Faculty Bibliography

OBJECTIVE:Hepatocellular carcinoma (HCC), the sixth most common cancer worldwide and third most common cause of cancer related death, is closely associated with the presence of cirrhosis. Survival is determined by the stage of the cancer, with asymptomatic small tumours being more amenable to treatment. Early diagnosis is dependent on regular surveillance and the primary objective of this survey was to gain a better understanding of the baseline attitudes towards and provision of ultrasound surveillance (USS) HCC surveillance in the UK. In addition, information was obtained on the stages of cancer of the patients being referred to and discussed at regional multidisciplinary team meetings. DESIGN:UK hepatologists, gastroenterologists and nurse specialists were sent a questionnaire survey regarding the provision of USS for detection of HCC in their respective hospitals. RESULTS:Provision of surveillance was poor overall, with many hospitals lacking the necessary mechanisms to make abnormal results, if detected, known to referring clinicians. There was also a lack of standard data collection and in many hospitals basic information on the number of patients with cirrhosis and how many were developing HCC was not known. For the majority of new HCC cases was currently being made only at an incurable late stage (60%). CONCLUSIONS:In the UK, the current provision of USS based HCC surveillance is poor and needs to be upgraded urgently.

Mitral regurgitation (MR) has a high prevalence in older patient populations of industrialized nations. Common etiologies are structural, degenerative MR and functional MR secondary to myocardial remodeling. Because of co-morbidities and associated high surgical risk, open surgical mitral repair/replacement is deferred in a significant percentage of patients. For these patients transcatheter repair/replacement are emerging as treatment options. Because of the lack of direct visualization, pre- and intra-procedural imaging is critical for these procedures. In this review, we summarize mitral valve anatomy, trans-catheter mitral valve replacement (TMVR) options, and imaging in the context of TMVR.

PURPOSE: Correctional settings create unique challenges for patients with special needs, including transgender patients, who have an increased rate of overall discrimination, sexual abuse, healthcare disparities, and improper housing. As part of our correctional health quality improvement process, we sought to review and evaluate the adequacy of care for transgender patients in the New York City jail system. METHODS: Using correctional pharmacy records, transgender patients receiving hormonal treatment were identified. A brief in-person survey was conducted to evaluate their care in the community before incarceration, medical care in jail, and experience in the jail environment. RESULTS: Survey findings and analysis of transgender patient healthcare-related complaints revealed opportunities for improvements in the provision of care and staff understanding of this population. Utilizing these findings, we conducted lesbian, gay, bisexual, and transgender (LGBT) trainings in all 12 jail clinics for medical, nursing, and mental health staff. Three months after LGBT training, patient complaints dropped by over 50%. After the development and implementation of a newly revised transgender healthcare policy, complaints dropped to zero within 6 months. CONCLUSION: Our efforts to assess the quality of care provided to transgender patients revealed significant areas for improvement. Although we have made important gains in providing quality care through the implementation of policies and procedures rooted in community standards and the express wishes of our patients, we continue to engage this patient population to identify other issues that impact their health and well-being in the jail environment.

BACKGROUND AND AIMS: The need for transpapillary drainage (TP) in patients undergoing transmural drainage (TM) of pancreatic fluid collections (PFC) remains unclear. The aims of this study were to compare treatment outcomes between patients with pancreatic pseudocysts undergoing TM versus combined (TM and TP) drainage (CD) and to identify predictors of symptomatic and radiologic resolution. METHODS: Retrospective review of 375 consecutive patients with PFC who underwent endoscopic ultrasound (EUS)-guided TM from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM and CD technical success, treatment outcomes (symptomatic and radiologic resolution) at follow-up, and predictors of treatment outcomes on logistic regression. RESULTS: A total of 375 patients underwent EUS-guided TM drainage of a PFC, of which 174 were pseudocysts. TM alone was performed in 95 (55%) and CD in 79 (45%) pseudocysts. Technical success: TM 92(97%) versus CD 35(44%) (P=0.0001). There was no difference in adverse events between the TM (15%) and CD (14%) cohorts (P=0.23). Median long-term (LT) follow-up after transmural stent removal was 324 days (interquartile range, 72-493 days) for TM and 201 days (interquartile range: 150-493 days) (P=0.37). There was no difference in LT symptomatic resolution (TM: 69% vs CD: 62%, P=0.61) or LT radiologic resolution (TM: 71% vs CD: 67%, P=0.79). TP attempt was negatively associated with LT radiologic resolution of pseudocyst (OR, 0.11; 95% CI, 0.02-0.8; P=0.03). CONCLUSIONS: TP has no benefit on treatment outcomes in patients undergoing EUS-guided TM of pancreatic pseudocysts and negatively impacts long-term resolution of PFC.

BACKGROUND AND AIMS: There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis. METHODS: AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures [p1] of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed. RESULTS: Five AETs were included with a total of 1049 graded ERCPs (mean +/- SD, 209.8 +/- 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 +/- 3.6 and 5.7 +/- 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence. CONCLUSION: This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.

Here we report two Enterobacter cloacae ST231 isolates co-producing KPC-3 and NDM-1, causing lethal infections in a tertiary hospital in China. The blaNDM-1-harboring plasmids carry IncA/C2 and IncR replicons, showing a mosaic plasmid structure, and the blaNDM-1 is harbored on a novel class I integron-like element. The blaKPC-3 is located on a Tn3-DeltablaTEM-1-blaKPC-3-DeltaTn1722 element, flanked by two 9-bp direct repeat sequences, and harbored on a novel IncX6 plasmid.

Smoldering multiple myeloma (SMM) is a pre-malignant condition with an inherent risk for progression to multiple myeloma (MM). The 2014 IMWG guidelines define smoldering multiple myeloma as a monoclonal gammopathy disorder with serum monoclonal protein (IgG or IgA) >/=30 g/L or urinary monoclonal protein >/=500 mg per 24 h and/or clonal bone marrow plasma cells 10-60 % without any myeloma-defining events or amyloidosis. The risk for progression of SMM to MM vary based on clinical, laboratory, imaging, and molecular characteristics. Observation, with periodic monitoring is the current standard of care for SMM. Over last few years, research advances in SMM have led to the delineation of newer risk factors for progression and identification of a "high-risk" group that would potentially benefit from early treatment. This review focuses on advances in the SMM risk-stratification model and recent clinical trials in this patient population.

Bacterial antimicrobial resistance has been associated with the up regulation of genes encoding efflux pumps and the down regulation of genes encoding outer membrane proteins (OMPs). Gene expression in bacteria is primarily initiated by sigma factors (sigma factors) such as RpoE, which plays an important role in responding to many environmental stresses. Here, we report the first observation that RpoE serves as an antibiotic resistance regulator in Salmonella enteric serovar Typhi (S. Typhi). In this study, we found that the rpoE mutant (DeltarpoE) of S. Typhi GIFU10007 has elevated resistance to several antimicrobial agents, including beta-lactams, quinolones, and aminoglycosides. Genomic DNA microarray analysis was used to investigate the differential gene expression profiles between a wild type and rpoE mutant in response to ampicillin. The results showed that a total of 57 genes displayed differential expression (two-fold increase or decrease) in DeltarpoE versus the wild-type strain. The expressions of two outer membrane protein genes, ompF and ompC, were significantly down-regulated in DeltarpoE (six and seven-fold lower in comparison to wild-type strain) and RamA, a member of the efflux pump AraC/XylS family, was up-regulated about four-fold in the DeltarpoE. Our results suggest RpoE is a potential antimicrobial regulator in S. Typhi, controlling both the down regulation of the OMP genes and up-regulating the efflux system.

Despite the established role of Ki67 labeling index in prognostic stratification of adrenocortical carcinomas and its recent integration into treatment flow charts, the reproducibility of the assessment method has not been determined. The aim of this study was to investigate interobserver variability among endocrine pathologists using a web-based virtual microscopy approach. Ki67-stained slides of 76 adrenocortical carcinomas were analyzed independently by 14 observers, each according to their method of preference including eyeballing, formal manual counting, and digital image analysis. The interobserver variation was statistically significant (P<0.001) in the absence of any correlation between the various methods. Subsequently, 61 static images were distributed among 15 observers who were instructed to follow a category-based scoring approach. Low levels of interobserver (F=6.99; Fcrit=1.70; P<0.001) as well as intraobserver concordance (n=11; Cohen κ ranging from -0.057 to 0.361) were detected. To improve harmonization of Ki67 analysis, we tested the utility of an open-source Galaxy virtual machine application, namely Automated Selection of Hotspots, in 61 virtual slides. The software-provided Ki67 values were validated by digital image analysis in identical images, displaying a strong correlation of 0.96 (P<0.0001) and dividing the cases into 3 classes (cutoffs of 0%-15%-30% and/or 0%-10%-20%) with significantly different overall survivals (P<0.05). We conclude that current practices in Ki67 scoring assessment vary greatly, and interobserver variation sets particular limitations to its clinical utility, especially around clinically relevant cutoff values. Novel digital microscopy-enabled methods could provide critical aid in reducing variation, increasing reproducibility, and improving reliability in the clinical setting.

The effect of fish consumption on blood pressure is controversial. The authors measured blood pressure and calculated oily fish servings per week in 677 community-dwellers aged 40 years and older living in rural coastal Ecuador. Using regression models with linear splines, the authors evaluated whether dietary fish intake was related to blood pressure levels, after adjusting for relevant confounders. Mean oily fish consumption was 9.1±5.6 servings per week. There was a nonlinear relationship between systolic pressure and fish servings. In the group of individuals consuming up to five servings per week, each serving significantly reduced systolic pressure by 2.3 mm Hg (P=.020). Any extra serving provided no further effects. The study shows an inverse relationship between oily fish consumption and systolic pressure. Currently recommended amounts of dietary oily fish intake per week (1-2 servings) might be insufficient to exert beneficial effects of fish in the control of blood pressure.