Intake of B vitamins and the risk of developing islet autoimmunity and type 1 diabetes in the TEDDY study.

PURPOSE: The aim was to study the association between dietary intake of B vitamins in childhood and the risk of islet autoimmunity (IA) and progression to type 1 diabetes (T1D) by the age of 10 years. METHODS: We followed 8500 T1D-susceptible children born in the U.S., Finland, Sweden, and Germany in 2004 -2010 from the Environmental Determinants of Diabetes in the Young (TEDDY) study, which is a prospective observational birth cohort. Dietary intake of seven B vitamins was calculated from foods and dietary supplements based on 24-h recall at 3 months and 3-day food records collected regularly from 6 months to 10 years of age. Cox proportional hazard models were adjusted for energy, HLA-genotype, first-degree relative with T1D, sex, and country. RESULTS: A total of 778 (9.2) children developed at least one autoantibody (any IA), and 335 (3.9%) developed multiple autoantibodies. 280 (3.3%) children had IAA and 319 (3.8%) GADA as the first autoantibody. 344 (44%) children with IA progressed to T1D. We observed that higher intake of niacin was associated with a decreased risk of developing multiple autoantibodies (HR 0.95; 95% CI 0.92, 0.98) per 1 mg/1000 kcal in niacin intake. Higher intake of pyridoxine (HR 0.66; 95% CI 0.46, 0.96) and vitamin B12 (HR 0.87; 95% CI 0.77, 0.97) was associated with a decreased risk of IAA-first autoimmunity. Higher intake of riboflavin (HR 1.38; 95% CI 1.05, 1.80) was associated with an increased risk of GADA-first autoimmunity. There were no associations between any of the B vitamins and the outcomes "any IA" and progression from IA to T1D.  CONCLUSION: In this multinational, prospective birth cohort of children with genetic susceptibility to T1D, we observed some direct and inverse associations between different B vitamins and risk of IA.

Detecting potential outliers in longitudinal data with time-dependent covariates.

BACKGROUND: Outliers can influence regression model parameters and change the direction of the estimated effect, over-estimating or under-estimating the strength of the association between a response variable and an exposure of interest. Identifying visit-level outliers from longitudinal data with continuous time-dependent covariates is important when the distribution of such variable is highly skewed. OBJECTIVES: The primary objective was to identify potential outliers at follow-up visits using interquartile range (IQR) statistic and assess their influence on estimated Cox regression parameters. METHODS: Study was motivated by a large TEDDY dietary longitudinal and time-to-event data with a continuous time-varying vitamin B12 intake as the exposure of interest and development of Islet Autoimmunity (IA) as the response variable. An IQR algorithm was applied to the TEDDY dataset to detect potential outliers at each visit. To assess the impact of detected outliers, data were analyzed using the extended time-dependent Cox model with robust sandwich estimator. Partial residual diagnostic plots were examined for highly influential outliers. RESULTS: Extreme vitamin B12 observations that were cases of IA had a stronger influence on the Cox regression model than non-cases. Identified outliers changed the direction of hazard ratios, standard errors, or the strength of association with the risk of developing IA. CONCLUSION: At the exploratory data analysis stage, the IQR algorithm can be used as a data quality control tool to identify potential outliers at the visit level, which can be further investigated.

Associations of dietary patterns between age 9 and 24 months with risk of celiac disease autoimmunity and celiac disease among children at increased risk.

BACKGROUND: Higher gluten intake in childhood is associated with increased incidence of celiac disease autoimmunity (CDA) and celiac disease. It remains to be studied whether different dietary patterns independent of gluten intake contribute to the incidence. OBJECTIVES: This study aimed to explore associations of dietary patterns by age 2 y with risk of CDA and celiac disease in genetically susceptible children. METHODS: Data was used from 6726 participants at genetic risk of type 1 diabetes and celiac disease enrolled in the observational cohort, The Environmental Determinants of Diabetes in the Young (TEDDY) study. Children were annually screened for tissue transglutaminase autoantibodies (tTGAs) from age 2 y. Principal component analysis extracted dietary patterns, based on intake of 27 food groups assessed by 3-d food records at age 9 to 24 mo. The primary outcome was CDA (i.e., persistently tTGA-positive in at least 2 consecutive samples), and the secondary outcome was celiac disease. During follow-up to mean age 11.0 (standard deviation 3.6) y, 1296 (19.3%) children developed CDA, and 529 (7.9%) were diagnosed with celiac disease. Associations of adherence to dietary patterns (per 5-unit increase) with the study outcomes were estimated by Cox regression models adjusted for risk factors including gluten intake. RESULTS: At age 9 mo, a dietary pattern higher in the food groups vegetable fats and milk was associated with reduced risk of CDA (hazard ratio [HR]: 0.88; 95% confidence interval [CI]: 0.79, 0.98; P = 0.02). At 24 mo, a dietary pattern higher in the food groups wheat, vegetable fats, and juices, and lower in milk, meat, and oats at age 24 mo was associated with increased risk of CDA (HR: 1.18; 95% CI: 1.05, 1.33; P < 0.001) and celiac disease (HR: 1.24; 95% CI: 1.03, 1.50; P = 0.03). CONCLUSIONS: Dietary patterns in early childhood are associated with risk of CDA and celiac disease in genetically predisposed children, independent of gluten intake.

HLA Genotype and Probiotics Modify the Association Between Timing of Solid Food Introduction and Islet Autoimmunity in the TEDDY Study.

OBJECTIVE: To study the interaction among HLA genotype, early probiotic exposure, and timing of complementary foods in relation to risk of islet autoimmunity (IA). RESEARCH DESIGN AND METHODS: The Environmental Determinants of Diabetes in the Young (TEDDY) study prospectively follows 8,676 children with increased genetic risk of type 1 diabetes. We used a Cox proportional hazards regression model adjusting for potential confounders to study early feeding and the risk of IA in a sample of 7,770 children. RESULTS: Any solid food introduced early (<6 months) was associated with increased risk of IA if the child had the HLA DR3/4 genotype and no probiotic exposure during the 1st year of life. Rice introduced at 4-5.9 months compared with later in the U.S. was associated with an increased risk of IA. CONCLUSIONS: Timing of solid food introduction, including rice, may be associated with IA in children with the HLA DR3/4 genotype not exposed to probiotics. The microbiome composition under these exposure combinations requires further study.

Improving burnout and well-being among medicine residents: Impact of a grassroots intervention compared to a formal program curriculum.

BACKGROUND: With growing resident burnout, Accreditation Council for Graduate Medical Education issued new requirements for program interventions to optimize resident well-being. Little evidence exists on how to best teach resiliency to residents. This study assesses the impact of both a grassroots intervention and formal resiliency curriculum on resident burnout and well-being. MATERIALS AND METHODS: From November 2016 to August 2017, residents in a large Internal Medicine Residency Program participated in grassroots wellness interventions from the resident-led Gator Council in Gainesville, FL USA. From August 2017 to June 2018, residents participated in a formal program-driven resiliency curriculum. Wellness interventions included monthly morning reports, bimonthly workshops, and biannual noon conferences. Pre- and postintervention Maslach Burnout Inventory (MBI) and Physician Well-Being Index (PWBI) assessed the effect of both interventions on resident burnout and well-being. Statistical analyses used Student's t-test, Fisher's exact tests, and linear regression model. RESULTS: One hundred and twenty-two residents participated in grassroots interventions. One hundred and seventeen (87 residents, 35 students) participated in formal curriculum. Mean MBI scores for all three sections did not differ between pre -and postgrassroots intervention (emotional exhaustion [EE] P = 0.46; depersonalization [DP] P = 0.43; personal accomplishment [PA] P = 0.73]) or between pre- and postcurriculum (EE P = 0.20; DP P = 0.40; PA P = 0.51). Students scored higher burnout levels compared to residents in EE (P = 0.001) and PA (P = 0.02). Pre- versus postcurriculum PWBI scores did not differ among residents (P = 0.20), while PWBI scores improved among students (P = 0.01). CONCLUSIONS: This study found no improvement in resident burnout or well-being from a bottom-up and top-down approach. Our results imply the need for an early wellness curriculum to improve student well-being given their higher level of burnout. System-wide efforts are vital to combat physician burnout.

A systematic review of the quality of conduct and reporting of survival analyses of tuberculosis outcomes in Africa.

BACKGROUND: Survival analyses methods (SAMs) are central to analysing time-to-event outcomes. Appropriate application and reporting of such methods are important to ensure correct interpretation of the data. In this study, we systematically review the application and reporting of SAMs in studies of tuberculosis (TB) patients in Africa. It is the first review to assess the application and reporting of SAMs in this context. METHODS: Systematic review of studies involving TB patients from Africa published between January 2010 and April 2020 in English language. Studies were eligible if they reported use of SAMs. Application and reporting of SAMs were evaluated based on seven author-defined criteria. RESULTS: Seventy-six studies were included with patient numbers ranging from 56 to 182,890. Forty-three (57%) studies involved a statistician/epidemiologist. The number of published papers per year applying SAMs increased from two in 2010 to 18 in 2019 (P = 0.004). Sample size estimation was not reported by 67 (88%) studies. A total of 22 (29%) studies did not report summary follow-up time. The survival function was commonly presented using Kaplan-Meier survival curves (n = 51, (67%) studies) and group comparisons were performed using log-rank tests (n = 44, (58%) studies). Sixty seven (91%), 3 (4.1%) and 4 (5.4%) studies reported Cox proportional hazard, competing risk and parametric survival regression models, respectively. A total of 37 (49%) studies had hierarchical clustering, of which 28 (76%) did not adjust for the clustering in the analysis. Reporting was adequate among 4.0, 1.3 and 6.6% studies for sample size estimation, plotting of survival curves and test of survival regression underlying assumptions, respectively. Forty-five (59%), 52 (68%) and 73 (96%) studies adequately reported comparison of survival curves, follow-up time and measures of effect, respectively. CONCLUSION: The quality of reporting survival analyses remains inadequate despite its increasing application. Because similar reporting deficiencies may be common in other diseases in low- and middle-income countries, reporting guidelines, additional training, and more capacity building are needed along with more vigilance by reviewers and journal editors.

Improving Preventive Care for Women through a Provider Reminder Tool.

OBJECTIVE: To determine the association of utilization of health maintenance tables (HMTs) as a provider reminder tool within the electronic medical record with the completion of women's preventive health services. METHODS: Guidelines from the US Preventive Services Task Force and the Advisory Committee on Immunization Practices were used to create the HMT. The study sample consisted of female patients between 18 and 74 years of age who visited the University of Florida Internal Medicine Clinic at Medical Plaza between February 15, 2016 and June 24, 2016. We determined whether a reminder system was used for each visit and whether the following preventive health services were up to date: breast cancer screening, cervical cancer screening, and human papillomavirus vaccination. χ2 tests of independence were performed to compare the number of up-to-date preventive measures associated with each provider reminder type. RESULTS: We divided the visits into four groups based on the type of provider reminder used: the HMT, the computer-generated reminder .HM, simple annotation, and no reminder. Compared with .HM, no reminder, and all non-HMT, HMT utilization had a statistically significant positive association with the completion of breast and cervical cancer screening and human papillomavirus vaccination. The difference between the HMT and simple annotation groups did not achieve statistical difference, however. CONCLUSIONS: Despite well-established, evidence-based guidelines for screening tests and immunizations effective in reducing cancer-related morbidity and mortality, significant gaps in routine preventive care remain. The HMT may be a provider-friendly and cost-effective reminder tool to enhance the preventive health care of women.

Physician Mothers and Breastfeeding: A Cross-Sectional Survey.

Objectives: To explore infant-feeding intentions and behavior of physician mothers as well as their breastfeeding enablers and obstacles. Study Design: A cross-sectional online survey was conducted among female physicians with at least one biological child recruited through the Academy of Breastfeeding Medicine. The main outcomes were duration of exclusive breastfeeding (EBF) and duration of any breastfeeding (BFD). We determined predictors of EBF and BFD. Results: The 570 participants reported intention to breastfeed at least 12 months in 78.1% of cases. Breastfeeding rates were 97.8%, 85.5%, and 55.4% at birth, 6, and 12 months. EBF rates were 88.5%, 76.3%, and 40.9% at birth, 3, and 6 months. Younger participant age, breastfeeding discontinuation not due to work-related demands, and heightened maternal satisfaction with BFD were associated with longer EBF and BFD. EBF at birth, less maternal stress, availability of time to express milk, and collegial support were associated with longer EBF. Longer maternal BFD goal, longer maternity leave, existence of laws or regulations to support breastfeeding among working mothers, later child order, and lower level of maternal depression were associated with longer BFD. Conclusions: Maternal infant-feeding intentions and work-related factors both play important roles in physician mothers' infant-feeding behavior. Longer maternity leave, regulations to support breastfeeding among working mothers, and workplace support might significantly improve physician mothers' BFD.

Characteristics of Faculty at Risk of Leaving Their Medical Schools: An Analysis of the StandPoint™ Faculty Engagement Survey.

PURPOSE: This study seeks to identify the characteristics and attitudes of faculty in US medical colleges who are at risk of leaving their institution. METHODS: This research leverages data from the AAMC StandPoint Faculty Engagement Survey administered to 37,779 faculty representing 36 institutions participating during 2013-2016. Univariate and multivariable robust logistic regression models were used to assess predictors of the intent to leave based on the question: "Do you plan to leave this medical school in the next 1-2 years?". RESULTS: Thirty percent (n=5559/18,475) of faculty responded that they were considering leaving their institution. Thirty-one percent of female faculty vs 29% of male faculty expressed an intent to leave. At-risk faculty were likely to be at junior faculty rank and at their institutions for 6-15 years vs other time periods (OR=1.16; p≤0.001). Having an administrative title (OR=0.72; p≤0.001) and receiving formal mentorship (OR=0.65; p≤0.001) were protective. Finally, faculty answering "disagree" or "strongly disagree" to any one of these StandPoint Survey questions were at > 6 fold risk of expressing an intent to leave: 1) I am satisfied with my opportunities for professional development, 2) I feel appreciated by my supervisor, 3) My day-to-day activities give me a sense of accomplishment. CONCLUSION: Faculty expressing an intent to leave their institution have an identifiable profile. Top concerns of at-risk faculty relate to supervisory relationships and growth opportunities rather than compensation or governance. Institutional leaders should consider these factors in the development of a proactive strategy to retain talented faculty.

An Interprofessional Primary Care-Based Transition of Care Clinic to Reduce Hospital Readmission.

BACKGROUND: Hospital readmission is a major burden for patients, caregivers, and health systems. Some readmissions may be avoided through timely follow-up in a transition clinic with an interprofessional approach to care. METHODS: We prospectively evaluated a cohort of adults >18 years, n = 203, who are patients of an affiliated academic internal medicine clinic with University of Florida Health and discharged from the hospital between November 1, 2016, and May 1, 2017. We sought to determine if follow-up in an interprofessional transition-of-care (TCM) clinic after discharge was associated with a reduction in hospital readmission when compared to standard follow-up at 30, 60, and 90 days. RESULTS: Follow-up in the TCM clinic was associated with reduced odds of hospital readmission at 90 days by 60%, (odds ratio [OR]: 0.40, P = 0.044, 95% confidence interval [CI] 0.16-0.97). Although the clinic failed to demonstrate a statistically significant association between clinic follow-up and in readmission at 30 (OR: 0.66, P = 0.36, 95% CI 0.27-1.59) and 60 days (OR: 0.67, P = 0.31, 95% CI 0.31-1.47), fewer readmissions were seen in patients seen by the TCM clinic. CONCLUSIONS: A primary care nested interprofessional transition-of-care clinic was associated with a reduction in hospital readmission.

Survival trends of metastatic small intestinal neuroendocrine tumor: a population-based analysis of SEER database.

BACKGROUND: Incidence of small intestinal neuroendocrine tumors (SNETs) is increasing and they now comprise the most common types of small intestinal cancer. SNETs frequently present with distant metastasis. Significant uncertainty prevails with regards to the surgical management strategies in metastatic SNETs. Therefore, we aim to analyze survival trends in metastatic SNET patients stratified by type of surgical treatment. METHODS: We analyzed the data from the SEER database: Incidence - SEER 18 Regs Research Data + Hurricane Katrina Impacted Louisiana Cases, Nov 2016 Sub (1973-2014 varying). Relative survival rates (RSRs) and hazard ratios (HRs) were measured for patients diagnosed with metastatic SNET between 2000 and 2014. Treatment received was divided into two broad categories; surgical resection and no surgery and further subcategorized into local resection (LR) (surgery of the primary tumor only) and radical resection (RR) (surgery for primary tumor and metastasectomy). RESULTS: We identified 1,138 metastatic SNET cases. Median age was 61 years. Median survival was 41 months and 5 year RSR was 72%. Age >50 years (HR 2.10, P<0.001), poorly differentiated histology (HR 3.50, P<0.001) and tumor size >2 cm (HR 1.27, P=0.07), showed poor outcome. The group which did not receive any tumor directed surgery showed the worst survival (5 years RSR 45.30% vs. 76%, respectively for no surgery vs. surgery group, P<0.001). We found no significant difference in survival between LR and RR (HR 1.01, 95% CI: 0.73-1.40, P=0.92). Upon further stratification, surgery significantly improved survival on patients who were >50 years (HR 0.37), and for primary tumor location in the duodenum (HR 0.13). CONCLUSIONS: Surgery for the primary tumor (LR or RR) significantly improved 5-year survival even in the presence of distant metastasis irrespective of primary tumor size, grade, or histology. Poor prognostic factors include, age >50 years, duodenal primary, tumor size >2 cm, and poorly differentiated histology.

Small bowel stricture is associated with abnormal motility on the cine MRI sequence in patients with Crohn's disease.

PURPOSE: A multiphasic cine sequence performed during magnetic resonance enterography (MRE) has been shown to increase diagnostic accuracy of MRE demonstrating limited movement in inflamed intestine in patients with Crohn's disease (CD). Our aim was to confirm in our study population that intestinal inflammation was associated with decreased motility and determine if factors suggestive of complicated disease such as the presence of a stricture or fistula were associated with decreased motility on the MRE cine sequence. METHODS: This was a retrospective study of 59 patients (mean age 40.8 ±â€¯16.1) with Crohn's disease who had a small bowel lesion on MRE. Two gastrointestinal radiologists independently scored MRE findings using a qualitative, subjective scoring system. Univariate and multivariable ordered logistic regression models were used to evaluate the associations between cine sequence score, radiologic image findings, and clinical data. RESULTS: On univariate analysis, radiologic findings reflecting active inflammation, the presence of a stricture, and penetrating disease were associated with decreased motility. On multivariable analysis, hyper-enhancement, the presence of a comb sign, and global evidence of active inflammation remained associated with decreased motility. Of the factors suggesting complicated disease, the presence of stricture (Odds Ratio 0.40, 95% Confidence Interval 0.17-0.95, p-value 0.038) was associated with decreased motility. CONCLUSIONS: As previously shown, well-established radiologic findings of bowel inflammation were associated with decreased small bowel motility. In this study, we have added that the radiologic finding of a fixed stricture is also associated with decreased motility.

Effect of Treating Vitamin D Deficiency in Uncontrolled Type 2 Diabetes: A Randomized, Placebo-Controlled Study.

BACKGROUND: Literature increasingly supports the inverse relationship of vitamin D (VitD) level and type 2 diabetes (T2DM). Proposed protective mechanisms of VitD include its anti-inflammatory effects, increased insulin secretion via pancreatic ß-cell stimulation, and downregulation of parathyroid hormone levels. Interventional studies show mixed results of VitD therapy in prediabetic patients with VitD deficiency or diabetic patients with normal VitD levels. STUDY QUESTION: Does high-dose VitD replacement improve glycemic control and microalbuminuria (MAU) in uncontrolled T2DM and concurrent VitD deficiency? STUDY DESIGN: This placebo-controlled, double-blinded study randomized 30 subjects aged 30-65 years with an elevated HbA1c level of 7.5%-10% and a low total 25-hydroxyvitamin-D value of <20 ng/mL to either placebo (n = 16) or ergocalciferol 50,000 IU (n = 14) once weekly for 8 weeks then once monthly for 4 months. MEASURES AND OUTCOMES: Primary outcome was difference in HbA1c from baseline to month 6 between the VitD-intervention group and the placebo-controlled group. Secondary end points were differences in total 25-hydroxyvitamin-D and MAU. Paired t tests and linear mixed-effects models were used for statistical analysis. RESULTS: No significant differences were seen in HbA1c or MAU between baseline versus postintervention visits within the placebo group (HbA1c: 8.4% ± 0.2 vs. 8.1% ± 0.3, P = 0.088; MAU: 94.1 mg/g ± 43.9 vs. 45.9 mg/g ± 20.2, P = 0.152) and the intervention group (HbA1c: 8.8% ± 0.3 vs. 8.7% ± 0.4, P = 0.692; MAU: 167.8 mg/g ± 70.1 vs. 108.5 mg/g ± 39.9, P = 0.356). The difference between placebo-slope and intervention-slope was nonsignificant for MAU (ß = -0.1 mg/g ± 0.4, P = 0.835) but was significant for total 25-hydroxyvitamin-D (ß = 11.7 ng/mL ± 2.5, P ≤ 0.001). Greater HbA1c reduction occurred unexpectedly in the placebo group ((Equation is included in full-text article.)= -0.4% ± 0.2) than in the intervention group ((Equation is included in full-text article.)= -0.2% ± 0.4), although the difference in slopes was not significant (ß = 0.2% ± 0.4, P = 0.640). CONCLUSIONS: Our proof-of-concept study found no benefit of high-dose VitD therapy in glycemic control and MAU in uncontrolled T2DM and VitD deficiency. Post hoc analyses raise concerns for high-dose VitD therapy to delay glycemic improvement. Large-scale interventional trials are much needed in this patient population to substantiate our findings and elucidate VitD's mechanisms on glucose metabolism.

The role of a best practice alert in the electronic medical record in reducing repetitive lab tests.

BACKGROUND: The recommendations of the American Board of Internal Medicine Foundation's "Choosing Wisely®" initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests. OBJECTIVE: To assess the effectiveness of an electronic medical record Best Practice Alert (BPA or "pop up") intervention aimed at reducing duplicate laboratory tests and hospital costs. DESIGN: Comparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention. SETTING: University of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014-2017. INTERVENTION: The electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the "ordering time", "collecting time", "resulting time", and the result itself. MAIN OUTCOME MEASURES: Percentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student's t-test and beta-binomial models were used to analyze the data. RESULTS: Results from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period. CONCLUSIONS: The present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

Safety and rate of delayed adverse events with lumen-apposing metal stents (LAMS) for pancreatic fluid collections: a multicenter study.

Background and study aims Endoscopic drainage with dedicated lumen-apposing metal stents (LAMS) is routinely performed for symptomatic pancreatic fluid collections (PFCs), walled-off necrosis (WON) and pseudocyst (PP). There has been increasing concern regarding delayed adverse events associated with the indwelling LAMS.  Patients and methods Multicenter retrospective analysis of consecutive patients who underwent endoscopic ultrasound (EUS)-guided LAMS placement for PFC from January 2010 to May 2017. Main outcomes included: (1) resolution of the PFC, (2) rate of delayed adverse events at follow-up, and (3) predictors of treatment failure and delayed adverse events on logistic regression. Results A total of 122 patients (mean age 50.9 years, 68 % male) underwent LAMS insertion for 64 WON (98.4 %) and 58 PP (98.3 %). PFC mean size was 10.6 cm. PFC resolution was significantly lower for WON (62.3 %) vs. PP (96.5 %) ( P  < 0.001) on imaging at a median of 4 weeks. Stent occlusion was identified in 18 (29.5 %) and 10 (17.5 %) patients with WON and PP, respectively ( P  = 0.13). There were no cases of delayed bleeding or buried stent on follow-up endoscopy. Use of electrocautery-enhanced LAMS was the only factor associated with treatment failure of WON (OR = 13.2; 95 % ci: 3.33 - 51.82, P  = 0.02) on logistic regression. There were no patient, operator, or procedure-related factors predictive of stent occlusion. Conclusions EUS-guided LAMS for PFC is associated with a low incidence of delayed adverse events. While nearly all PPs resolve at 4 weeks permitting LAMS removal shortly thereafter, many WON persist, with use of electrocautery-enhanced LAMS being the sole predictor of treatment failure.

What a medical school chair wants from the dean.

Economic pressure has led the evolution of the role of the medical school dean from a clinician educator to a health care system executive. In addition, other dynamic requirements also have likely led to changes in their leadership characteristics. The most important relationship a dean has is with the chairs, yet in the context of the dean's changing role, little attention has been paid to this relationship. To frame this discussion, we asked medical school chairs what characteristics of a dean's leadership were most beneficial. We distributed a 26-question survey to 885 clinical and basic science chairs at 41 medical schools. These chairs were confidentially surveyed on their views of six leadership areas: evaluation, barriers to productivity, communication, accountability, crisis management, and organizational values. Of the 491 chairs who responded (response rate =55%), 88% thought that their dean was effective at leading the organization, and 89% enjoyed working with their dean. Chairs indicated that the most important area of expertise of a dean is to define a strategic vision, and the most important value for a dean is integrity between words and deeds. Explaining the reasons behind decisions, providing good feedback, admitting errors, open discussion of complex or awkward topics, and skill in improving relations with the teaching hospital were judged as desirable attributes of a dean. Interestingly, only 23% of chairs want to be a dean in the future. Financial acumen was the least important skill a chair thought a dean should hold, which is in contrast to the skill set for which many deans are hired and evaluated. After reviewing the literature and analyzing these responses, we assert that medical school chairs want their dean to maintain more traditional leadership than that needed by a health care system executive, such as articulating a vision for the future and keeping their promises. Thus, there appears to be a mismatch between what medical school chairs perceive they need from their dean and how the success of a dean is evaluated.

Community-based diagnosis of non-communicable diseases and their risk factors in rural and urban Haiti: a cross-sectional prevalence study.

OBJECTIVE: To estimate the prevalence of hypertension, diabetes and chronic kidney disease and their risk factors in a rural and urban region of Haiti. SETTING AND PARTICIPANTS: Community health workers enumerated 2648 households (909 rural and 1739 urban) via a multistage cluster random sampling method from July 2015 to May 2016, completed 705 rural and 1419 urban assessments for adults aged 25-65 years. OUTCOME MEASURES: We performed a WHO STEPS based questionnaire, measured two blood pressure values, weight, height, abdominal circumference and point of care test finger stick blood sample for haemoglobin A1c, creatinine and cholesterol (total, high density lipoprotein (HDL) and triglycerides). RESULTS: After adjusting for age and sex, the overall prevalence rates of hypertension, diabetes and chronic kidney disease were 15.6% (±2.93%), 19.7% (±1.57%) and 12.3% (±2.72%), respectively. Of the three non-communicable diseases (NCDs), only diabetes showed a significant difference between rural and urban sites (p=0.000), with the rural site (23.1%) having a higher prevalence than the urban site (16.4%). When comparing male and female participants, females were significantly more likely than males to have an NCD (p≤0.011). Females had a higher prevalence of most of the risk factors when compared with males. The urban location had a higher prevalence than the rural location for four risk factors that showed a significant difference between location (p≤0.037). CONCLUSIONS: Women in Haiti had significantly higher prevalence rates of most NCDs and risk factors than men, and urban populations frequently, but not always, had higher rates of NCDs risk factors than the rural population. Further, it was shown that using point of care blood tests combined with community health workers, it is feasible to screen for NCDs and risk factors in remote areas which otherwise have limited access to healthcare.

Bronchoalveolar lavage (BAL) cells in idiopathic pulmonary fibrosis express a complex pro-inflammatory, pro-repair, angiogenic activation pattern, likely associated with macrophage iron accumulation.

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease of unknown cause characterized by alveolar epithelial damage, patchy interstitial fibrosis and diffuse microvascular abnormalities. In IPF, alveolar clustering of iron-laden alveolar macrophages-a common sign of microhemorrhage, has been associated with vascular abnormalities and worsening of pulmonary hypertension. As iron-dependent ROS generation has been shown to induce unrestrained macrophage activation in disease models of vascular damage, we explored alveolar macrophage activation phenotype in IPF patients (n = 16) and healthy controls (CTR, n = 7) by RNA sequencing of bronchoalveolar lavage (BAL) cells. The frequencies of macrophages in BAL cells were 86+4% and 83.4+8% in IPF and CTR groups, respectively (p-value = 0.41). In IPF patients, BAL cells showed increased iron-dependent ROS generation (p-value<0.05 vs CTR). Gene expression analysis showed overrepresentation of Gene Ontology processes/functions and KEGG pathways enriched in upregulated M1-type inflammatory (p-value<0.01), M2-type anti-inflammatory/tissue remodeling (p-value<0.0001), and MTPP-type chronic inflammatory/angiogenic (p-value<0.0001) chemokine and cytokine genes. The ex vivo finding was confirmed by the induction of iron-dependent ROS generation and chemokine/cytokine overexpression of Ccl4, Cxcl10 (M1), Il1rn (M2), Cxcl2, and Cxcl7 (MTPP) in MH-S murine immortalized alveolar macrophages exposed to ferric ammonium citrate in culture (p-value<0.05 vs CTR). The data show alveolar macrophage expression of a pro-inflammatory, tissue remodeling and angiogenic complex activation pattern, suggesting that iron accumulation may play a role in macrophage activation.

Life after per-oral endoscopic myotomy: long-term outcomes of quality of life and their association with Eckardt scores.

BACKGROUND AND AIMS: The clinical efficacy of per-oral endoscopic myotomy (POEM) has been commonly established by reduction in the Eckardt score (<3) after the procedure. However, achalasia can lead to significant impairment in the patient's quality of life that may go beyond the 4 classic achalasia symptoms as measured by the Eckardt score. The aims of our study were to evaluate the effect of POEM on short-term and long-term health-related quality of life (HRQOL) and to assess the association between HRQOL and Eckardt scores. METHODS: Single-center, prospective, cohort study of consecutive POEMs during a 3-year period. Eckardt and HRQOL scores as measured by the short-form survey questionnaire (SF-36) were obtained at baseline and at various intervals after POEM. Comparison of the mean scores was described by using univariate linear regression. The association between Eckardt scores and HRQOL were calculated by using a linear, mixed-model analysis. RESULTS: POEM was performed in 143 consecutive patients (54% male; mean ± standard deviation [SD] age, 56.9 ± 17.9 years). At long-term follow-up (mean 16.4 months, range 12-40), both the HRQOL baseline mental and physical component scores improved significantly from 61.5 ± 2.2 to 71.2 ± 3.6; (P < .021) and from 55.8 ± 2.2 to 63.6 ± 3.3; (P = < .034), respectively. Mixed-model analysis showed a significant association between Eckardt and all HRQOL scores (P < .001). CONCLUSION: POEM improved all dimensions of HRQOL as measured by the SF-36 survey at both short-term and long-term follow-up. A strong association was seen between Eckardt scores and all HRQOL domains. Further studies with the use of disease-specific HRQOL instruments are warranted. (Clinical trial registration number: NCT01832779.).

Effective communication of cross-sectional imaging findings in Crohn's disease: comparing conventional EMR reporting to a published scoring system.

PURPOSE: The purpose of the article is to compare information regarding small bowel lesions in Crohn's disease (CD) patients communicated by a published scoring system and radiology reports from electronic medical record (EMR) of cross-sectional abdominal imaging. METHODS: Two gastrointestinal radiologists (reference readers) blinded to EMR reports scored cross-sectional imaging exams using a published scoring system. Investigators compared EMR and radiologist scores based on the mentioned findings and severity documentation of each variable. Statistical analysis involved means and difference in proportions and logistic regression modeling. RESULTS: Seventy-three CD patients, with average age 40.6 years (± SD 14.4), having 80 small bowel lesions on imaging were included. EMR reports reliably mentioned within the consensus score included thickness (79%, p = 0.000), enhancement (70%, p = 0.000), active inflammation (86%, p = 0.000), perienteric fluid (82%, p = 0.000), and presence of stricture (62%, p = 0.002). Minimal lumen diameter (19%, p = 0.000), comb sign (19%, p = 0.000), lesion length (57%, p = 0.06), and fistula (50%, p = 1.0) were reported less often. There was a strong association between the EMR and scoring scale in noting severity of active inflammation (88%, p = 0.000), perienteric fluid (76%, p = 0.000), and internal fistula (71%, p = 0.000). The proportion matching severity values of comb sign and minimal lumen were 24% and 21%, respectively (p = 0.000). Severity matches for stricture were less likely among the non-GI radiologists (odds ratio = 0.33, SE = 0.168, p = 0.029). The odds of reporting stricture and fistula severity were 3.6 and 5.7, respectively, on MRE. CONCLUSIONS: Findings and severity of inflammation were communicated consistently. Stricture severity including minimal luminal diameter, was less reliably reported, though its prognostic significance impacts management.