Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial.

OBJECTIVE: In US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low-risk to moderate-risk patients with suspected upper GI bleeding. METHODS: We conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital. RESULTS: The trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit. CONCLUSIONS: VCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.

Online Involvement for Georgia Student Teachers During Covid-19.

As concerns about Covid-19 rapidly escalated in March 2020 in the United States, all levels of education were impacted. A unique population (student teachers) faced challenges from two perspectives: as students and as teachers forced to teach and learn from a distance. Student Teachers, or preservice teachers (PST), are university students finishing a degree and/or teacher certification program by serving as an intern in a school setting. As schools were closed, these PSTs may not have been given access to the online learning platforms of their cooperating teachers (CT) and were no longer included in classroom instruction. The purpose of this study was to examine how the sudden shift away from traditional face-to-face instruction, co-teaching, and mentorship affected the involvement of music PSTs and their CT mentors in one region of the United States. Specifically, the research questions were: (1) How and in what ways were PSTs involved in planning, instruction, and/or assessment synchronously and asynchronously after school closures? (2) In what subdomains (performance, music theory/ear-training, etc.) were PSTs engaged in instruction and learning activities? (3) What challenges and solutions did PSTs report related to Covid-19 closures? A survey was sent, via email, to PSTs attending teacher preparation programs at universities in the state of Georgia at the end of the spring semester. Thirty-seven participants responded to the survey questions representing about 32% of all PSTs in Georgia in Spring 2020. Twenty-one were not given access to the online teaching platform of their placement school. A thematic analysis of the open-ended questions identified common themes including whether experiences were perceived as negative or positive. Of the PSTs given access, the majority of their responsibilities and experiences were creating assignments, additional help videos, participating in Zoom meetings, and assessing student assignment submissions. Of these experiences, interestingly, most were classified as positive by the PSTs. However, the importance of face-to-face interactions for both PST and the P-12 students was mentioned throughout survey responses. Approximately 10 PSTs mentioned their CT relationship/interaction and four of the respondents noted that their CT never reached out for help; however, six noted collaborative meetings or teaching with their CT. Importantly, some PSTs reported a lack of knowledge related to the planning and implementation of music instruction in the online modality. Therefore, teacher preparation programs should consider incorporating technology including online solutions into the music curriculum so that future music educators may more flexibly incorporate both in-person and distance learning.

Gastrointestinal and Hepatic Manifestations of COVID-19: Evolving Recognition and Need for Increased Understanding in Vulnerable Populations.

The novel coronavirus, SARS-CoV-2, has caused a global pandemic with high morbidity and mortality. It was first observed to cause a severe acute respiratory syndrome. However, gastrointestinal and hepatic manifestations have been increasingly recognized. Gastrointestinal symptoms include diarrhea, epigastric pain, nausea, and vomiting. Diarrhea is the most common GI manifestation of SARS-CoV-2 and can present without or without respiratory symptoms. Patients with GI symptoms have been associated with longer duration of illness and may be associated with more severe illness. Mechanism of diarrhea is thought to be related to direct viral cytotoxicity occurring when the SARS-CoV-3 enters GI cells via the ACE-2 receptor. Inflammatory response and cytokine release likely contributes to symptoms. SARS-CoV-2 can cause hepatic injury. Studies have shown mild to moderate elevation of liver enzymes. The pattern of liver abnormalities can be hepatocellular, cholestatic or mixed. Patients with severe infection have significantly higher rates of liver injury and worse outcomes. Proposed mechanisms for injury include immune mediated systemic inflammatory response, direct cytotoxicity from viral replication and hypoxia-reperfusion dysfunction. Recent data suggests that GI and hepatic injury may be under-recognized manifestation of SARS-CoV-2 infection. Patients with diarrhea and liver disease may have a worse prognosis. The rapidly evolving literature continues to reveal a growing body of information which enables updated guidance for management. More investigation is needed which focuses on vulnerable patients, including the elderly, those with underlying illness, as well as, racial and ethnic minorities.

Video capsule endoscopy for upper gastrointestinal hemorrhage in the emergency department: A systematic review and meta-analysis.

OBJECTIVE: The assessment of the severity of upper gastrointestinal hemorrhage in emergency department (ED) patients is difficult to assess with commonly available diagnostic tools. Small studies have shown that video capsule endoscopy (VCE) is a promising risk-stratification method and may be better than current clinical decision rules such as the Rockall score and the Glasgow Blatchford score. This review aims to assess the accuracy of VCE to detect active upper gastrointestinal hemorrhage compared to a reference standard. METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was used to perform a review of studies that have measured the diagnostic accuracy of VCE. Studies were included if they measured ED use of VCE for upper GI hemorrhage as compared to a reference standard of an esophagogastroduodenoscopy (EGD). A meta-analysis was performed on select patients using a fixed effects and random-effects model to determine the primary outcome of diagnostic test accuracy. RESULTS: 40 studies were screened for eligibility and five studies representing 193 patients met the inclusion and exclusion criteria. All patients received both a VCE and an EGD. The sensitivity and specificity of VCE were 0.724 and 0.748, respectively. The diagnostic odds ratio was 6.29 (95% CI: 3.23-12.25) and the summary receiver operating characteristic curve was 0.782. CONCLUSIONS: VCE demonstrated high accuracy for detecting upper GI hemorrhage in this meta-analysis of existing studies. In light of the potential advantages of VCE in the ED, further research is warranted to further establish its role.

The Conductor As Visual Guide: Gesture and Perception of Musical Content.

Ensemble conductors are often described as embodying the music. Researchers have determined that expressive gestures affect viewers' perceptions of conducted ensemble performances. This effect may be due, in part, to conductor gesture delineating and amplifying specific expressive aspects of music performances. The purpose of the present study was to determine if conductor gesture affected observers' focus of attention to contrasting aspects of ensemble performances. Audio recordings of two different music excerpts featuring two-part counterpoint (an ostinato paired with a lyric melody, and long chord tones paired with rhythmic interjections) were paired with video of two conductors. Each conductor used gesture appropriate to one or the other musical element (e.g., connected and flowing or detached and crisp) for a total of sixteen videos. Musician participants evaluated 8 of the excerpts for Articulation, Rhythm, Style, and Phrasing using four 10-point differential scales anchored by descriptive terms (e.g., disconnected to connected, and angular to flowing.) Results indicated a relationship between gesture and listeners' evaluations of musical content. Listeners appear to be sensitive to the manner in which a conductor's gesture delineates musical lines, particularly as an indication of overall articulation and style. This effect was observed for the lyric melody and ostinato excerpt, but not for the chords and interjections excerpt. Therefore, this effect appears to be mitigated by the congruence of gesture to preconceptions of the importance of melodic over rhythmic material, of certain instrument timbres over others, and of length between onsets of active material. These results add to a body of literature that supports the importance of the visual component in the multimodal experience of music performance.