Novel Use of a Uniquely Designed, Lumen-Apposing, Metal Stent in Benign Gastric Outlet Obstruction in Two Patients.

Current guidelines recommend management of benign gastric outlet obstruction (GOO) with serial dilations. Self-expanding metal stents are effective, but their use is complicated by high rates of migration. We present two cases from our institution where a uniquely designed, lumen-apposing metal stent (LAMS) was successfully used to alleviate benign GOO without stent migration.

Recurrent Abdominal Pain and Bowel Edema in a Middle-Aged Woman.

A woman presented to the emergency department with sharp abdominal pain and no evidence of a food-borne illness. How would you treat the patient?

Cardiovascular disease and nonalcoholic fatty liver disease: does histologic severity matter?

GOALS: We aimed to investigate the prevalence of cardiovascular disease in patients with nonalcoholic steatohepatitis (NASH) versus non-NASH fatty liver. BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease, which is a leading cause of death in this patient population. NASH is a subset of NAFLD that carries a higher risk of progression to cirrhosis and its associated complications. STUDY: We conducted a retrospective chart review of patients with biopsy-confirmed NAFLD, including NASH and non-NASH fatty liver, within the Gastroenterology and Hepatology clinic at Brooke Army Medical Center. Patients with secondary causes of chronic liver disease were excluded. The patients' records were reviewed for the presence of significant cardiovascular disease, which was defined as a history of stroke, unstable angina, myocardial infarction, congestive heart failure, or need for revascularization. RESULTS: Nine hundred thirteen patients were identified and 377 patients met inclusion and exclusion criteria and were included in the final analysis. Of these, 219 patients had biopsies showing the presence of at least grade I NASH. The overall prevalence of cardiovascular disease was 6.63%. After controlling for age, sex, body mass index, and the presence of diabetes, there was no significant increase in the prevalence of cardiovascular disease in the NASH cohort over the non-NASH group. CONCLUSIONS: Cardiovascular disease is common among patients with NAFLD. However, no increased risk of cardiovascular disease was found among those patients with NASH as compared with those with non-NASH fatty liver.

Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.

BACKGROUND: Prior research on reducing variation in housestaff handoff procedures have depended on proprietary checkout software. Use of low-technology standardization techniques has not been widely studied. PURPOSE: We wished to determine if standardizing the process of intern sign-out using low-technology sign-out tools could reduce perception of errors and missing handoff data. METHODS: We conducted a pre-post prospective study of a cohort of 34 interns on a general internal medicine ward. Night interns coming off duty and day interns reassuming care were surveyed on their perception of erroneous sign-out data, mistakes made by the night intern overnight, and occurrences unanticipated by sign-out. Trainee satisfaction with the sign-out process was assessed with a 5-point Likert survey. RESULTS: There were 399 intern surveys performed 8 weeks before and 6 weeks after the introduction of a standardized sign-out form. The response rate was 95% for the night interns and 70% for the interns reassuming care in the morning. After the standardized form was introduced, night interns were significantly (p < .003) less likely to detect missing sign-out data including missing important diseases, contingency plans, or medications. Standardized sign-out did not significantly alter the frequency of dropped tasks or missed lab and X-ray data as perceived by the night intern. However, the day teams thought there were significantly less perceived errors on the part of the night intern (p = .001) after introduction of the standardized sign-out sheet. There was no difference in mean Likert scores of resident satisfaction with sign-out before and after the intervention. CONCLUSION: Standardized written sign-out sheets significantly improve the completeness and effectiveness of handoffs between night and day interns. Further research is needed to determine if these process improvements are related to better patient outcomes.