Gender-Specific Factors Influencing Gastroenterologists to Pursue Careers in Advanced Endoscopy: Perceptions vs Reality.

INTRODUCTION: In 2020, only 19% of 63 matched advanced endoscopy (AE) fellows were women. This study evaluates the gender-specific factors that influence gastroenterologists to pursue careers in AE. METHODS: An anonymous survey was distributed to gastroenterology fellows and attendings through various gastroenterology society online forums. Data were collected on demographics, training, mentorship, current practice, family planning, and career satisfaction. RESULTS: Women comprised 71.1% of the 332 respondents. 24.7% of female fellows plan to pursue an AE career compared with 37.5% of male fellows (P = 0.195). The main motivating factor for both genders was interest in the subject area. Interest in another subspecialty was the main deterring factor for both genders. Women were more deterred by absence of same-sex mentors (P < 0.001), perception of gender-based bias in the workplace (P = 0.009), family planning (P = 0.018), fertility/pregnancy risks from radiation (P < 0.001), and lack of ergonomic equipment (P = 0.003). AE gastroenterologists of both genders were satisfied with their career decision and would recommend the field to any fellow. Most respondents (64%) believed that more female role models/mentors would improve representation of women in AE. DISCUSSION: There are multiple gender-specific factors that deter women from pursuing AE. Increasing the number of female role models is strongly perceived to improve representation of women in AE. Most AE attendings are satisfied with their career and would recommend it to fellows of any gender. Thus, early targeted mentorship of female trainees has potential to improve recruitment of women to the field.

Donor Characteristics and Regional Differences in the Utilization of HCV-Positive Donors in Liver Transplantation.

Importance: Increased utilization of hepatitis C virus (HCV)-positive liver allografts for liver transplant (LT) has been endorsed as one of several ways to combat national organ shortages. However, HCV-positive donors remain poorly characterized, and Organ Procurement and Transplantation Network regional differences in the utilization of HCV-positive liver allografts are unclear. Objective: To characterize HCV-positive donors and the allografts that come from them. Design, Setting, and Participants: In this cross-sectional study, the Scientific Registry of Transplant Recipients database was queried for all donors who underwent HCV testing from June 2015 to December 2018. Clinical and allograft characteristics were evaluated, and utilization across the United States was studied. Patients with positive or negative results for HCV antibody (Ab) and HCV nucleic acid amplification testing (NAT) were included in this study. Donors utilized for living donor transplant and pediatric (age <18 years) recipients were excluded. Main Outcomes and Measures: The primary comparison was between donors who were HCV Ab positive and those who were HCV Ab negative. Regional variations in the utilization of HCV-positive and HCV-negative donors were analyzed. Results: Of 24 500 donors utilized for LT, 1887 (7.7%) were HCV Ab positive; 64.4% of HCV Ab-positive donors were HCV NAT positive. HCV Ab-positive donors were younger (median [interquartile range] age, 35 [29-46] years vs 40 [27-54] years) and had fewer comorbidities, such as diabetes (8.3% vs 12.0%) and hypertension (25.9% vs 35.2%), compared with HCV Ab-negative donors. These findings were even more pronounced in HCV Ab-positive /NAT-positive compared with HCV Ab-positive/NAT-negative donors. Organ Procurement and Transplantation Network regions 2, 3, 10, and 11 had the highest absolute utilization of HCV Ab-positive donors, accounting for 64.4% of all HCV Ab-positive donors used in the United States. Region 1 had the highest relative utilization of HCV Ab-positive donors (18.7%). The use of HCV Ab-positive donors in some regions was associated with the rate of drug overdose, but this was not always the case. Similar utilization results were found with HCV NAT-positive donors. Conclusions and Relevance: In this cross-sectional study, HCV-positive donors were younger and healthier than utilized HCV-negative donors. Significant differences exist in the utilization of HCV-positive donors across the 11 Organ Procurement and Transplantation Network regions, which is not entirely explained by organ demand or by higher availability of HCV-positive livers as per the distribution of the opioid epidemic. Initiatives to increase the use of HCV-positive donors, particularly in regions of high organ demand, should be implemented.

Primary EUS-guided biliary drainage versus ERCP drainage for the management of malignant biliary obstruction: A systematic review and meta-analysis.

EUS-guided biliary drainage (EUS-BD) has been used as a salvage modality for relief of malignant biliary obstruction (MBO) after a failed ERCP. Multiple recent randomized controlled trials (RCTs) and observational studies have been published to assess the suitability of EUS-BD as a first-line modality for achieving palliative BD. We aimed to perform a systematic review and meta-analysis comparing primary EUS-BD versus ERCP for MBO. We searched PubMed, Medline, and Embase up to January 1, 2019, to identify RCTs and observational studies evaluating the efficacy and safety of primary EUS-BD (without a prior attempted ERCP) versus ERCP. Quality of RCTs and observational studies was assessed using Jadad and Newcastle-Ottawa scores, respectively. The outcomes of interest were technical success, clinical success, odds of requiring a repeat intervention, and procedure-related adverse events. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. Meta-analysis was performed using the random effects model in RevMan 5.3 (the Cochrane Collaboration, the Nordic Cochrane Centre, Copenhagen, Denmark). Five studies (three RCTs and two observational studies) with 361 patients were included. Both procedures achieved comparable technical success (OR: 1.20 [0.44-3.24], I2 = 0%) and clinical success (OR: 1.44, confidence interval [CI]: 0.63-3.29, I2 = 0%). The overall adverse outcomes (OR: 1.59 [0.89-2.84]) did not differ between the two groups. In the ERCP group, 9.5% of patients developed procedure-related pancreatitis versus zero in the EUS group (risk difference = 0.08%, P = 0.02). There was no statistically significant difference in nonpancreatitis-related adverse events. The odds of requiring reintervention for BD (1.68 [0.76-3.73], I2 = 42%) did not differ significantly. The ERCP group had significantly higher odds of requiring reintervention due to tumor overgrowth (5.35 [1.64-17.50], I2 = 0%). EUS-BD has comparable technical and clinical success to ERCP and can potentially be used as a first-line palliative modality for MBO where expertise is available. ERCP-related pancreatitis which can cause significant morbidity can be completely avoided with EUS.

Liver transplant for hepatocellular carcinoma in the United States: Evolving trends over the last three decades.

Hepatitis C virus infection has been the most common etiology in HCC-related liver transplantation (LT). Since 2014, direct-acting antivirals (DAAs) have dramatically improved HCV cure. We aimed to study the changing pattern of etiologies and impact in outcome in HCC-related LT according to HCV treatment-era through retrospective analysis of the Scientific Registry of Transplant Recipients (SRTR) database (1987-2017). A total of 27 855 HCC-related liver transplants were performed (median age 59 years, 77% male). In the DAA era (2014-2017) there has been a 14.6% decrease in LT for HCV-related HCC; however, HCV remains the most common etiology in 50% of cases. In the same era, there has been a 50% increase in LT for NAFLD-related HCC. Overall survival was significantly worse for HCV-related HCC compared to NAFLD-related HCC during pre-DAA era (2002-2013; P = .031), but these differences disappeared in the DAA era. In addition, HCV patients had a significant improvement in survival when comparing the DAA era with IFN era (P < .001). Independent predictors of survival were significantly different in the pre-DAA era (HCV, AFP, diabetes) than in the DAA era (tumor size). HCV-related HCC continues to be the main indication for LT in the DAA era, but patients' survival has significantly improved and is comparable to that of NAFLD-related HCC.

A comparison of diverticulitis in Crohn's disease versus ulcerative colitis.

BACKGROUND AND AIM: Inflammatory bowel disease (IBD) and diverticulitis both increase morbidity, especially when associated with in-patient hospitalization. This study aimed to evaluate whether hospitalization burden differs for diverticulitis in patients with a history of Crohn's disease (CD) compared to ulcerative colitis (UC). METHOD: All patients hospitalized for acute diverticulitis with pre-existing UC or CD in 2014 were selected using the national in-patient sample. Cases were identified using the International Classification of Diseases, Ninth Edition codes. Primary outcomes were mortality, cost of admission, length of stay (LOS), and colectomy. RESULTS: A total of 1815 patients were admitted with diverticulitis, and those with CD had a hospitalization associated with decreased cost (aOR -14 537, 95% CI -27 316 to -1758; P = 0.026) and LOS (aOR -1.31, 95% CI -2.41 to -0.208; P = 0.02) compared to UC. A second analysis comparing diverticulitis hospitalization between those with CD and those with the absence of IBD showed no significant difference in mortality (aOR 2.47, 95% CI 0.59 to 10.36; P = 0.22), LOS (aOR 0.03, 95% CI -0.47 to 0.54; P = 0.92), or cost of admission (aOR -2196, 95% CI -6933 to 2539; P = 0.36) between the cohorts. CONCLUSION: Patients with UC have worsened hospitalization outcomes when being treated for diverticulitis compared to CD. While the findings may be a result of a difference in colectomy rates, the etiology may also be multifactorial. These conclusions have not been previously described, and further investigations would better characterize these associations.

Association of Autoimmune Hepatitis and Cardiovascular Disease.

BACKGROUND: Autoimmune Hepatitis is a chronic liver disease while Cardiovascular Disease is seen in inflammatory states. This study sought to determine if Cardiovascular Disease was associated with Autoimmune Hepatitis. METHODS: The National Inpatient Sample selected patients with a primary diagnosis of Autoimmune Hepatitis and secondary diagnosis of Cardiovascular Disease in 2014. The primary outcome was the association of Autoimmune Hepatitis with Cardiovascular Disease. Secondary outcomes evaluated the hospital burden with Cardiovascular Disease. RESULTS: 16,375 patients with Autoimmune Hepatitis were included in the study. There was a decreased association between Autoimmune Hepatitis and Cardiovascular Disease (aOR 0.77, 95% CI 0.69-0.85, p < 0.00), Coronary Artery Disease, (aOR 0.75, 95% CI 0.67-0.85, p < 0.00), and Peripheral Vascular Disease (aOR 0.75, 95% CI 0.60-0.93, p = 0.01). Moreover, Coronary Artery Disease comprises 84% of the overall Cardiovascular Disease cohort and did not demonstrate significantly increased length of stay (aOR -0.53, 95% CI -1.16 to 0.12, p = 0.11) or hospitalization cost (aOR -6711, 95% CI -14336 to 912, p = 0.08). DISCUSSION: The decreased association between Autoimmune Hepatitis and Cardiovascular Disease is likely multifactorial in etiology. Consequently, this observation requires further examination with prospective trials.

Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy.

BACKGROUND: Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD. MATERIALS AND METHODS: The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay. RESULTS: A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014. CONCLUSIONS: Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.

Reconstructive Surgery Camp for Leprosy Deformities in a Tertiary Hospital: An Example of Service Delivery at Low Costs.

INTRODUCTION: Seventy percent of all cases of leprosy in the world occur in India. 8,462 new cases of disability were reported in India between 2010-11. Reconstructive Surgery Camps (RSC) provide free of cost plastic surgical expertise to patients of leprosy with deformity. AIM: The aim of this article was to report the outcomes of a RSC in a tertiary level university hospital in India. We also described the types of deformities in the patient group and the cost of conducting such a camp. MATERIALS AND METHODS: The RSC involved 130 patients with leprosy related deformities operated by a team of plastic surgeons in a tertiary university hospital over 5 days. Health workers of the National Leprosy Elimination Program identified patients at community level. The camp was funded by the central government of India and the patients were provided incentives for undergoing treatment. RESULTS: Plantar ulcer was the commonest deformity (51.5%) while lagopthalmos (9.2%) was the least common deformity in the patient group. The overall complication rate in our study was around 10.6% (n=11). The total cost of this camp was 730,000 rupees (£7029.9). CONCLUSION: Reconstructive surgery in a camp setup is a low cost alternative of correcting leprosy related deformity. It also provides valuable practical experience in reconstructive surgery to surgical trainees. Tertiary hospital based camps for conducting large-scale surgeries may be a cost effective alternative to reduce waiting lists in public health sectors. Long-term studies monitoring patients operated in a camp setting would be worthwhile.

Pneumobilia with gastric outlet obstruction.

Complications of peptic ulcer disease (PUD) like gastric outlet obstruction (GOO) and biliary fistula have become extremely rare with the advent of proton-pump inhibitors.This is a case of PUD presenting with GOO, a cholecystoduodenal fistula discovered incidentally on upper gastrointestinal endoscopy, and the presence of pneumobilia on a contrast-enhanced CT of the abdomen. A gastrojejunostomy with internal pyloric exclusion was performed. Since the patient did not have any signs of biliary tract disease,we decided not to operate on the fistula to prevent injury to the bile duct. The patient had an uneventful recovery.

Extraskeletal osteosarcoma of the larynx: an extremely unusual tumour.

Osteosarcoma of the larynx is probably the rarest mesenchymal tumour of the larynx, with only 16 cases reported so far. The majority of them occur in males between the sixth and eighth decades of life. Patients usually present with non-specific symptoms such as dysphonia and upper airway compromise. The most common site of distant metastasis is the lung. Clinically, the tumour follows an aggressive course and is associated with high mortality. The case we present is unusual as it occurred at a young age (38 years) as compared with the norm and it did not arise from the endolarynx, unlike many of the other cases. This was the only known case where a Pearson near-total laryngectomy was performed whereby the patient's natural speech mechanism was preserved. This surgery was possible because the contralateral half of the larynx was clearly disease free and the interarytenoid region was uninvolved. The patient underwent postoperative adjuvant external beam radiotherapy beginning 4 weeks after surgery. The patient is doing well after 15 months of follow-up and shows no signs of recurrence.

Electromyographic evaluation of blink reflex as a tool for early diagnosis of neurological dysfunction in patients of hypothyroidism.

BACKGROUND: Neurological dysfunction is an important consequence of hypothyroidism. Some of the neurologic manifestations of hypothyroidism include somnolence, lethargy, impaired memory and concentration, depression and entrapment neuropathy. Rarer but reversible neurological manifestations include cerebellar ataxia, psychosis, dementia and myxedema coma. PURPOSE: The aim of the present study was to evaluate the usefulness of the blink reflex as a method for obtaining an early diagnosis of central nervous system dysfunction in hypothyroid patients who do not have signs or symptoms of nervous system dysfunction. METHODS: Forty-eight patients with mean age 40 (± 11), with newly diagnosed primary hypothyroidism and 20 healthy control subjects were included in the study. The patients were divided into subclinical and overt hypothyroidism. Patients with normal T3/T4 with elevated TSH were considered subclinical hypothyroids. For blink reflex testing, subjects lay supine on a bed in a warm room with eyes gently closed. Recordings were performed with an EMG machine (Nihon Kohdeni'Neuropack), with a filter setting of 20 Hz to 10 kHz, using an analysis time of 50 ms. Recordings were performed with surface recording electrodes (Dantec 13K60, Copenhagen, Denmark). RESULTS: Second ipsilateral response (R2I) and second contralateral response (R2C) latencies in hypothyroidism were prolonged relative to controls, and the differences were statistically significant (P<0.001 and P<0.001, respectively). Latency of Rl, R2I, and R2C did not correlate linearly free T3, free T4, or TSH values in the hypothyroid group. CONCLUSION: The finding of abnormal blink reflex responses in hypothyroid individuals raises the notion that they may be useful in detecting early changes and in the follow-up of the patients with the disorder.