Clinical outcomes of long-term transmural drainage with double pigtail stents in disconnected pancreatic duct syndrome.

Background: Disconnected pancreatic duct syndrome (DPDS) is a common cause of recurrent pancreatic fluid collections (PFCs), often requiring repeat drainage. Following initial drainage with lumen apposing metal stents (LAMS), replacement with transmural double pigtail stents (DPS) has been shown to be a viable drainage modality mitigating the risk of recurrence. The sparsity of literature on the consequences of this strategy requires further investigation. We analyze our outcomes of long-term transmural drainage with DPS in patients with DPDS and assess the safety and efficacy of this technique. Methods: This retrospective review of a prospectively maintained database from November 2015-May 2022 included all patients with DPDS who underwent removal of LAMS and replacement with long-term transmural DPS. Patient demographics, collection characteristics, drainage technique and outcomes, as well as follow-up data was collected and analyzed using descriptive statistics. Results: There were 139 patients who underwent endoscopic drainage of PFCs with LAMS during the study period. Seventy-eight patients [walled-off necrosis (n=65) and pseudocysts (n=13)] were found to have DPDS. Of these, 44 patients underwent successful LAMS removal followed by replacement with DPS and were included in the analysis. The median age was 57 years and 14 (32%) were female. The median stent dwell time was 394 days [interquartile range (IQR) 245, 853 days]. Spontaneous stent migration was seen in seven patients (16%), one of whom developed a PFC recurrence which was managed conservatively. The second recurrence was seen in a patient with indwelling DPS which did not require further intervention. There were no locoregional adverse events secondary to long-term indwelling DPS. Among the 28 patients who were followed for a year, three patients developed new-onset diabetes, and chronic pancreatitis (CP) changes in the disconnected segment were seen in eight patients, five of whom required pancreatic enzyme supplementation. Conclusions: Placement of long-term transmural DPS is an effective modality for preventing collection re-accumulation with a favorable safety profile. Randomized prospective studies are essential to investigate the optimal removal timing of indwelling stents to prevent loco-regional complications. Given the realized risk of CP in the disconnected pancreas, follow-up cross sectional imaging may help guide further therapy.

EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis.

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

Understanding downstream service profitability generated by dermatology faculty in an academic medical center: a key driver to promotion of access-to-care.

Hiring new dermatology faculty at academic medical centers (AMCs) can be a difficult process. Academic dermatology departments, however, must have the financial freedom to nimbly respond to the needs of their community. To determine the downstream revenue and profitability produced by dermatology faculty, a retrospective review of charges and expenses downstream of professional services was performed to assess dermatology faculty and nurse practitioners from January 2019 to December 2020 at a single AMC in the southern United States. The downstream revenue per dermatology faculty was calculated using institutional data based on the number of services performed and the exact compensation per service. When this was not possible, the Medicare Allowable Charge was used to estimate the compensation for the service provided. Revenue was included from internal referrals to dermatopathology, Mohs surgery and repairs, chemistry and microbiology labs, radiology, and phototherapy. Profitability was calculated using institutional cost data to estimate the expense of each additional unit of services performed. The most valuable source of downstream income was dermatopathology services, which generated $85,395/provider in 2019 and $102,746/provider in 2020. Mohs surgery was also a significant source of downstream revenue contributing $92,715 in 2019 and $96,599 in 2020. Repairs after Mohs surgery internal referrals generated $30,036 in 2019 and $36,507 in 2020. The total contributions of chemistry and microbiology labs, radiology, and phototherapy were considerable but less impactful overall. The total downstream revenue calculated from these services for 2019 was $228,304/provider and $255,549 in 2020. The total downstream profitability for these services was calculated to be $112,597/provider in 2019 and $92,344/provider in 2020. In conclusion, faculty of academic dermatology departments produces a great deal more revenue and profitability for AMCs than the sum of their professional charges.

Skin cancer knowledge, attitudes, and practices among non-medical skin care professionals: A narrative review of cross-sectional and interventional studies.

BACKGROUND: Skin cancers are the most common malignancies in the United States. Total body skin examination by a physician, especially a dermatologist, is the gold standard for detecting suspicious lesions that may require further evaluation. Non-medical professionals (NMPs) including massage therapists, estheticians, hairdressers, and cosmetologists have the unique opportunity to frequently examine their client's skin outside of a clinical setting. By evaluating their knowledge of and comfort with evaluation of suspicious lesions, multiple studies have gauged the utility of patient encounters with NMPs for skin cancer detection. Several studies have also focused on assessment of intervention strategies for assessing and improving NMPs ability to detect suspicious lesions and to refer for physician evaluation when necessary. AIMS: To conduct a narrative review of skin cancer knowledge, attitudes, and practices among NMPs. PATIENTS/METHODS: A systematic search of the databases yielded 16 studies for review. A total of 8 cross-sectional studies examined the knowledge and attitudes of NMPs toward skin evaluation, and 8 studies assessed interventional strategies for improving NMPs' ability to assess skin lesions for consideration of physician referral. RESULTS: This review finds that NMPs are open to the idea of examining the exposed body surfaces relevant to their work with clients and are willing to refer for physician evaluation when needed. Multiple interventional strategies have demonstrated success with educating NMPs on the importance of skin surveillance and the characteristic physical examination findings associated with skin cancers. CONCLUSION: Strengthening the readiness of NMPs to examine their client's skin offers an opportunity to reduce time to skin cancer diagnosis, improve patient outcomes, and lower healthcare-associated costs of skin cancer treatment.

Effects of health beliefs, social support, and self-efficacy on sun protection behaviors among medical students: testing of an extended health belief model.

Sun protection behaviors (SPB) are important modifiable risk factors for skin cancer. As the most common malignancies in the world, skin cancers account for significant morbidity, mortality, and economic burden. Physicians play a key role in educating patients about proper SPB. Medical education provides the foundation for physician understanding of SPB and future patient education. The Health Belief Model (HBM) is a theoretical model that offers constructs to help explain health behaviors. This cross-sectional study examined a convenience sample of 186 medical student to assess their engagement in SPB through the lens of the 6 HBM constructs and social support. Overall, we found engagement in SPB among our cohort to be low. About 70.4% report never using wide-brimmed hats and only 44.6% often or always use sunscreen. Hierarchical multiple regressions were performed in three blocks to analyze the relationship between the independent variables (HBM constructs and social support) and dependent variable (SPB) after controlling for the influence of demographic covariates. In our health constructs model, beliefs about susceptibility, benefits minus barriers, and self-efficacy were found to be significant predictors of engaging in SPB. Addition of social support in the final model did not significantly improve prediction of SPB engagement. These findings support use of educational programs based on HBM for the improvement of SPB among medical students.

Skin cancer-related knowledge, attitudes, beliefs, and practices among the population in Gulf Cooperation Council countries: a systematic search and literature review.

Skin cancers are the most common malignancies diagnosed worldwide. In Gulf Cooperation Council (GCC) countries, skin cancer remains a significant health burden. Multiple studies have attempted to elucidate patient knowledge and attitudes regarding skin cancer risks and behavioral interventions to reduce risks. A systematic literature search of relevant articles was conducted in PubMed, ScienceDirect, and the Saudi Digital Library databases. A narrative analysis of relevant study results was conducted. A total of 12 studies were reviewed across GCC. These studies revealed common themes among GCC populations. Many study participants were aware that excess sun exposure represents a threat to health and increases cancer risk. Several studies reported sun exposure, with a mean of 19.13 h per week. More studies reported patients engaging in lower or no sunscreen use rather than regular sunscreen use. There are discrepancies in the understanding of sun exposure risk and risk mitigation practices among the study populations. Skin cancer poses a significant burden to patients in GCC countries and improved patient education will enhance population health.