EUS-guided versus percutaneous liver biopsy: A prospective randomized clinical trial.

Background and Objectives: Prospective studies comparing EUS-guided liver biopsy (EUS-LB) to percutaneous LB (PC-LB) are scarce. We compared the efficacy and safety of EUS-LB with those of PC-LB in a prospective randomized clinical trial. Methods: Between 2020 and 2021, patients were enrolled and randomized (1:1 ratio). The primary outcome was defined as the proportion of patients with ≥11 complete portal tracts (CPTs). The sample size (n = 80) was calculated based on the assumption that 60% of those in the EUS-LB and 90% of those in the PC-LB group will have LB with ≥11 CPTs. The secondary outcomes included proportion of patients in whom a diagnosis was established, number of CPTs, pain severity (Numeric Rating Scale-Pain Intensity), duration of hospital stay, and adverse events. Results: Eighty patients were enrolled (median age, 53 years); 67.5% were female. Sixty percent of those in the EUS-LB and 75.0% of those in the PC-LB group met the primary outcome (P = 0.232). The median number of CPTs was higher in the PC-LB (17 vs 13; P = 0.031). The proportion of patients in whom a diagnosis was established was similar between the groups (92.5% [EUS-LB] vs 95.0% [PC-LB]; P = 1.0). Patients in the EUS-LB group had less pain severity (median Numeric Rating Scale-Pain Intensity, 2.0 vs 3.0; P = 0.003) and shorter hospital stay (2.0 vs 4.0 hours; P < 0.0001) compared with the PC-LB group. No patient experienced a serious adverse event. Conclusions: EUS-guided liver biopsy was safe, effective, better tolerated, and associated with a shorter hospital stay.

Perigastric Hematoma Masquerading as a Gastric Tumor.

Perigastric and intramural gastric hematomas rarely occur, with most cases associated with trauma, coagulopathy, and peptic ulcer disease. Furthermore, hematomas in the upper gastrointestinal tract are commonly located in the esophagus and duodenum. In this case report, we describe a hematoma masquerading as a gastric tumor on esophagogastroduodenoscopy (EGD) in a 54-year-old male presenting with melena. Initial computed tomography (CT) imaging suggested gastrointestinal stromal tumor (GIST) as the probable cause. We performed endoscopic ultrasound (EUS) with findings consistent with a perigastric hematoma, which aligned with the patient's diagnosis of splenic vein thrombosis (SVT) and numerous collateral vessels communicating with the hematoma. Interventional radiology (IR) was consulted for further management, although we ultimately chose a conservative approach.

The Attending of the Day ("The Pretending"): An Exercise in Autonomy.

Background As regulations governing appropriate resident supervision increase, it has become increasingly difficult to provide residents with the appropriate level of autonomy during their training years. The "Attending of the Day" describes an experiential teaching method that provides a balance between learners' autonomy and appropriate supervision. Methodology Each day one member of the inpatient team is selected as the "Attending of the Day," or "The Pretending." She or he then performs the typical duties of the teaching faculty, from medical decision-making regarding patient care to educating other team members during rounds. "The Pretending" is directly supervised by the clinical faculty. Results Using the grounded theory methodology, we analyzed 935 anonymous evaluations from students and residents over 14 years, leading to the identification of the following three major themes: created an enabling learning environment, provided autonomy, and improved confidence. These results led to the inclusion of the technique as part of the Back to Bedside initiative, which was rated as an essential tool in building confidence and autonomy by 75% of the participants in the 2018 Accreditation Council for Graduate Medical Education's Back to Bedside residents' well-being survey. Recently, the Jacobs School of Medicine launched the Moments of Excellence in Education: Recognition and Inspiration (MEE:RI) program which gives students a way to recognize exemplary moments of teaching they encounter. The "Attending of the Day" method received recognition as a transformative experience in students' medical education. Conclusions The "Attending of the Day" is the first innovative experiential learning technique that allows learners of all levels in both Undergraduate Medical Education (UME) and Graduate Medical Education (GME) to practice and assess autonomy. This innovation suggests that residents and students are looking for opportunities to challenge themselves. "The Pretending" allows them to experience those challenges in an empowering learning environment while they gradually build their confidence on the path to achieving progressive autonomy.

Severe Cholestatic Drug-Induced Liver Injury With Cephalosporin Use.

Drug-induced liver injury (DILI) is a phenomenon that occurs with nearly all classes of medications. Cholestatic DILI represents a fraction of these cases and can present as bland cholestasis, cholestatic hepatitis, secondary sclerosis cholangitis, and vanishing bile duct syndrome. Risk factors have been identified for cholestatic DILI, including older age, genetic determinants, and certain medications such as amoxicillin-clavulanate. Here, we describe a complicated case of severe cholestatic DILI secondary to cephalosporin use. A 27-year-old female presented to the hospital initially with fever and abdominal pain for four weeks after an emergency C-section for pre-eclampsia and hemolysis, elevated liver enzymes, lowered platelets (HELLP) syndrome. She was found to have a retroperitoneal abscess and underwent bilateral drain placement. She was initially started on cefazolin, and then coverage was broadened to cefepime. Shortly after, alkaline phosphatase (ALP) rose and peaked at 3498 IU/L, with aspartate aminotransferase (AST) and alanine transaminase (ALT) elevated at 274 IU/L and 122 IU/L, respectively. Extensive testing for secondary causes and a liver biopsy were consistent with DILI. Liver enzymes down-trended with the cessation of cefepime. This case report highlights that prompt recognition of the culprit medication is paramount to recovering normal liver function.

Deprescribing Proton Pump Inhibitors in an Academic, Primary Care Clinic: Quality Improvement Project.

GOAL: The goal of this study was to reduce the percentage of inappropriately prescribed proton pump inhibitors (PPIs) in patients aged 50 and older from 80% (baseline) to 60% within 12 months in an academic, internal medicine clinic. BACKGROUND: The use of PPIs has increased drastically worldwide. Internal medicine clinic patients had inappropriate use of PPIs for an average of 4 to 5 years. STUDY: A multidisciplinary quality improvement team used the Plan-Do-Study-Act Model of health care improvement and performed a root cause analysis to identify barriers to inappropriate use of PPIs. The outcome measure was the percentage of patients inappropriately prescribed PPI. Process measures were completion rates of PPI risk assessment and esophagogastroduodenoscopy. Interventions included the creation of customized electronic health record templates and education to providers and patients. Analysis was performed using monthly statistical process control charts. RESULTS: The average rate of PPI discontinuation was 51.1% (n=92/180), which corresponds to 30.0% inappropriate PPI usage within 12 months. The mean PPI discontinuation rate in the 1-year prestudy, study and 6 months poststudy period was 2.0%, 32.0%, and 49.7%, respectively. The mean esophagogastroduodenoscopy completion rate was 49.8% from the baseline of <30%. CONCLUSIONS: We achieved a statistically significant and sustainable reduction of inappropriate PPI use to 30% from the baseline rates of 80% and surpassed our goal within 12 months. This quality improvement was unique as no pharmacy personnel was utilized in this process. The multifaceted strategies in a safety-net internal medicine clinic resulted in successful deprescribing of PPI and can be replicated in other setting.

Improving hepatitis C screening and diagnosis in patients born between 1945 and 1965 in a safety-net primary care clinic.

Individuals born between 1945-1965 represent 81% of all persons chronically infected with hepatitis C virus (HCV) in the USA and are largely unaware of their positive status. The baseline HCV screening rate in this population in an academic internal medicine clinic at a US hospital was less than 3.0%. The goal was to increase the rate of HCV screening in patients born between 1945 and 1965 to 20% within 24 months. The quality improvement team used the Plan Do Study Act Model. Outcome measures included HCV antibody screening, HCV RNA positive rate and linkage to hepatology care. Process measures included HCV antibody order and completion rates. The quality improvement team performed a root cause analysis and identified barriers for HCV screening and linkage to care. The key elements of interventions included redesigning nursing workflow, use of health information technology and educating patients, physicians and nursing staff about HCV. The HCV screening rate was 30.3% (391/1291) within 24 months. The HCV antibody positive rate was 43.5% (170/391), and HCV RNA positive rate was 95.3% (162/170). HCV infection was diagnosed in 12.5% (162/1291) of patients or 41.4% (162/391) of the screened population. Of those positive, 70% (114/162) were linked to hepatology care within the 24-month project timeframe. Eighty percent of patients seen by a hepatologist were treated with direct-acting antivirals agents. The HCV screening rate was sustained at 25.4% during the post-project 1-year period. Engagement of a multidisciplinary team and education to patients, physicians and nursing staff were the key drivers for success.

Faecal immunochemical testing implementation to increase colorectal cancer screening in primary care.

Colorectal cancer (CRC) is the second leading cause of cancer death in USA, and CRC screening remains suboptimal. The aim of this quality improvement was to increase CRC screening in the internal medicine clinic (IMC) patients, between the ages of 50-75 years, from a baseline rate of 50%-70% over 12 months with the introduction of faecal immunochemical test (FIT) testing. We used the Plan-Do-Study-Act (PDSA) method and performed a root cause analysis to identify barriers to acceptance of CRC screening. The quality improvement team created a driver diagram to identify and prioritise change ideas. We developed a process flow map to optimise opportunities to improve CRC screening. We performed eight PDSA cycles. The major components of interventions included: (1) leveraging health information technology; (2) optimising team work, (3) education to patient, physicians and IMC staff, (4) use of patient navigator for tracking FIT completion and (5) interactive workshops for the staff and physicians to learn motivational interview techniques. The outcome measure included CRC screening rates with either FIT or colonoscopy. The process measures included FIT order and completion rates. Data were analysed using a statistical process control and run charts. Four hundred and seven patients visiting the IMC were offered FIT, and 252 (62%) completed the test. Twenty-two (8.7%) of patients were FIT positive, 14 of those (63.6%) underwent a subsequent diagnostic colonoscopy. We achieved 75% CRC screening with FIT or colonoscopy within 12 months and exceeded our goal. Successful strategies included engaging the leadership, the front-line staff and a highly effective multidisciplinary team. For average-risk patients, FIT was the preferred method of screening. We were able to sustain a CRC screening rate of 75% during the 6-month postproject period. Sustainable annual FIT is required for successful CRC screening.