The evolving paradigm of alcohol-associated hepatitis and liver transplantation.

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Developing a Novel Case-Based Gastroenterology/Hepatology Online Resource for Enhanced Education During and After the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic reshaped the delivery of medical education, necessitating novel modes of instruction to facilitate distance learning. Online medical education resources provide opportunities for self-directed and asynchronous learning. GISIM is a free, open access educational website dedicated to gastroenterology (GI)/hepatology, which teaches pathophysiology and disease management, and supports clinical reasoning skill development through interactive, dynamic, case presentation-based journeys. AIMS: (1) To describe the creation of a mobile-optimized, GI/hepatology educational resource for medical trainees, and (2) to report on trainee feedback on completing and authoring GISIM cases. METHODS: GISIM was created on WordPress and modeled after NephSIM, an e-learning platform dedicated to Nephrology. Content was developed by internal medicine residents and GI/hepatology fellows and attendings. Cases are interactive, prompting users to select differential diagnoses and management plans, with immediate feedback provided on response. Self-reported user demographics and website feedback were collected with an embedded survey. A separate survey evaluated case authors' experiences. RESULTS: GISIM launched in February 2021 and received 12,184 website views and 2003 unique visitors between February 1 2021 and February 28 2022. New cases are disseminated bimonthly. Sixty-one user surveys were collected, with a majority completed by fellows (38%) and residents (26%). All users found the website easy to use and most reported enhanced understanding of case topic areas. Nine author surveys were collected. Authors reported significant learning on chosen topics and improved clinical knowledge through their participation. CONCLUSIONS: We developed a novel GI/hepatology case-based resource that enables distance learning and was perceived as a valuable educational tool by users and authors.

Enhanced Communication for Interhospital Transfers Increases Preparedness in an Academic Tertiary Care Center.

OBJECTIVES: This quality improvement project sought to enhance clinical information sharing for interhospital transfers to an inpatient hepatology service comprised of internal medicine resident frontline providers (housestaff) with the specific aims of making housestaff aware of 100% of incoming transfers and providing timely access to clinical summaries. INTERVENTIONS: In February 2020, an email notification system to senior medicine residents responsible for patient triage shared planned arrival time for patients pending transfer. In July 2020, a clinical data repository ("Transfer Log") updated daily by accepting providers (attending physicians and subspecialty fellows) became available to senior medicine residents responsible for triage. METHODS: Likert scale surveys were administered to housestaff before email intervention (pre) and after transfer log intervention (post). The time from patient arrival to team assignment (TTA) in the electronic medical record was used as a proxy for time to patient assessment and was measured pre- and postinterventions; >2 hours to TTA was considered an extreme delay. RESULTS: Housestaff reported frequency of access to clinical information as follows: preinterventions 4/31 (13%) sometimes/very often and 27/31 (87%) never/rarely; postinterventions 11/26 (42%) sometimes/very often and 15/26 (58%) never/rarely (p = 0.02). Preinterventions 12/39 (31%) felt "not at all prepared" versus 27/39 (69%) "somewhat" or "adequately"; postinterventions 2/24 (8%) felt "not at all prepared" versus 22/24 (92%) somewhat/adequately prepared (p = 0.06). There was a significant difference in mean TTA between pre- and posttransfer log groups (62 vs. 40 minutes, p = 0.01) and a significant reduction in patients with extreme delays in TTA post-email (18/180 pre-email vs. 7/174 post-email, p = 0.04). CONCLUSION: Early notification and increased access to clinical information were associated with better sense of preparedness for admitting housestaff, reduction in TTA, and reduced frequency of extreme delays in team assignment.

Burnout Among Transplant Hepatologists in the United States.

Burnout among transplant hepatologists has not been well characterized. The goal of this study was to describe the prevalence and predictors of burnout among practicing transplant hepatologists in the United States. We designed a 69-item survey, including the Maslach Burnout Inventory (MBI)-Human Services Survey and questions on provider demographics, practice characteristics, and psychological factors. The survey was administered to practicing US transplant hepatologists between October and December 2019. We described burnout using MBI subscales (emotional exhaustion [EE], depersonalization [DP], and personal accomplishment [PA]) and determined significant predictors of burnout, which we defined as high EE, using univariate and multivariate analyses. A total of 185 transplant hepatologists completed the survey (response rate = 25% of 738 practicing transplant hepatologists in the United States). A total of 40% reported high EE, whereas 17% and 16% reported high DP and low PA, respectively. On multivariate analysis, respondents with more than 5 colleagues (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.23-0.84) reporting adequate time for outpatient visits (OR, 0.42; 95% CI, 0.22-0.80), reporting greater comfort with their clinical caseload (OR, 0.61; 95% CI, 0.39-0.96), and reporting higher confidence in their prior training (OR, 0.49; 95% CI, 0.28-0.87) had a lower likelihood of high EE. Working 6 or more hours from home outside of work per week (OR, 2.04; 95% CI, 1.07-3.89) predicted a higher likelihood of burnout. Compensation, age, gender, career phase, caregiver status, and transplant center volume did not predict burnout. Of the surveyed transplant hepatologists, 40% experienced burnout, predicted mostly by factors related to work-time distribution, peer support, and affect. These findings should prompt development of system-level initiatives.

Findings of Hepatic Severe Acute Respiratory Syndrome Coronavirus-2 Infection.

BACKGROUND & AIMS: Liver injury due to coronavirus disease 2019 (COVID-19) is being increasingly recognized. Abnormal liver chemistry tests of varying severities occur in a majority of patients. However, there is a dearth of accompanying liver histologic studies in these patients. METHODS: The current report details the clinical courses of 2 patients having severe COVID-19 hepatitis. Liver biopsies were analyzed under light microscopy, portions of liver tissue were hybridized with a target probe to the severe acute respiratory syndrome coronavirus-2 S gene, and small sections from formalin-fixed paraffin-embedded liver tissue were processed for electron microscopy. RESULTS: The liver histology of both cases showed a mixed inflammatory infiltrate with prominent bile duct damage, endotheliitis, and many apoptotic bodies. In situ hybridization and electron microscopy suggest the intrahepatic presence of severe acute respiratory syndrome coronavirus-2, the findings of which may indicate the possibility of direct cell injury. CONCLUSIONS: On the basis of the abundant apoptosis and severe cholangiocyte injury, these histopathologic changes suggest a direct cytopathic injury. Furthermore, some of the histopathologic changes may resemble acute cellular rejection occurring after liver transplantation. These 2 cases demonstrate that severe COVID-19 hepatitis can occur even in the absence of significant involvement of other organs.

Faculty Development Workshop for Endoscopic Teaching Techniques.

Introduction: Given the substantial variability in endoscopy teaching that gastroenterology fellows can be expected to encounter over the course of their fellowship, it is important to identify a standard set of behaviors that faculty can adopt to help trainees gain competence in endoscopy at an efficient rate. There remains a scarcity of easily distributed, effective tools for faculty development in regard to teaching endoscopy. Methods: Based on a prior qualitative study, we developed a three-part trigger video to be used for discussion during a faculty development session. We utilized three role-play scenarios between a fellow and supervisor managing a gastrointestinal bleed in the endoscopy suite. We summarized the implementation and instructions in a faculty guide. We used a postsession survey to measure effectiveness of the faculty development session. Results: This workshop has been successfully administered twice in 2018 with over 30 gastroenterologists and hepatologists involved in endoscopic teaching. Overall, all faculty have found the workshop useful in learning about endoscopic teaching behaviors and helpful in adjusting their own behaviors in endoscopic teaching. Discussion: We developed a faculty development workshop specifically for teaching endoscopy to gastroenterology trainees that is widely generalizable to other programs. Overall, we found a high level of satisfaction amongst the participants who have completed it. The tools we created can be easily tailored to complement any existing faculty development session and extrapolated to similar procedural disciplines.

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study.

BACKGROUND: Despite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention. MEASURES: Rates of AD and GCD completion, as well as self-reported barriers to ACP. INTERVENTION: Provider-led ACP in patients with decompensated cirrhosis without a prior documented AD. OUTCOMES: Sixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers. CONCLUSIONS/LESSONS LEARNED: Addressing provider and system-specific barriers dramatically improved documentation rates of ACP.

What Makes a Good Endoscopic Teacher: A Qualitative Analysis.

OBJECTIVE: Teaching learners to perform endoscopic procedures is challenging, yet effective endoscopy teaching practices are not well-described in the literature, and prior studies have focused on perspectives of supervising physicians rather than learners. We sought to characterize, from the perspective of endoscopy learners, endoscopic teaching behaviors perceived as beneficial and detrimental to learning using qualitative methods. DESIGN: This is a prospective qualitative content analysis. Gastroenterology fellows from 2 tertiary care centers anonymously provided feedback regarding supervising physicians' teaching behaviors during endoscopic training between March 2016 and December 2016. Preprinted cards were completed at the conclusion of procedures to document behaviors that fellows perceived as enhancing or hampering their learning. Two investigators performed content analysis of written comments; each identified behavior was assigned positive or negative valence. SETTING: Mount Sinai Hospital in New York, New York and University of California San Francisco in San Francisco, California. Both institutions are academic tertiary care centers. PARTICIPANTS: A total of 19 gastroenterology fellows at 2 training institutions participated. RESULTS: A total of 239 teaching behaviors were identified by 19 fellows who worked with 31 supervising physicians; 29 unique behaviors were identified and organized into 7 themes: teaching, learning environment, autonomy, communication, coaching, feedback, and professionalism. Of all, 185 (77.4%) behaviors were reported as beneficial, and 54 (22.6%) as detrimental to the learning experience. Behaviors related to teaching were most often perceived as beneficial, while behaviors related to professionalism and communication were most often perceived as detrimental to learning. CONCLUSIONS: Specific teaching behaviors may help or hinder learning of endoscopic skills. These behaviors may be useful for efforts related to teaching evaluation, faculty development, and direct teaching.

Efficient long-term depletion of CD20+ B cells by rituximab does not affect gut-resident plasma cells.

The vast majority of antibody-producing B cells are located within the gastrointestinal tract and are key players in maintaining homeostasis. The failure of rituximab, a potent B cell-depleting agent, to ameliorate ulcerative colitis in a single clinical trial has dampened enthusiasm to study B cells in patients with inflammatory bowel disease (IBD). However, several lines of evidence suggest that intestinal B cells may be affected in IBD. Additionally, the pathophysiological mechanisms underlying rituximab's lack of efficacy in IBD remain unclear. Here, on the basis of detailed immunophenotyping of a patient who underwent a colonoscopy 6 months after the end of rituximab-based therapy, we observed that rituximab did not deplete colon-resident plasma cells (PCs) while ablating all CD20+ B cells in tissues and in the circulation. On the basis of these observations, we propose that one factor underlying the lack of efficacy of rituximab relates to the fact that it does not affect the entire B cell compartment in tissues, sparing the intestinal-resident PCs while effectively depleting CD20+ B cell populations. Thus, we contend that, despite the results of the Rituximab study, there is a need for more intensive B cell-oriented research in inflammatory disorders, including IBD.

Comparison of Endoscopic Ultrasound-Fine-Needle Aspiration and Endoscopic Ultrasound-Fine-Needle Biopsy for Solid Lesions in a Multicenter, Randomized Trial.

BACKGROUND & AIMS: Endoscopic ultrasound with fine-needle aspiration (FNA) is the standard of care for tissue sampling of solid lesions adjacent to the gastrointestinal tract. Fine-needle biopsy (FNB) may provide higher diagnostic yield with fewer needle passes. The aim of this study was to assess the difference in diagnostic yield between FNA and FNB. METHODS: This is a multicenter, prospective randomized clinical trial from 6 large tertiary care centers. Patients referred for tissue sampling of solid lesions were randomized to either FNA or FNB of the target lesion. Demographics, size, location, number of needle passes, and final diagnosis were recorded. RESULTS: After enrollment, 135 patients were randomized to FNA (49.3%), and 139 patients were randomized to FNB (50.7%).The following lesions were sampled: mass (n = 210, 76.6%), lymph nodes (n = 46, 16.8%), and submucosal tumors (n = 18, 6.6%). Final diagnosis was malignancy (n = 192, 70.1%), reactive lymphadenopathy (n = 30, 11.0%), and spindle cell tumors (n = 24, 8.8%). FNA had a diagnostic yield of 91.1% compared with 88.5% for FNB (P = .48). There was no difference between FNA and FNB when stratified by the presence of on-site cytopathology or by type of lesion sampled. A median of 1 needle pass was needed to obtain a diagnostic sample for both needles. CONCLUSIONS: FNA and FNB obtained a similar diagnostic yield with a comparable number of needle passes. On the basis of these results, there is no significant difference in the performance of FNA compared with FNB in the cytologic diagnosis of solid lesions adjacent to the gastrointestinal tract. ClinicalTrials.gov identifier: NCT01698190.

Small Bowel Neoplasms and Polyps.

The small intestine is a relatively privileged organ that only rarely develops malignant or even benign tumors. Given this rarity, the relative inaccessibility of the organ during routine endoscopic procedures, and the typical absence or nonspecific nature of clinical manifestations, these tumors often go undiagnosed. Treatment and prognosis are tailored to each histological subtype of tumor. This chapter will discuss the epidemiology, presentation, diagnostics, and management for the most common small bowel tumors, and will highlight the importance of recognizing patients at higher risk of small bowel neoplasia.

Predictors of Successful Endoscopic Closure of Gastrointestinal Defects: Experience from a Single Tertiary Care Center.

BACKGROUND/AIMS: Endoscopic closure is technically feasible in the majority of gastrointestinal defects. The aim of this study is to evaluate the technical and clinical outcomes, and identify variables predicting successful outcomes in patients with attempted closure. METHODS: This is a retrospective study of patients undergoing endoscopic closure of gastrointestinal defects between December 2007 and May 2013 at a single tertiary care center. Technical success (TS) was defined as successful closure of the defect at the time of endoscopy. Clinical improvement (CI) was defined as improvement in symptoms. Clinical resolution (CR) was defined as documented radiographic closure of defect or clinical resolution of symptoms. Acute defects were diagnosed within 6 weeks, while chronic defects were those that persisted for >6 weeks, prior to index therapeutic endoscopy. RESULTS: Fifty patients underwent 77 endoscopies for leaks (n = 23), fistulas (n = 22), and perforations (n = 5). TS occurred in 46/50 (92%). Overall, 34/50 (68%) patients had CR. CR was significantly higher for acute defects as compared to chronic defects (89.7 vs. 38.1%, OR 14.1, CI 3.19-62.1, p < 0.001). Of 24 patients who required repeat attempts at endoscopic closure, 14 (58%) achieved CR. Acute defects (p = 0.04) and those with initial CI (p = 0.001) were statistically more likely to achieve CR after a repeat attempt. CONCLUSION: TS and CR are achieved in majority of patients. Acute defects are more likely to achieve CR. In cases where a defect persists, a repeat attempt at endoscopic closure should be attempted.

Sendai and Fukuoka Consensus Guidelines Identify Advanced Neoplasia in Patients With Suspected Mucinous Cystic Neoplasms of the Pancreas.

BACKGROUND & AIMS: Little is known about whether the 2006 Sendai guidelines or 2012 Fukuoka guidelines are being used to determine the level of risk posed by suspected pancreatic mucinous cystic neoplasms (PCNs). We evaluated whether the guidelines accurately predicted which patients with suspected PCNs, which was based on cross-sectional imaging findings, would be found to have advanced neoplasia in surgery. METHODS: We performed a retrospective study of data collected from 194 patients with cystic lesions of the pancreas, which were assessed by cross-sectional imaging analyses, who underwent surgery for suspected PCNs at the Hospital at the University of Pennsylvania from 2000 through 2008. Imaging data were used to classify patients according to the Sendai guidelines as high risk or low risk and according to the Fukuoka guidelines as high risk, worrisome, or low risk. Pathology analyses of samples collected during surgery were used as the reference. A logistic regression model was created to identify factors associated with advanced neoplasia. The Sendai and Fukuoka guideline criteria were analyzed by univariate and multivariable logistic regression analyses. RESULTS: Advanced neoplasias were found in 36 patients (18.5%; 22 invasive cancers and 14 high-grade dysplasias). The median size of cysts was 33 mm. All patients found to have invasive cancers were accurately assigned to the Sendai guidelines high risk or Fukuoka guidelines high risk groups. However, 3 patients in the Sendai guidelines low risk and 2 patients in the Fukuoka guidelines low risk groups were found to have high-grade dysplasia. The Sendai guidelines identified patients with advanced neoplasia with 91.7% sensitivity, 21.5% specificity, 21% positive predictive value, and 91.9% negative predictive value. A designation of Fukuoka guidelines high risk identified patients with advanced neoplasia with 55.6% sensitivity, 73% specificity, 32% positive predictive value, and 87.9% negative predictive value. Overall, there was no statistically significant difference between the guidelines in predicting which patients had advanced neoplasia. On multivariate analysis, the presence of a mural nodule (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.33-6.27; P = .008), dilated main pancreatic duct >10 mm (OR, 7.44; 95% CI, 2.36-23.52; P = .001), or enhancing solid component (OR, 2.92; 95% CI, 1.16-7.64; P = .02) were associated with detection of advanced neoplasia in pancreatic cysts. CONCLUSION: On the basis of a retrospective analysis, the Sendai and Fukuoka guidelines accurately determine which patients with pancreatic cysts have advanced neoplasia. The guidelines accurately recommended surgical resection for all patients found to have invasive cancer, although some patients with high-grade dysplasia were missed. The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias. Cyst size was not associated with advanced neoplasia.