Faculty Bibliography

INTRODUCTION: Cholecystectomy remains one of the most common surgical procedures in the United States with a rate of greater than 750,000 annually. Of these cases, approximately 1-2% are complicated by a bile leak. Although the rate of bile leaks is relatively low, the morbidity and mortality can be very high with patients rapidly deteriorating after presentation usually due to sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) can detect greater than 95% of leaks and provide therapeutic intervention aimed at eliminating the pressure gradient across the Sphincter of Oddi which promotes the flow of bile into the duodenum to heal the injured portion of the biliary tree. This case aims to show the significant clinical benefit of endoscopic management of bile leaks, although with the novel use of direct cholangioscopy. CASE DESCRIPTION/METHODS: This is a case of a 45-year-old woman with no significant past medical history who presented to an outside hospital with cholecystitis and underwent open cholecystectomy. Surgery was complicated by duodenal injury which was primary repaired and a Jackson- Pratt (JP) drain was left in place. Bilious fluid returned from the JP drain on post-operative day two and she underwent an ERCP which confirmed a bile leak and a sphincterotomy was performed and a stent was placed. She was referred to our center for stent removal four months later and at the time her cholangiogram was negative for leak so a stent was not replaced (Figure 1).Within a week of the procedure she had bilious return from the JP drain and a tube study preformed via the JP drain was read as a ?normal T-tube? cholangiogram (Figure 2). As there was suspected erosion of the JP drain into the biliary tree and high concern for creating a biliary injury when removing the drain, direct cholangioscopy was used for safe removal and identification of the leak (Figure 3). The biliary injury was sealed with a fully covered self-expanding metal stent with excellent results and no further evidence of ongoing leak. DISCUSSION: ERCP remains the preferred treatment option for bile leaks and prevents patients from having to undergo corrective operation.4 In this case there was high concern for creating a biliary injury when removing the drain, thereby direct cholangioscopy was used for safe removal and identification of the leak. To our knowledge this is the first report of JP drain erosion into the CBD with use of direct cholangioscopy and ERCP as endoscopic management for removal and treatment of biliary injury. (Figure Presented)

Background: Identifying the main drivers of mortality is essential to develop novel therapies for alcoholic hepatitis (AH). The role of hemodynamic parameters such as mean blood pressure (MAP) on patient survival has not been explored. Methods: We aim at investigating the impact of new clinical parameters on 28 and 90-day transplant-free survival among patients with AH. We performed a prospective observational study (InTeam Consortium) of 267 eligible patients admitted with an episode of AH. Survival at 28 and 90 days was assessed with the Kaplan-Meier method and the log-rank Mantel-Cox test. Factors showing a clinically and statistically significant association to the outcome in univariate analyses were selected for the initial models. The final models were fitted by using a step-wise forward method based on model likelihood ratios. Results: 267 patients were included in the final analysis with a median MELD score of 23 (23-27) and a median MAP at admission of 86 (77.3-93.5), median IQR. The global 90-day transplant-free survival was 71.9%. MAP at admission was found to be a risk factor for 90-day mortality in the univariate analysis 0.95 (0.93-0.98; p<0.001). A threshold of 80 mmHg was associated with a HR of 2.88 (1.72-4.83; p<0.001). Using this cut-off, we observed a significant increase in mortality in patients with low MAP at 28 (5.3 vs 26.1%) and 90 days (19.3 vs 42.6 %) p<0.001 (Figure). The prevalence of baseline SIRS was similar between both groups. We next explored the influence of the MELD score (using the cut-off of 21 that defines severe AH) in patients with a baseline MAP< or >=80 mmHg. Using both parameters, patients were stratified into 4 groups according to their 90-day mortality risk: MELD<21 and MAP>=80 mmHg: 7.8% mortality; MELD<21 and MAP<80 mmHg, 20% mortality, MELD>=21 and MAP>=80 mmHg, 26.6% mortality and MELD>=21 and MAP<80 mmHg, 45.2% mortality. Importantly, MAP was found to be an independent risk factor for mortality in the multivariate analysis HR of 0.95(0.94-0.99; p=0.07) (model including: age, HE, MELD and MAP). There was a significant association between a baseline MAP<80 mmHg and the development of acute Kidney Injury (AKI) during the follow-up (p=0.001). Conclusion: In patients with AH, lower baseline MAP is associated with increased 28 and 90-day mortality, independently of MELD, and with a higher rate of AKI. Early resuscitation aimed at increasing arterial pressure could be beneficial on patient outcomes. (Figure Presented)

Aim and objective Injunctive norms about smoking, the perceived approval or acceptability of smoking from friends or wider peer group, have rarely been studied outside the Western world. We investigated injunctive norms and the associations with smoking susceptibility in adolescents in Hong Kong, where most adolescents are negative towards smoking. Methods In 2017/18, 7031 Secondary 1-5 (US grade 7-11) students (48.9% boys; mean age 14.3, SD 1.7) were surveyed.Students reported the perceived approval of smoking from good friends (disapprove/neutral/approve) and the perception of whether most secondary school students accepted smoking (no/yes). Smoking susceptibility referred to the lack of a firm intention not to smoke in the next 12 months, when good friends smoked in front, or when a good friend offered a cigarette. Logistic regression yielded adjusted odds ratios (AORs) of smoking susceptibility for injunctive norms in never smokers, adjusting for sociodemographic characteristics and school clustering effect. Results Overall, 1.3%, 21.1% and 77.5% of students perceived approval, neutral response and disapproval of smoking from good friends, respectively. Some (5.8%) perceived that most students accepted smoking. In never smokers (n=6472, 92.5%), compared with perceived disapproval from good friends, perceived neutral response (AOR 3.58, 95% CI 2.86-4.50) and approval (5.41, 2.93-9.97) were associated with smoking susceptibility. The perception that most students accepted smoking was also associated with smoking susceptibility (2.73, 2.02-3.71). Conclusions Injunctive norms were associated with smoking susceptibility in Hong Kong never smoking adolescents. Addressing misperceptions of others' approval or acceptability of smoking may help prevent adolescent smoking. Funding General Research Fund (17629016), Research Grants Council of Hong Kong Special Administrative Region, China

Introduction: We evaluate the effectiveness of a single-session Cognitive Behavioral Therapy-Insomnia (CBT-I) program performed in a large group setting, structured to effectively address the high prevalence of disease. Methods: Kaiser Permanente (Fontana) conducts a CBT-I (Sleep Eazzzy) consisting of one 2.5 hour session in groups of 20 taught by a physician assistant. Program addresses: sleep hygiene, sleep beliefs, relaxation techniques, sleep restriction, and sleep position optimization. Individual telephone follow-up is repeated until signiicant improvement or patient declines further follow-up (program completed). Subjective responses from inal telephone follow-up were compared to baseline. Number of healthcare encounters and prescription ills 1 year prior to CBT and 1 year after program completion were compared to objectively assess. Results: 363 patients referred over 12 months completed CBT-I (average 1.3 telephone calls.) 321 (88%) reported improvement (31% reported resolution of insomnia). Statistically signiicant improvement was seen comparing mean pre/post program sleep parameters: sleep latency (57 vs 26 minutes), awakenings (3.0 vs 1.4), total sleep time (5.0 vs 6.5 hours). The 134 patients on sleep medications decreased their use (6.1 vs 4.0 nights/week), and 41 (30%) discontinued sleep medications. Improvements were similar for all groups: men (133), women (233), obstructive sleep apnea (117), use anti-depressants (68), ibromyalgia (30), shiftworkers (20), restless leg syndrome (20). There was decrease in # primary care ofice visits 1 year after program completion compared to 1 year prior to CBT (4.5 vs 3.7; p<0.01). Prescription ills of sleep and antidepressant medications showed no pre/post change; however, pattern of ills reveal crescendo of use prior to CBT and decrescendo after program completion. These differences were not evident in the control group. Conclusion: A single-session CBT program in a large group setting may effectively treat insomnia based on subjective impr!

Social anxiety disorder (SAD) is influenced by multiple genetic and environmental factors. Imaging genomics combines genotyping with neuroradiological techniques, such as functional MRI (fMRI) and positron emission tomography (PET), to investigate samples relevant to psychiatric pathophysiology. Neuroanatomical areas implicated in SAD include the amygdala, prefrontal cortex, hippocampus, and striatum. Recent investigations have suggested that allelic polymorphisms may play a role in the disorder; 2 candidate genes, the serotonin transporter (SLC6A4) and catechol-O-methyl transferase (COMT), are described. The biology of extinction learning is relevant to therapeutic approaches that aim to augment existing psychotherapies. In the future, novel uses of imaging genomics integrated with rational, biologically informed treatments will offer a more refined understanding of this complex and disabling disorder