Strongyloides stercoralis Hyperinfection and Concomitant Cytomegalovirus Gastroenteritis in an Immunocompromised Host.

Strongyloides stercoralis infection typically presents with nonspecific gastrointestinal symptoms and no definitive or pathognomonic endoscopic findings. Disease burden can vary depending on a patient's immune status. Immunocompromised patients with strongyloidiasis can develop tremendous disease burden, extraintestinal dissemination, and are at risk for coinfection with other organisms. We present the case of an immunocompromised patient presenting with multiple gastrointestinal complaints found to have S. stercoralis hyperinfection and concomitant cytomegalovirus gastroenteritis.

Evaluation of Dysplasia in Barrett Esophagus.

Barrett esophagus (BE) is the precursor lesion to adenocarcinoma of the esophagus. The current surveillance strategy of 4-quadrant Seattle protocol biopsies has been associated with sampling error and missing higher-risk lesions, and there is often less adherence to endoscopic surveillance with long segments. Advancements in endoscopic imaging and sampling techniques allow for better surveillance of BE, particularly when assessing for dysplasia. This article highlights the key endoscopic imaging and sampling advancements in the evaluation of dysplasia in BE.

Using the Objective Structured Clinical Examination to Assess ACGME Competencies in Pediatric Gastroenterology Fellows.

BACKGROUND: The Accreditation Council for Graduate Medical Education has described 6 core competencies with which trainees should demonstrate proficiency. Using the Objective Structured Clinical Examination (OSCE), we aimed to assess 4 of these competencies among Pediatric Gastrointestinal (GI) fellows (PGs). METHODS: Eight first-year PGs from 6 medical centers in the New York area participated in a 4-station OSCE with trained standardized patient (SP) actors. The cases included an emergency department (ED) consult, or "ED Consult" for lower gastrointestinal bleeding; "Breaking Bad News" focusing on CF nutritional complications; "Second Opinion" for abdominal pain; "Transition of Care" for inflammatory bowel disease. At each station, attending faculty observed the encounters behind a 1-way mirror. SPs and faculties provided immediate feedback to the examined fellows. Previously validated OSCE checklists were used to assess performance. On completion, fellows attended debriefing sessions and completed surveys about the educational value. RESULTS: Median overall milestone competency scores were 6.9 (PC1), 4.8 (PC2), 5.9 (MK1), 5.7 (MK2), 6.4 (ICS1), 6.9 (Prof1), and 6.7 (Prof3). Overall, fellows score highest (7/9) on the inflammatory bowel disease "Transition of Care" case, found the "Breaking Bad News" Cystic Fibrosis OSCE to be the most challenging, and were most comfortable with the "ED Consult" OSCE, as a commonly encountered scenario. Overall, the fellows rated the educational value of the program highly. CONCLUSIONS: To our knowledge, although the OSCE has been validated in other medical fields, this is the first OSCE program developed for PGs fellows. These OSCEs have included Accreditation Council for Graduate Medical Education competencies, serving to assess fellows' skills in these areas while exposing them to challenging medical and psychosocial cases that they may not frequently encounter.

Comparison of fetal mesencephalic grafts, AAV-delivered GDNF, and both combined in an MPTP-induced nonhuman primate Parkinson's model.

We combined viral vector delivery of human glial-derived neurotrophic factor (GDNF) with the grafting of dopamine (DA) precursor cells from fetal ventral mesencephalon (VM) to determine whether these strategies would improve the anti-Parkinson's effects in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated monkeys, an animal model for Parkinson's disease (PD). Both strategies have been reported as individually beneficial in animal models of PD, leading to clinical studies. GDNF delivery has also been reported to augment VM tissue implants, but no combined studies have been done in monkeys. Monkeys were treated with MPTP and placed into four balanced treatment groups receiving only recombinant adeno-associated virus serotype 5 (rAAV5)/hu-GDNF, only fetal DA precursor cells, both together, or a buffered saline solution (control). The combination of fetal precursors with rAAV5/hu-GDNF showed significantly higher striatal DA concentrations compared with the other treatments, but did not lead to greater functional improvement in this study. For the first time under identical conditions in primates, we show that all three treatments lead to improvement compared with control animals.

Peripheral nerve injuries following gunshot fracture of the humerus.

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.