Karger AG, Basel.)

Pancreatic cancer, although infrequent, has a very poor prognosis, making it one of the 4 or 5 most common causes of cancer mortality in developed countries. Its incidence varies greatly across regions, which suggests that lifestyle factors such as diet, and environmental factors, such as vitamin D exposure, play a role. Because pancreatic cancer is strongly age-dependent, increasing population longevity and ageing will lead to an increase of the global burden of pancreatic cancer in the coming decades. Smoking is the most common known risk factor, causing 20-25% of all pancreatic tumors. Although a common cause of pancreatitis, heavy alcohol intake is associated only with a modest increased risk of pancreatic cancer. While viruses do not represent a major risk factor, people infected with Helicobacter pylori appeared to be at high risk of pancreatic cancer. Many factors associated with the metabolic syndrome, including overweight and obesity, impaired glucose tolerance, and long-standing diabetes also increase the risk disease, while atopic allergy and use of metformin as a treatment for diabetes have been associated with a reduced risk of pancreatic cancer. A family history of pancreatic cancer is associated with an increased risk of pancreatic cancer and it is estimated that 5-10% of patients with pancreatic cancer have an underlying germline disorder. Having a non-O blood group, another inherited characteristic, has also been steadily associated with an increased risk of pancreatic cancer. While many risk factors for pancreatic cancer are not modifiable, adopting a healthy lifestyle could substantially reduce pancreatic cancer risk., (Copyright © 2010 S. Karger AG, Basel.)

Pancreatic cancer, although infrequent, has an exceptionally high mortality rate, making it one of the four or five most common causes of cancer mortality in developed countries. The incidence of pancreatic cancer varies greatly across regions, which suggests roles for lifestyle factors, such as diet, or environmental factors, such as vitamin D exposure. Smoking is the most common known risk factor, and is the cause of 20-25% of all pancreatic tumors. Alcohol does not seem to be a risk factor, unless it leads to chronic pancreatitis, which is a probable risk factor. Long-standing diabetes increases the risk of pancreatic cancer, but can also be an early manifestation of pancreatic tumors. 5-10% of patients with pancreatic cancer have an underlying germline disorder, while the remaining percentage of cancer cases is thought to be caused by somatic mutations. Some individual studies suggest that mutations in various polymorphic genes can lead to small increases in the risk of pancreatic cancer, but these findings need to be replicated. Rising prevalence of smoking in developing countries, improved diagnosis and increasing population longevity are all likely to increase the global burden of pancreatic cancer in the coming decades.

The etiology of colorectal cancer is complex and multifactorial. Tobacco smoke has been found to be associated both with colorectal adenoma and cancer development. It was hypothesized that tobacco smoking could interact with genetic factors, providing different risk estimates according to different genetic predisposition. We reviewed and summarized by a meta-analytic approach the evidence from the literature on the interaction of smoking with the five most studied gene polymorphisms (GSTM1, GSTT1, mEH3, mEH4, NAT2). We calculated pooled Odds Ratios for each gene-smoking combination by random effects models, and provided a pooled P-value for gene-smoking interaction. Heterogeneity among studies was evaluated by the Q statistic and I(2). Overall, 27 case-control studies or nested case-control studies are included in this review: 12 presented data on GSTM1 polymorphism, eight on GSTT1, seven on mEH3, mEH4, and 10 on NAT2. We found a weak suggestion of an antagonistic effect of mEH3 low or medium metabolizer with smoking on colorectal adenoma risk (pooled P-value for the interaction: 0.02): smokers carriers of mEH3 low or medium metabolizer had slightly lower risk (Odds Ratio; 95% Confidence Interval: 1.6; 1.2-2.1) than smokers with mEH3 high metabolizer (1.8; 1.4-2.4). A non-significant positive interaction between GSTT1 null genotype and smoking was suggested for colorectal adenoma risk. None of the other common genetic polymorphisms involved in tobacco carcinogens metabolism seemed to modify the smoking-related risk of colorectal adenoma or cancer.

Objectives: It is unknown whether after an initial attack of acute pancreatitis, the inflamed gland heals completely, or whether and under what circumstances the disease progresses to chronic pancreatitis. Therefore, the aim of this study was to investigate the progression of disease from acute to chronic pancreatitis., Methods: During a 20-year period, 532 patients who were hospitalized after an initial attack of acute pancreatitis were followed up for an average of 7.8 years (range: 1 day to 19.7 years). We used the Kaplan-Meier method to study the frequency of recurrent attacks of pancreatitis, subsequent development of chronic pancreatitis, and all-cause mortality during the follow-up period in patients with pancreatitis due to different causes., Results: During the follow-up period, recurrent pancreatitis developed in 88 (16.5%) patients. The annual relapse rates were 5.3, 1.5, 0.6, and 1.9/100 per year in patients with acute pancreatitis due to alcohol, gallstones (biliary), and other identified causes of unknown origin (idiopathic), respectively. Chronic pancreatitis developed only in alcoholics, independent of the severity of the first attack and also of discontinuation of alcohol and nicotine consumption. The cumulative incidence of chronic pancreatitis was 13% in 10 years and 16% in 20 years. After surviving a second attack, the incidence of chronic pancreatitis increased distinctly to 38% after only 2 years of follow-up. Smoking significantly enhanced the risk of progression from acute to chronic alcoholic pancreatitis., Conclusions: The progression from acute to chronic pancreatitis occurred only in alcoholics. In this group, a substantial number of patients developed chronic pancreatitis in a short period of time after surviving a second attack of acute pancreatitis. Both alcohol consumption and smoking at this time are risk factors for the transition from acute to chronic pancreatitis.

Objective: To examine the association of baseline and lifetime ethanol intake with cancer of the pancreas in the European Prospective Investigation into Cancer and Nutrition (EPIC)., Methods: Included in this analysis were 478,400 subjects, of whom detailed information on the intake of alcoholic beverages at baseline and over lifetime was collected between 1992 and 2000. During a median follow-up time of 8.9 years, 555 non-endocrine pancreatic cancer cases were observed. Multivariate Cox proportional hazard models were used to examine the association of ethanol intake at recruitment and average lifetime ethanol intake and pancreatic cancer adjusting for smoking, height, weight, and history of diabetes., Results: Overall, neither ethanol intake at recruitment (relative risk (RR) = 0.94, 95% confidence interval (CI) 0.69-1.27 comparing 30+ g/d vs. 0.1-4.9 g/d) nor average lifetime ethanol intake (RR = 0.95, 95% CI 0.65-1.39) was associated with pancreatic cancer risk. High lifetime ethanol intake from spirits/liquor at recruitment tended to be associated with a higher risk (RR = 1.40, 95% CI 0.93-2.10 comparing 10+ g/d vs. 0.1-4.9 g/d), but no associations were observed for wine and beer consumption., Conclusion: These results suggest no association of alcohol consumption with the risk of pancreatic cancer.

Background & Aims: Only severe acute pancreatitis requires treatment, according to the principles of intensive care medicine in an intensive care or intermediate care unit. The aim of the study was to define and evaluate a simple clinical algorithm for rapid initial identification of patients with a first attack of acute pancreatitis who do not require intensive care., Methods: This prospective study included 394 patients who were admitted to the Municipal Clinic of Lüneburg, Germany, between 1987 and 2003. From a number of parameters of disease severity on admission, 3 parameters that showed the strongest prediction of a nonsevere course (no rebound tenderness and/or guarding, normal hematocrit level, and normal serum creatinine level) were combined to form the harmless acute pancreatitis score (HAPS). The score then was validated in a German multicenter study including 452 patients between 2004 and 2006., Results: In both the initial and the validation set, the HAPS correlated with a nonsevere course of the disease (P < .0001). The score correctly identified a harmless course in 200 (98%) of 204 patients., Conclusions: The HAPS enables identification, within approximately 30 minutes after admission, of patients with acute pancreatitis whose disease will run a mild course. The high level of accuracy of this test (98%) will allow physicians to identify patients quickly who do not require intensive care, and potentially those who will not require inpatient treatment at all. Thus, the HAPS may save substantial hospital costs.

Acute pancreatitis continues to be a diagnostic and therapeutic challenge for physicians and surgeons. It ranks third in the list of hospital discharges for gastro-intestinal diseases. In most patients the cause is either gallstones or alcoholism. The overall mortality is less than 5%, but severe acute pancreatitis leads to prolonged hospitalization and much higher mortality. There are important differences in disease susceptibility and case fatality rates: the incidence is higher in blacks than in whites, and mortality is higher in older patients than in younger patients. Reports from various countries reveal that the frequency of acute pancreatitis is increasing, perhaps in relation to rising obesity rates, which would increase the likelihood of gallstone pancreatitis. Conversely, mortality rates for acute pancreatitis are declining in many, but not all, reports.