Part II: Contract Negotiation and Job Preparation-The Gastroenterology Perspective.

GI fellowships do not mandate curricula in career development. Often, fellows resort to peer mentorship for guidance. Fellows should recognize that the path to a successful career varies greatly based on how one defines and measures success. Keywords are preferr Through introspection, fellows will be able to craft their ideal post-fellowship position that balances wants versus needs. In this article, we cover four practical tips for trainees entering the job negotiation process.

Navigating the "First Gastroenterology Job" Search for American and International Medical Graduates.

GI fellowships do not mandate curricula in career development. Often, fellows resort to peer mentorship for guidance. Fellows should recognize that the path to a successful career varies greatly based on how one defines and measures success. Through introspection, fellows will be able to craft their ideal post-fellowship position that balances wants versus needs. In this article, we cover the breadth of post-fellowship opportunities available with a focus on unique considerations for LGBTQ+ and IMG trainees.

Decreased Risk of Preeclampsia in Women with Inflammatory Bowel Disease on Anti-Tumor Necrosis Factor Therapy.

BACKGROUND: Evidence suggests that upregulation of tumor necrosis factor-alpha (TNF-α) plays a role in immune dysregulation in both preeclampsia and inflammatory bowel disease (IBD). AIMS: We aimed to investigate whether anti-TNF therapy during pregnancy decreases the risk of preeclampsia in women with IBD. METHODS: The study population included women with IBD and pregnancies who were followed at a tertiary care center from 2007 to 2021. Cases of preeclampsia were compared with controls with a normotensive pregnancy. Data on patient demographics, disease type and activity, pregnancy complications, and additional risk factors for preeclampsia were collected. The association between anti-TNF therapy and preeclampsia was analyzed using univariate analysis and multivariate logistic regression. RESULTS: Women with preeclampsia were more likely to have a preterm delivery (44% vs. 12%, p < 0.001). More women without preeclampsia were exposed to anti-TNF therapy during pregnancy than women with preeclampsia (55% vs. 30%, p = 0.029). The majority of women (32/44) on anti-TNF therapy, either adalimumab or infliximab, continued to have some degree of exposure during the third trimester. Though not significant, multivariate analysis showed a trend towards a protective effect of anti-TNF therapy against developing preeclampsia if exposed during the third trimester (OR 0.39; 95% CI 0.14-1.12, p = 0.08). CONCLUSIONS: In this study, anti-TNF therapy exposure was higher in IBD patients who did not develop preeclampsia than in those who did. While not significant, there was a trend towards a protective effect of anti-TNF therapy against preeclampsia if exposed during the third trimester.

Artificial intelligence for polyp detection during colonoscopy: a systematic review and meta-analysis.

BACKGROUND: Artificial intelligence (AI)-based polyp detection systems are used during colonoscopy with the aim of increasing lesion detection and improving colonoscopy quality. PATIENTS AND METHODS: We performed a systematic review and meta-analysis of prospective trials to determine the value of AI-based polyp detection systems for detection of polyps and colorectal cancer. We performed systematic searches in MEDLINE, EMBASE, and Cochrane CENTRAL. Independent reviewers screened studies and assessed eligibility, certainty of evidence, and risk of bias. We compared colonoscopy with and without AI by calculating relative and absolute risks and mean differences for detection of polyps, adenomas, and colorectal cancer. RESULTS: Five randomized trials were eligible for analysis. Colonoscopy with AI increased adenoma detection rates (ADRs) and polyp detection rates (PDRs) compared to colonoscopy without AI (values given with 95 %CI). ADR with AI was 29.6 % (22.2 % - 37.0 %) versus 19.3 % (12.7 % - 25.9 %) without AI; relative risk (RR] 1.52 (1.31 - 1.77), with high certainty. PDR was 45.4 % (41.1 % - 49.8 %) with AI versus 30.6 % (26.5 % - 34.6 %) without AI; RR 1.48 (1.37 - 1.60), with high certainty. There was no difference in detection of advanced adenomas (mean advanced adenomas per colonoscopy 0.03 for each group, high certainty). Mean adenomas detected per colonoscopy was higher for small adenomas (≤ 5 mm) for AI versus non-AI (mean difference 0.15 [0.12 - 0.18]), but not for larger adenomas (> 5 - ≤ 10 mm, mean difference 0.03 [0.01 - 0.05]; > 10 mm, mean difference 0.01 [0.00 - 0.02]; high certainty). Data on cancer are unavailable. CONCLUSIONS: AI-based polyp detection systems during colonoscopy increase detection of small nonadvanced adenomas and polyps, but not of advanced adenomas.

Quality assurance of computer-aided detection and diagnosis in colonoscopy.

Recent breakthroughs in artificial intelligence (AI), specifically via its emerging sub-field "deep learning," have direct implications for computer-aided detection and diagnosis (CADe and/or CADx) for colonoscopy. AI is expected to have at least 2 major roles in colonoscopy practice-polyp detection (CADe) and polyp characterization (CADx). CADe has the potential to decrease the polyp miss rate, contributing to improving adenoma detection, whereas CADx can improve the accuracy of colorectal polyp optical diagnosis, leading to reduction of unnecessary polypectomy of non-neoplastic lesions, potential implementation of a resect-and-discard paradigm, and proper application of advanced resection techniques. A growing number of medical-engineering researchers are developing both CADe and CADx systems, some of which allow real-time recognition of polyps or in vivo identification of adenomas, with over 90% accuracy. However, the quality of the developed AI systems as well as that of the study designs vary significantly, hence raising some concerns regarding the generalization of the proposed AI systems. Initial studies were conducted in an exploratory or retrospective fashion by using stored images and likely overestimating the results. These drawbacks potentially hinder smooth implementation of this novel technology into colonoscopy practice. The aim of this article is to review both contributions and limitations in recent machine-learning-based CADe and/or CADx colonoscopy studies and propose some principles that should underlie system development and clinical testing.

Gastro-caval fistula after distal esophageal resection: a case report and review of the literature.

Peptic ulceration with fistula formation into the inferior vena cava is rare, difficult to diagnose, and associated with high mortality. The nonspecific signs and symptoms make diagnosis challenging, delaying optimal treatment. Although there have been reports on duodeno-caval fistulas, gastric communication with the inferior vena cava is very rare. We report the second case of a fatal gastro-caval fistula and performed a review of the literature on entero-caval fistulas to emphasize the importance of early suspicion and to understand the most common presentation, as well as the best diagnostic and treatment modalities of this rare pathology.

The important role of immunization in alcoholic and non-alcoholic chronic liver disease: A population-based study.

OBJECTIVE: To determine differences in frequencies of vaccine-preventable diseases between alcoholic liver disease (ALD) and non-alcoholic liver disease (NALD) patients. METHODS: This population-based cohort study used USA national inpatient sample ICD-9 codes from January 2012 to September 2015. Frequencies of admissions for ALD and NALD in patients with pneumococcal pneumonia, influenza, herpes zoster virus, varicella zoster virus, hepatitis A, hepatitis B, human papilloma virus, meningococcal meningitis, diphtheria, pertussis and tetanus were measured. Frequencies and patients' characteristics were compared for ALD and NALD using χ2 test and multivariate logistic regression analysis. RESULTS: There was no difference in admissions for hepatitis A and pneumococcal pneumonia between the ALD and NALD groups. There were fewer admissions for hepatitis B (1.17% vs 1.80%, odds ratio [OR] 0.64, P < 0.01), herpes zoster (0.12% vs 0.17%, OR 0.69, P < 0.01), influenza (0.16% vs 0.26%, OR 0.59, P < 0.01) and all others (0.005% vs 0.015%, OR 0.36, P = 0.01) in the ALD group than the NALD group. The extreme all patient refined-diagnosis related groups mortality risk was 15.24% in ALD and 7.77% in NALD admissions (P < 0.0001). CONCLUSIONS: The most frequent vaccine-preventable disease in both groups was hepatitis B. Patients with NALD had higher odds of admissions for hepatitis B, herpes zoster virus, influenza and other vaccine-preventable disease than ALD patients. However, the ALD group had a higher risk of mortality when admitted to hospital with a vaccine-preventable disease than the NALD group.

Vaccine-Preventable Diseases in Hospitalized Patients With Inflammatory Bowel Disease: A Nationwide Cohort Analysis.

BACKGROUND: Inflammatory bowel disease (IBD) entails a higher risk of infections, including those that could be prevented with immunizations. Current Advisory Committee on Immunization Practices and American College of Gastroenterology vaccine recommendations for patients with IBD are based on low levels of evidence. METHODS: We conducted a population-based descriptive cohort study using the US National Inpatient Sample ICD-9 codes from 2012 to 2015. We measured the frequency of patients with IBD who were admitted to the hospital with a vaccine-preventable disease (VPD). Frequencies and demographics were determined and compared between patients with IBD and patients without IBD. RESULTS: Of discharges, 596,485 (2.08%) were secondary to a VPD, and 7180 (1.2%) were found to have both a VPD and IBD (including Crohn disease and ulcerative colitis). The most common VPDs among patients with IBD were herpes zoster virus (HZV) (34.9%) and hepatitis B virus (31.6%), followed by influenza (22.1%). Pneumococcal pneumonia (9.1%) and hepatitis A virus (2.4%) were less common. Inpatients with IBD were twice as likely to have HZV when compared to non-IBD inpatients (odds ratios [OR] = 2.30 [95% CI, 2.06-2.58], P < 0.0001) This finding was consistent for every study year. Pneumococcal pneumonia [OR = 0.62 (95% CI, 0.52-0.74), P < 0.0001] and influenza [OR = 0.72 (95% CI, 0.63-0.81), P < 0.0001] were significantly lower in the IBD population. There was no difference for other VPDs. CONCLUSIONS: HZV was the most frequent VPD in IBD inpatients. Patients with IBD have a higher rate of hospital admissions with HZV and a lower rate of pneumococcal pneumonia and influenza admissions when compared with non-IBD patients. For other VPDs, patients with IBD have the same rate of admission as the general population.

Sevelamer-Associated Rectosigmoid Ulcers in an End-Stage Renal Disease Patient.

Sevelamer carbonate is a commonly prescribed anion-exchange resin administered orally to prevent hyperphosphatemia in patients with chronic kidney disease. We present a rare case of a 33-year-old man with end-stage renal disease and diabetic gastroparesis on sevelamer carbonate, who presented with hematochezia and was found to have rectosigmoid ulcers induced by sevelamer crystals. His hematochezia resolved after switching from sevelamer carbonate to lanthanum carbonate. Clinicians and pathologists must be aware of the possibility of drug-induced mucosal ulceration associated with sevelamer use as a potential etiology of a gastrointestinal bleed.

Adenoma recurrence after endoscopic mucosal resection: propensity score analysis of old and new colonoscopes and Sydney recurrence tool implementation.

BACKGROUND AND STUDY AIMS: Risk factors for colorectal adenoma recurrence after endoscopic mucosal resection (EMR) have been well documented. We assessed the efficacy of the newer 190 colonoscope versus the standard 180 colonoscope for complete resection of lateral spreading lesions. PATIENTS AND METHODS: A single-center, retrospective study of patients who underwent EMR with Olympus 180 or 190 colonoscopes from January 1, 2010 to September 30, 2016. We included patients with lesions ≥ 20 mm and surveillance colonoscopy (SC1) after index EMR. A propensity score approach with inverse probability weighting was used to control for potential confounders. A secondary aim was to identify risk factors for recurrence and assess the applicability of the Sydney EMR recurrence tool (SERT) by grading each lesion of our cohort and analyzing associations with recurrence. RESULTS: Two hundred ninety-one lesions met inclusion criteria for the study. Odds ratio (OR) for recurrence with the 190 colonoscope was 1.06 ( P  = .85). Adenoma size ( P  = .02) and use of argon plasma coagulation (APC; P  < .001) were risk factors for recurrence. Lesions with SERT scores > 0 had a higher recurrence risk during follow-up (32 % vs 21 %; OR 1.71; P  = .05). Lesions with SERT scores = 0 reached a plateau for recurrence at 12 and 18 months in Kaplan-Meier curves. CONCLUSIONS: The use of 190 colonoscopes did not measurably affect adenoma recurrence at SC1. Recurrence was associated with adenoma size, complementary APC for resection, and SERT scores > 0. Lesions with SERT scores = 0 that remain negative for recurrence at 18 months may return to routine surveillance.