Top Tips for Direct Percutaneous Endoscopic Jejunostomy (DPEJ) Tube Placement.

Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ.

Epidemiology and Socioeconomic Impact of Pancreatic Cancer: An Analysis of the Global Burden of Disease Study 1990-2019.

INTRODUCTION: The aim of this study is to estimate the global burden of pancreatic cancer from 1990 to 2019. METHODS: We reconstructed the Global Burden of Diseases (GBD) study results for pancreatic cancer across 204 countries and territories. Our study generated estimates for key disease burden indicators, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs), and cost. Linear regression analysis of the natural logarithm of age-standardized outcomes was used to calculate annual percent change. RESULTS: In 2019, there were a total of 530,296 incident and 442,101 prevalent cases of pancreatic cancer, resulting in 531,107 deaths and 11.5 million DALYs lost. The age-standardized incidence and prevalence of pancreatic cancer has increased from 5.22 (95% CI 4.97-5.40) to 6.57 (CI 6.00-7.09) per 100,000 people per year, and 4.1 (95% CI 3.95-4.26) to 5.4 (CI 4.96-5.87), respectively. This equated to 10 million (95% CI 9.5 to 10.4 million) incident cases of pancreatic cancer. The number of DALYs lost as a result of pancreatic cancer was 225 million years (95% CI 216-234 million years). Mortality from pancreatic cancer increased over the study period from 3.7 (95% CI 3.54-3.83) to 6.9 (95% CI 6.36-7.32). Incidence, prevalence, DALYs, and mortality were higher in countries with a higher socio-demographic index. CONCLUSIONS: Pancreatic cancer is rising around the world and is associated with a high economic burden. Programs aimed at reducing modifiable risk factors are needed.

Multi-ethnic transcriptome-wide association study of prostate cancer.

The genetic risk for prostate cancer has been governed by a few rare variants with high penetrance and over 150 commonly occurring variants with lower impact on risk; however, most of these variants have been identified in studies containing exclusively European individuals. People of non-European ancestries make up less than 15% of prostate cancer GWAS subjects. Across the globe, incidence of prostate cancer varies with population due to environmental and genetic factors. The discrepancy between disease incidence and representation in genetics highlights the need for more studies of the genetic risk for prostate cancer across diverse populations. To better understand the genetic risk for prostate cancer across diverse populations, we performed PrediXcan and GWAS in a case-control study of 4,769 self-identified African American (2,463 cases and 2,306 controls), 2,199 Japanese American (1,106 cases and 1,093 controls), and 2,147 Latin American (1,081 cases and 1,066 controls) individuals from the Multiethnic Genome-wide Scan of Prostate Cancer. We used prediction models from 46 tissues in GTEx version 8 and five models from monocyte transcriptomes in the Multi-Ethnic Study of Atherosclerosis. Across the three populations, we predicted 19 gene-tissue pairs, including five unique genes, to be significantly (lfsr < 0.05) associated with prostate cancer. One of these genes, NKX3-1, replicated in a larger European study. At the SNP level, 110 SNPs met genome-wide significance in the African American study while 123 SNPs met significance in the Japanese American study. Fine mapping revealed three significant independent loci in the African American study and two significant independent loci in the Japanese American study. These identified loci confirm findings from previous GWAS of prostate cancer in diverse populations while PrediXcan-identified genes suggest potential new directions for prostate cancer research in populations across the globe.

Recognizing intrapancreatic accessory spleen via EUS: Interobserver variability.

BACKGROUND AND OBJECTIVE: Accessory spleen (AS) may be encountered as an intrapancreatic lesion on EUS. This can look similar to other pancreatic pathologies and may lead to unnecessary interventions. The goal of this study was to evaluate the accuracy of EUS in distinguishing intrapancreatic AS (IPAS) from other pancreatic lesions. MATERIALS AND METHODS: Twelve sets of endoscopic images of the spleen and various pancreatic lesions confirmed on histology or cytology were gathered. Ten endosonographers were asked to characterize and identify the lesions. The responses were analyzed via Excel and the interobserver agreement was analyzed using Gwet's agreement coefficient statistic via Stata I/C v15. RESULTS: In our sample, the interobserver agreement was 0.37 (-+1-1; 0-0.2 poor, 0.2-0.4 fair, 0.4-0.6 moderate, 0.6-0.8 substantial, and 0.8-1.0 almost perfect) for determining whether or not the pancreatic lesion is IPAS. The reviewers were able to correctly determine IPAS endosonographically with a sensitivity of 77%, specificity of 74%, and positive and negative predictive values of 50% and 92%, respectively. CONCLUSION: There is a moderate-to-substantial interobserver agreement in describing the sonographic characteristics of the pancreatic lesions, such as the shape, echogenicity compared to spleen, echotexture, and border of the lesions. However, the interobserver agreement is only fair when deciding if the pancreatic lesion is an IPAS. The similar profile of IPAS and pancreatic neuroendocrine tumor could confound the diagnosis of IPAS, thus contributing to the decreased interobserver agreement. This study demonstrates that EUS criteria alone are not accurate for IPAS diagnosis. Fine-needle aspiration (FNA) may be required for a confirmatory diagnosis.

CholedochoClip: A Case of Obstructive Jaundice 14 Years after Cholecystectomy.

Gallstone disease is a common gastrointestinal pathology that may result in surgical intervention. While cholecystectomy has relatively minimal risks, surgical clip migration is a rare complication that can cause severe morbidity and mortality. This report describes a rare phenomenon of a biliary stone forming onto a migrated surgical clip 14 years after cholecystectomy causing an obstructive jaundice. This case illustrates the importance of keeping a migrated surgical clip on the differential when encountering patients with symptoms of cholangitis after cholecystectomy.

Endoscopy- and Monitored Anesthesia Care-Assisted High-Resolution Impedance Manometry Improves Clinical Management.

BACKGROUND: High-resolution impedance manometry (HRiM) is the test of choice to diagnose esophageal motility disorders and is particularly useful for identifying achalasia subtypes, which often guide therapy. HRiM is typically performed without sedation in the office setting. However, a substantial number of patients fail this approach. We report our single-center experience on endoscopy-assisted HRiM under monitored anesthesia care (MAC) in adults to demonstrate the feasibility and effectiveness of this approach. METHODS: Patients who had failed prior HRiM attempts received propofol under MAC. Patients then underwent an upper endoscopy, followed immediately by passage of a Diversateck HRiM motility catheter through the nares and under direct visualization into the stomach, often using the tip of the endoscope to guide the catheter. We then awakened the patients and asked them to perform 10 saline swallows. RESULTS: We successfully completed HRiM studies in 14 consecutive patients. Six patients had achalasia; two had esophagogastric junction outflow obstruction; two had absent contractility; one had distal esophageal spasm; one had ineffective esophageal motility; and one had a normal study. The majority of these patients were treated successfully with targeted interventions, including per oral endoscopic myotomy, gastrostomy, botox injection, medical therapy, and dietary modifications.

Injection drug use and patterns of highly active antiretroviral therapy use: an analysis of ALIVE, WIHS, and MACS cohorts.

BACKGROUND: Sustained use of antiretroviral therapy has been consistently shown to be one of the primary predictors of long-term effectiveness. Switching and discontinuation reflect patient and provider decisions that may limit future treatment options. In this study, we utilize data reported at semi-annual study visits from three prospective cohort studies, the AIDS Link to IntraVenous Exposure (ALIVE), the Women's Interagency HIV Study (WIHS), and the Multicenter AIDS Cohort Study (MACS), to investigate determinants of HAART modification with a particular focus on reported injection drug use (IDU). METHODS: Longitudinal data collected between 1996 and 2004 contributed from 2,266 participants (37% with a reported history of IDU) who reported initiating their first HAART regimen during follow-up were utilized. Separate proportional-hazards models were used to identify factors measured prior to HAART-initiation associated with the time to first HAART discontinuation and first switch of components of HAART among continuous HAART users. RESULTS: The use of PI- vs. NNRTI-based regimens among HAART users with and without any history of IDU was similar over follow-up. The median time to a first report of discontinuation of HAART was 1.1 years for individuals with a history of IDU but 2.5 years for those without a history of IDU and multivariate analyses confirmed overall that individuals with a history of IDU were at greater risk for HAART discontinuation (adj RH = 1.24, 95% CI: 1.03-1.48). However, when restricting to data contributed after 1999, there was no longer any significant increased risk (adj RH = 1.05, 95% CI: 0.81-1.36). After adjusting for pre-HAART health status and prior ARV exposure, individuals who were ethnic/racial minorities, reported an annual income < $10,000/year, and were not employed were at significantly greater risk for HAART discontinuation. The median time to a first change in HAART regimen was approximately 1.5 years after first HAART report and was not elevated among those with a history of IDU (adj RH = 1.09, 95% CI: 0.89-1.34). CONCLUSION: Our analyses demonstrate that injection drug use by itself does not appear to be an independent risk factor for HAART switching or discontinuation in more recent years. However, as continued HAART use is of paramount importance for long-term control of HIV infection, efforts to improve maintenance to therapy among disadvantaged and minority populations remain greatly needed.