Factors Affecting the Learning Curve in the Endoscopic Ultrasound-Guided Sampling of Solid Pancreatic Lesions: A Prospective Study.

Background/Aims: Endosonography is associated with a long learning curve. We aimed to assess variables that may influence the diagnostic outcomes in endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) of solid pancreatic tumors regarding the level of endoscopists' experience. Methods: Consecutive patients undergoing EUS-guided puncture of solid pancreatic tumors (eight endosonographers, including six trainees) were prospectively enrolled. An experienced endosonographer was defined as having performed at least 250 EUS examinations, including 75 FNA/Bs. The final diagnosis was determined by cytopathology, histopathology, or clinical follow-up. Results: In total, 283 EUS-FNA/Bs of solid pancreatic tumors (75.6% malignant) in 239 patients (median age 69 years, 57.6% males) were enrolled. Trainees performed 149/283 (52.7%) of the interventions. Accuracy and sensitivity for detecting malignancy were significantly higher in the expert group than in the trainee group (85.8% vs 73.2%, p=0.01 and 82.5% vs 68.4%, p=0.02). Solid lesions evaluated by an expert using FNB needles showed the best odds for a correct diagnosis (odds ratio, 3.07; 95% confidence interval, 1.15 to 8.23; p=0.02). More experienced endoscopists achieved better accuracy in sampling via the transduodenal approach (86.7% vs 68.5%, p<0.001), in the sampling of malignant lesions (82.5 vs 68.4, p=0.02), and in the sampling of lesions located in the pancreatic head (86.1 vs 69.1, p=0.02). In cases involving these factors, we observed a moderate improvement in the diagnostic accuracy after 40 attempts. Conclusions: Transduodenal approach, pancreatic head lesions, and malignancy were recognized as the most important clinical factors affecting the learning curve in EUS-FNA/B of solid pancreatic lesions.

Challenges in hepatitis C elimination despite highly effective antiviral agents in patients with and without intravenous drug use.

AIM: To assess the adherence to treatment, sustained virologic response (SVR) rate, and reinfection rate in hepatitis C patients with and without intravenous drug use. METHODS: This retrospective study included hepatitis C patients, evaluated and treated in our hepatology outpatient clinic between January 2014 and October 2019. The following information was extracted from the patient's file: the presence of positive viral load for hepatitis C virus (HCV), active and recent (in the last 6 months) use of i.v. drugs, HCV genotype, treatment regimen, SVR, HCV reinfection rate, coinfection with human immunodeficiency virus (HIV) and ongoing opioid substitution therapy (OST). RESULTS: We included 431 hepatitis C patients, 234 people who inject drugs (PWID) and 197 non-PWID. Most patients were treated with direct-acting antivirals (DAA) only. The rate of documented SVR by treated patients was significantly higher in the non-PWID cohort (91.5% vs. 61.5%, p < 0.0001), while noncompliance (did not show up to start treatment) rate or refusal of treatment was significantly higher in the PWID cohort (19.4% vs. 8.9%, p = 0.004). In the PWID cohort, younger age and recent (in the last 6 months) or ongoing i.v. drug use was associated with noncompliance: 31.1 ± 8.4 years vs. 35.8 ± 10.6 years (p = 0.02) and 33.3% vs. 12.8% (p = 0.0008), respectively. Ongoing OST was associated with better compliance: 61.1% vs. 46.1% (p = 0.04). CONCLUSION: To achieve elimination of hepatitis C better treatment strategies are needed, especially in PWIDs.