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Racial differences in susceptibility and progression of pancreatitis have been reported in epidemiologic studies using administrative or retrospective data. There has been little study, however, on the clinical profile, causes, and outcome of chronic pancreatitis (CP) in black patients. We analyzed data on black patients with CP prospectively enrolled in the multicenter North American Pancreatitis Studies from 26 US centers during the years 2000-2014. CP was defined by definitive evidence on imaging studies or histology. Information on demographics, etiology, risk factors, disease phenotype, treatment, and perceived effectiveness was obtained from responses to detailed questionnaires completed by both patients and physicians. Of the 1,159 patients enrolled, 248 (21%) were black. When compared with whites, blacks were significantly more likely to be male (60.9 vs. 53%), ever (88.2 vs. 71.8%), or current smokers (64.2 vs. 45.9%), or have a physician-defined alcohol etiology (77 vs. 41.9%). There was no overall difference in the duration of CP although for alcoholic CP, blacks had a longer duration of disease (8.6 vs. 6.97 years; P=0.02). Blacks were also significantly more likely to have advanced changes on pancreatic morphology (calcifications (63.3 vs. 55.2%), atrophy (43.2 vs. 34.6%), pancreatic ductal stricture or dilatation (72.6 vs. 65.5%) or common bile duct stricture (18.6 vs. 8.2%)) and function (endocrine insufficiency 39.9 vs. 30.2%). Moreover, the prevalence of any (94.7 vs. 83%), constant (62.6 vs. 51%), and severe (78.4 vs. 65.8%) pain and disability (35.1 vs. 21.4%) were significantly higher in blacks. Observed differences were in part related to variances in etiology and duration of disease. No differences in medical or endoscopic treatments were seen between races although prior cholecystectomy (31.1 vs. 19%) was more common in white patients. Differences were observed between blacks and whites in the underlying cause, morphologic expression, and pain characteristics of CP, which in part are explained by the underlying risk factor(s) with alcohol and tobacco being much more frequent in black patients as well as disease duration.

Actual surgical creation of vascular access has unacceptable failure rates of which stenosis formation is a major cause. We have shown previously in idealized models of side-to-end arteriovenous fistula that disturbed flow, a near-wall hemodynamic condition characterized by low and oscillating fluid shear stress, develops in focal points that corresponds closely to the sites of future stenosis. Our present study was aimed at investigating whether disturbed flow occurs in patient-specific fistulae, too. We performed an image-based computational fluid dynamics study within a realistic model of wrist side-to-end anastomosis fistula at six weeks post-surgery, with subject-specific blood rheology and boundary conditions. We then categorized disturbed flow by means of established hemodynamic wall parameters. The numerical analysis revealed laminar flow within the arterial limbs and a complex flow field in the swing segment, featuring turbulent eddies leading to high frequency oscillation of the wall shear stress vectors. Multidirectional disturbed flow developed on the anastomosis floor and on the whole swing segment. Reciprocating disturbed flow zones were found on the distal artery near the floor and on the inner wall of the swing segment. We have found that both multidirectional and reciprocating disturbed flow develop on the inner side of the swing segment in a patient-specific side-to-end fistula used for vascular access after six weeks post-operatively. This has obvious implications for elucidating the hemodynamic forces involved in the initiation of venous wall thickening in vascular access.

Background It has been shown that intracranial artery stenosis (ICAS) plays a key role in Chinese ischemic stroke or transient ischemic attack (TIA) patients. Many vascular diseases can lead to ICAS, such as atherosclerosis, dissection, vasculitis, moyamoya disease, and reversible cerebral vasoconstriction syndrome (RCVS). In addition, progression of intracranial atherosclerotic disease (ICAD) will increase the risk of ischemic cerebrovascular events. The ICASMAP study primarily aims to determine the etiology and disease distribution of ICAS using noninvasive magnetic resonance (MR) imaging and evaluate the rate for progression of ICAD in symptomatic population. Methods The ICASMAP study is a prospective, observational, and multicenter study by recruiting 300 subjects (18–80 years old) with recent stroke or TIA (within 2 weeks after onset of symptoms) in China. All the subjects will undergo MR imaging examination including brain and intracranial artery MR imaging at baseline. In addition, the clinical risk factors will be collected and blood biomarkers will be tested. A subgroup of more than 200 subjects who were diagnosed with ICAD according to baseline MR imaging will be followed up for 2 years. During the follow‐up study, MR imaging examination will be performed at 12 and 24 months. The primary end point is presence of progression of intracranial artery atherosclerotic plaques. Conclusions The ICASMAP study investigates the etiology of ICAS and progression of ICAD in Chinese stroke patients and may help to improve the precise diagnosis and intervention of ICAS and stroke prevention. The ICASMAP study aims to determine the etiology and disease distribution of ICAS using noninvasive magnetic resonance (MR) imaging and evaluate the risk factors for progression of ICAD in symptomatic population. In this study, we will recruit 300 subjects (18–80 years old) with recent stroke or TIA in China. The ICASMAP study investigates the etiology of ICAS and progression of ICAD in Chinese stroke patients and may help to improve the precise diagnosis and intervention of ICAS and stroke prevention.

Background Disease behavior in Crohn's disease (CD) may be modified by disease location and genotype. Disease behavior may change over time, and thus analysis requires follow-up. To date, there have been few pediatric studies that have evaluated the association between disease behavior and genotype with prolonged follow-up. The aim of our study was to evaluate the effect of genotype, phenotype, and ethnicity on disease behavior in pediatric CD. Methods Evaluation of 128 pediatric CD was followed by analysis of 232 pediatric and adult-onset CD patients. Inclusion required at least 2 years of follow-up. Phenotype, ethnicity, and disease duration were recorded. Patients were genotyped for polymorphisms in the NOD2/CARD15 gene. Results Colonic involvement was more frequent in younger patients. Pediatric disease at end of follow-up was classified as inflammatory (78%), penetrating (7%), and stricturing (17%). Duration of follow-up (mean 4.9 pediatric and 6.4 years mixed) was associated with more stricturing and penetrating disease. There was no association between mean age of onset and NOD2/CARD15, or either of these with disease behavior. These observations were replicated in the mixed cohort. Sephardic Jewish origin was inversely correlated with inflammatory behavior (P = 0.006), independent of NOD2/CARD15 genotype. Conclusions Duration of disease and ethnicity, irrespective of NOD2/CARD15 genotype and age of onset, were the only predictors for penetrating or stricturing disease.

Surgical creation of new anastomosis has been proposed as the preferred treatment for perianastomotic stenoses of fistulae. However, disadvantages of surgical approach have included (1) frequent conversion of fistula to a graft by using synthetic graft material to create a new anastomosis, (2) shortening the length of the cannulation segment by proximal autologous arteriovenous neoanastomosis, and (3) abandoning the fistula altogether in favor of a synthetic graft. We report the results of a prospective study using percutaneous balloon angioplasty (PTA) to treat fistulae with perianastomotic lesions. Seventy-three consecutive patients undergoing 112 PTA procedures for the treatment of perianastomotic lesions were studied. Primary and secondary patency rates were calculated. Procedure success, procedure-related complications, and conversion of fistulae to grafts were recorded. The initial success rate was 97%. The degree of stenosis before and after PTA was 81±9 and 11±11%, respectively. Primary patency rates at 6, 12, and 18 months were 75, 51, and 41%, respectively. Secondary patency rates at 6, 12, and 18 months were 94, 90, and 90%, respectively. Grade I hematoma occurred in three and vein rupture in two cases. No grafts were inserted. These outcomes are superior to those that have been reported for surgery. The outpatient PTA is safe and effective for the management of perianastomotic stenosis. Because of its advantage of fistula preservation, the percutaneous approach should be considered as the preferred first-line therapy for the management of perianastomotic fistula lesions.

Background The distribution of cerebral ischemic infarction and stenosis in ischemic stroke may vary with age-group, race and gender. This study was conducted to understand the risk factors and characteristics of cerebral infarction and stenosis of vessels in young Chinese patients with ischemic stroke. Methods This was a retrospective study, from January 2007 to July 2012, of 123 patients ≤50 years diagnosed with acute ischemic stroke. Patient characteristics were compared according to sex (98 males and 25 females) and age group (51 patients were ≤45 years and 72 patients were 46–50 years). Characteristics of acute ischemic infarction were studied by diffusion weighted imaging. Stenosis of intra- and extracranial arteries was diagnosed by duplex sonography, head magnetic resonance angiography (MRA) or cervical MRA. Results Common risk factors were hypertension (72.4 %), dyslipidemia (55.3 %), smoking (54.4 %) and diabetes (33.3 %). Lacunar Infarction was most common in our patients (41.5 %). Partial anterior circulation infarction was predominant in females (52.0 vs 32.7 %; P  = 0.073) and posterior circulation infarction in males (19.8 vs 4 %; P  = 0.073). Multiple brain infarctions were found in 38 patients (30.9 %). Small artery atherosclerosis was found in 54 patients (43.9 %), with higher prevalence in patients of the 46–50 years age-group. Intracranial stenosis was more common than extracranial stenosis, and middle cerebral artery stenosis was most prevalent (27.3 %). Stenosis in the anterior circulation was more frequent than in the posterior circulation ( P  < 0.001). Conclusions In these young patients, hypertension, smoking, dyslipidemia and diabetes were common risk factors. Intracranial stenosis was most common. The middle cerebral artery was highly vulnerable.

Background. Long-term use of cocaine (⩾ 15 years) and antiretroviral therapy (ART) have been implicated in cardiovascular complications. Nevertheless, the individual and combined effects of ART and cocaine use on silent coronary artery disease have not been fully investigated. Methods. Computed tomography coronary angiography was performed for 165 human immunodeficiency virus (HIV)– infected African American study participants aged 25– 54 years in Baltimore, Maryland, with contrast-enhanced 64-slice multidetector computed tomography imaging. Results. Significant (⩾ 50%) coronary stenosis was detected in 24 (15%) of 165 participants. The prevalence of significant stenosis among those who had used cocaine for ⩾ 15 years and had received ART for ⩾ 6 months was 42%. Exact logistic regression analysis revealed that long-term cocaine use (adjusted odds ratio, 7.75; 95% confidence interval, 2.26– 31.2) and exposure to ART for ⩾ 6 months (adjusted odds ratio, 4.35; 95% confidence interval, 1.30– 16.4) were independently associated with the presence of significant coronary stenosis. In addition, after controlling for confounding factors, both stavudine use for ⩾ 6 months or combivir use for ⩾ 6 months were independently associated with the presence of significant coronary stenosis. Conclusions. Long-term exposure to ART may be associated with silent coronary artery disease; however, the magnitude of increased risk associated with ART was much lower than the risk associated with cocaine use or traditional risk factors. Cardiovascular monitoring and aggressive modification of cardiovascular risk factors are essential for reducing the risk of coronary artery disease in HIV-infected individuals. Extensive efforts should also be made to develop effective cocaine use cessation programs for HIV-infected cocaine users.

We describe two women presenting with severe postpartum headache associated with hypertension but with no other signs or investigation results to suggest pre-eclampsia. In one case, the headache was associated with atypical subarachnoid haemorrhage. The variable nature of the headache and the degree of associated hypertension raised the clinical suspicion of reversible cerebral vasoconstriction syndrome, confirmed on MR angiography. Both patients took nimodipine until the cerebral vasoconstriction had resolved radiologically.

In the West, removal of the uvula is predominantly undertaken as part of palatal surgery, in cases of obstructive sleep apnoea. In the developing world, such as the Middle East and Africa, uvulectomy is a more common practice. The uvula is removed for curative or preventive purposes, or as part of ritual practice. Due to immigration from developing to developed world countries, and to Western doctors working abroad, such doctors are increasingly being confronted with unfamiliar traditional healing practices, within a medical context. The Medline and Embase online databases were systematically searched for literature on traditional uvulectomy. We present a review of this literature. We also present the first report, to our best knowledge, of obstructive sleep apnoea as a late complication of traditional uvulectomy. Traditional uvulectomy may be complicated by post-operative haemorrhage and local infections, among many other problems. We report cases of obstructive sleep apnoea and snoring caused by palatal stenosis resulting from traditional uvulectomy during childhood.

Despite a higher risk of stroke, blacks are less likely than whites to receive the invasive procedures that are used to diagnose and treat cerebrovascular disease, particularly carotid endarterectomy. Explanations for the lower rate of procedural use include racial bias, racial differences in pathophysiology of cerebrovascular disease, affordability, and racial variation in patient decisions regarding care. Studies consistently indicate that blacks are less likely to have severe atherosclerotic lesions of the carotid arteries, reducing their likelihood of being appropriate candidates for carotid endarterectomy. Although ability to pay does not explain the observed variation in use of carotid endarterectomy, it may influence the evaluation process prior to hospitalization. A racial difference in patients' decisions about health care for cerebrovascular disease has never been investigated; it should be a topic of future studies.