Impact of a computer-based teaching module on characterization of diminutive colon polyps by using narrow-band imaging by non-experts in academic and community practice: a video-based study.

BACKGROUND: Experts can accurately characterize the histology of diminutive polyps with narrow-band imaging (NBI). There are limited data on the performance of non-experts. OBJECTIVE: To assess the impact of a computer-based teaching module on the accuracy of predicting polyp histology with NBI by non-experts (in academics and community practice) by using video clips. DESIGN: Prospective, observational study. SETTING: Academic and community practice. PARTICIPANTS: A total of 15 gastroenterologists participated-5 experts in NBI, 5 non-experts in academic practice, and 5 non-experts in community practice. INTERVENTION: Participants reviewed a 20-minute, computer-based teaching module outlining the different NBI features for hyperplastic and adenomatous polyps. MAIN OUTCOME MEASUREMENTS: Performance characteristics in characterizing the histology of diminutive polyps with NBI by using short video clips before (pretest) and after (posttest) reviewing the teaching module. RESULTS: Non-experts in academic practice showed a significant improvement in the sensitivity (54% vs 79%; P < .001), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 69%; P < .001) in the posttest. Non-experts in community practice had significantly higher sensitivity (58% vs 75%; P = .004), specificity (76% vs 90%; P = .04), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 72%; P < .001) in the posttest. Performance of experts in NBI was significantly better than non-experts in both academic and community practice. LIMITATIONS: Selection bias in selecting good quality videos. Performance not assessed during live colonoscopy. CONCLUSION: Academic and community gastroenterologists without prior experience in NBI can achieve significant improvements in characterizing diminutive polyp histology after a brief computer-based training. The durability of these results and applicability in everyday practice are uncertain.

The utility of lower endoscopic ultrasound-guided fine needle aspiration for the diagnosis of benign and malignant pelvic diseases.

BACKGROUND: The utility of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of pelvic masses has been suggested but limited data are available in the literature regarding its diagnostic accuracy. GOALS: To report our institutional experience with EUS-FNA for the diagnosis of a variety of pelvic diseases. METHODS: Patients who were referred for the evaluation of pelvic lesions using lower EUS-FNA were included in this retrospective analysis if they had available surgical pathology (obtained after EUS) which was considered the gold standard against which the EUS-FNA findings would have been compared. The diagnostic accuracy of EUS-FNA for pelvic masses was analyzed and any early or late complications after the procedure were reported. A pelvic mass was defined in the study as any mass seen with an imaging modality in the pelvic area including those involving the colonic wall. RESULTS: Twenty patients had EUS-FNA followed by surgery for whom FNA cytology and surgical pathology findings were available. EUS-FNA reached the correct diagnosis in 19 out of 20 patients, whereas for the missing 1 malignant lymph node wherein FNA revealed benign cytology, surgical specimen confirmed metastatic colon cancer. The sensitivity and specificity of EUS-FNA were 90% and 100%, respectively, with positive and negative predictive values of 100% and 90%, respectively. No early or late complications were encountered with this procedure for the sampling of cystic and noncystic masses. CONCLUSIONS: EUS-FNA has excellent diagnostic accuracy for pelvic masses. It represents a safe procedure with excellent yield and thus may be used as a first line modality for the evaluation and diagnosis of pelvic masses within its reach.

Financial Attitudes and Behaviors of Internal Medicine and Internal Medicine-Pediatrics Residents.

BACKGROUND: Residents graduate from medical school with increasing levels of debt and also may possess poor financial knowledge and practices. Prior studies have assessed resident financial knowledge and interest in financial education, yet additional information regarding their attitudes about personal finance and financial planning could be essential for the development of relevant curricula. OBJECTIVE: We assessed baseline financial attitudes and planning behaviors of internal medicine and internal medicine-pediatrics residents in 3 geographically diverse academic programs. METHODS: A modified version of the Financial Industry Regulatory Authority National Financial Capability survey was administered anonymously to residents in 3 programs in spring 2017. Outcomes included levels of educational debt, positive financial planning behaviors, perception of finances and debt, and education about personal finance. RESULTS: Response rate was 62% (184 of 298). Rates of educational debt were high, with 81% (149 of 184) of respondents reporting educational debt, and the majority owing more than $100,000. Residents' financial practices were variable, and residents could be grouped into 1 of 3 categories-concerned-engaged, concerned-unengaged, and unconcerned-unengaged-based on their engagement with debt and financial management. Residents with high debt (> $250,000) had a bimodal distribution of respondents who strongly agreed and those who strongly disagreed they were concerned about debt. CONCLUSIONS: Resident financial attitudes and practices are variable, ranging from highly engaged residents actively managing their financial wellness to unengaged residents who have low concern, despite high educational debt.

Gastroparesis secondary to a demyelinating disease: a case series.

BACKGROUND: Gastroparesis has a number of etiologies. The main ones are secondary to a complication from diabetes mellitus, related to post vagotomy or post gastric surgical resections, or idiopathic when the etiology is unclear. Gastroparesis secondary to a demyelinating disease of the brain is unusual. CASE PRESENTATION: A 22-year-old woman was referred for acute onset of intractable nausea and vomiting. She also had cerebellar deficits, dysphagia and paresthesias. Magnetic resonance imaging (MRI) of the brain revealed an isolated area of demyelination in the medullary region. Another 24-year-old woman had a similar presentation with right hemiplegia and MRI of the brain revealed a distal medullary region. Both these patients had an abnormal gastric emptying test. Gastroparesis and neurological deficits improved with intravenous corticosteroids. While the former patient has had no further recurrences, the latter patient developed multiple sclerosis within three months of presentation. CONCLUSION: A demyelinating disease is a rare cause gastropareis, but should be suspected when symptoms of gastroparesis are associated with neurological deficits. MRI might help in the diagnosis and intravenous coriticosteroids can address the underlying disease process and improve gastric emptying, especially when used early during the course of the disease.

Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Lesions: A Systematic Review of Technical and Procedural Variables.

Endoscopic ultrasound (EUS)-guided tissue acquisition has emerged over the last decade as an invaluable diagnostic tool in approaching the different pancreatic lesions. Given the safety and minimal invasiveness of this approach combined with the high diagnostic yield, it became the standard of care when dealing with different pancreatic pathologies. However, some variables regarding this procedure remain not fully understood. These can influence the diagnostic yield of the procedure and include the presence of the on-site cytopathologist, the type and size of the needle used as well as obtaining aspiration versus core biopsy, the number of passes and the sampling technique, and the role of suction and stylet use among others. We performed a comprehensive literature search using PubMed, Google Scholar, and Embase for studies that assessed these variables. Eligible studies were analyzed using several parameters such as technique and procedure, with the aim of reviewing results from an evidence-based standpoint.

Groove Pancreatitis: A Rare form of Chronic Pancreatitis.

CONTEXT: Groove pancreatitis is a rare form of chronic pancreatitis affecting the "groove" of the pancreas among the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are associations with long-term alcohol abuse, smoking, peptic ulcer disease, heterotopic pancreas, gastric resection, biliary disease, and anatomical or functional obstruction of the minor papilla. The diagnosis can be challenging. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography are the preferred imaging modalities. The treatment of choice is conservative although surgical intervention can sometimes be required. CASE REPORT: A 57-year-old male with a history of human immunodeficiency virus and hepatitis B presented with 4 days of epigastric pain. Abdominal exam revealed absent bowel sounds and epigastric tenderness. He had a creatinine of 1.72 mg/dL, potassium of 2.9 mmol/L, and a normal lipase level of 86 U/L. Liver enzymes and total bilirubin were normal. Computed tomography abdomen showed high-grade obstruction of the second portion of the duodenum without any obvious mass. An esophagogastroduodenoscopy showed a mass at the duodenal bulb causing luminal narrowing, with biopsies negative for malignancy. Magnetic resonance imaging revealed a mass in the region of the pancreatic head and descending duodenum. EUS revealed a 3 cm mass in the region of pancreatic head with irregular borders and no vascular invasion. Fine needle aspiration (FNA) was nondiagnostic. The patient then underwent a Whipple's procedure. Pathology of these specimens was negative for malignancy but was consistent with para-duodenal or groove pancreatitis. CONCLUSION: The low incidence of groove pancreatitis is partly due to lack of familiarity with the disease. Groove pancreatitis should be considered in the differential for patients presenting with pancreatic head lesions and no cholestatic jaundice, especially when a duodenal obstruction is present, and neither duodenal biopsies nor pancreatic head FNA confirm adenocarcinoma.

Barrett's esophagus.

PURPOSE OF REVIEW: Barrett's esophagus continues to be a popular topic among clinicians and researchers alike. Population based studies have finally been undertaken to better identify subset populations at high risk of developing Barrett's esophagus, and possible better tolerated alternatives to standard endoscopy for cost-effective screening. In addition, several studies over the past year have marked a transition from identifying those with Barrett's esophagus and in need of intensive surveillance, to an increasing number of novel treatment therapies that are now primed to move from experimental protocols to clinical practice. RECENT FINDINGS: Obesity's role as a risk factor for the development of Barrett's esophagus continues to be better defined. Various disorders affecting the motility of the gastrointestinal tract, such as celiac sprue and scleroderma, and their relationship with Barrett's esophagus development are becoming more widely recognized. The use of endoscopic mucosal resection and photodynamic therapy for treatment of dysplastic Barrett's esophagus continues to gain increased acceptance, with an additional wealth of supportive data for its effectiveness becoming available. SUMMARY: The past year has brought many advances in the epidemiology and endoscopic treatment of those with Barrett's esophagus. Clinicians will benefit from this review of these advances to ensure better patient outcomes.

Barrett's esophagus.

PURPOSE OF REVIEW: Significant advances have been made over the past year to identify individuals with Barrett's esophagus, who are at increased risk of malignant transformation. We summarize some of the important advances in that regard including: improved understanding in areas of epidemiology of those with Barrett's esophagus, identification of the pathways responsible for dysplastic and metaplastic development, selection of patient populations who would most benefit from surveillance protocols, and identification of biomarkers signifying progression of metaplastic changes. RECENT FINDINGS: Barrett's esophagus is being better recognized in patients presenting with extra-esophageal symptoms of gastroesophageal reflux such as chronic cough and asthma. Recent reports from some surgical series further suggest the importance of gastric and even duodenal reflux in the etiology of esophageal metaplastic development. In vitro experiments using acidic environments, to stimulate MAPK pathways, suggest an etiology for increased COX-2 expression. There appears to be a select group of individuals with familial predilection for the development of Barrett's esophagus. Retrospective studies continue to show apparent survival benefit in individuals with Barrett's esophagus undergoing surveillance endoscopy. Endoscopic ablative therapy may provide clinicians an attractive alternative to surgical resection in individuals with high-grade esophageal dysplasia and early adenocarcinoma. SUMMARY: The past year has brought many advances in the epidemiology, pathogenesis, surveillance, and treatment of those with Barrett's esophagus. Clinicians will benefit from review of these advances, and use of the most up-to-date data to ensure better patient outcomes.

Barrett esophagus.

PURPOSE OF REVIEW: Strides have been made in the past year to identify means of decreasing mortality from esophageal adenocarcinoma. This requires a thorough understanding of the risk factor for its development, Barrett esophagus. This article summarizes the most up-to-date and important advancements involving the epidemiology, screening, pathogenesis, surveillance, and treatment of Barrett esophagus over the past year. RECENT FINDINGS: Much of the literature over the past year involving Barrett esophagus centered on selecting subsets of patients who would benefit most from screening and surveillance protocols. Risk factors such as increasing age, heartburn symptoms, increasing length of Barrett's segment, and male sex are increasingly identified as increasing the risk for malignant esophageal transformation. New technologies, using smaller endoscopes, may allow more cost-effective screening in selected patient populations. Methylene blue continues to grow in acceptance for its utility in assisting identification of Barrett esophagus during endoscopy. Some concern has been raised recently about DNA damage secondary to the use of methylene blue, but the clinical significance of this is unknown. High-magnification endoscopy to identify certain mucosal patterns suggesting Barrett esophagus is also gaining acceptance, perhaps allowing more accurate surveillance in patients with this condition. Much controversy continues regarding the treatment of Barrett esophagus to prevent the development of esophageal adenocarcinoma. Data reports may show some advantage of surgical antireflux therapy in reducing the risk of adenocarcinoma, but a recent meta-analysis disputes this claim. Chromosomal abnormalities resulting in tumor suppressor dysfunction continue to be revealed. SUMMARY: The past year has brought many new advances involving the diagnosis, surveillance, and treatment of Barrett esophagus. It is important for physicians to be aware of these developments, to identify individuals in whom interventions may be undertaken to decrease the risk of the development of esophageal adenocarcinoma.