Removal of a superinfected intragastric balloon.

Superinfected intragastric balloon removal.

KRT17High/CXCL8+ tumor cells display both classical and basal features and regulate myeloid infiltration in the pancreatic cancer microenvironment.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) is generally divided in two subtypes, classical and basal. Recently, single cell RNA sequencing has uncovered the co-existence of basal and classical cancer cells, as well as intermediary cancer cells, in individual tumors. The latter remains poorly understood; here, we sought to characterize them using a multimodal approach. EXPERIMENTAL DESIGN: We performed subtyping on a single cell RNA sequencing dataset containing 18 human PDAC samples to identify multiple intermediary subtypes. We generated patient-derived PDAC organoids for functional studies. We compared single cell profiling of matched blood and tumor samples to measure changes in the local and systemic immune microenvironment. We then leveraged longitudinally patient-matched blood to follow individual patients over the course of chemotherapy. RESULTS: We identified a cluster of KRT17-high intermediary cancer cells that uniquely express high levels of CXCL8 and other cytokines. The proportion of KRT17High/CXCL8+ cells in patient tumors correlated with intra-tumoral myeloid abundance, and, interestingly, high pro-tumor peripheral blood granulocytes, implicating local and systemic roles. Patient-derived organoids maintained KRT17High/CXCL8+cells and induced myeloid cell migration in an CXCL8-dependent manner. In our longitudinal studies, plasma CXCL8 decreased following chemotherapy in responsive patients, while CXCL8 persistence portended worse prognosis. CONCLUSIONS: Through single cell analysis of PDAC samples we identified KRT17High/CXCL8+ cancer cells as an intermediary subtype, marked by a unique cytokine profile and capable of influencing myeloid cells in the tumor microenvironment and systemically. The abundance of this cell population should be considered for patient stratification in precision immunotherapy.

Simulation Training Improves Trainee Technical Skill and Procedural Attitudes in Endoscopic Gastrostomy Tube Placement.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tube placement remains a core competency of gastroenterology fellowship, although this procedure is performed infrequently. Some training programs lack sufficient procedural volume for trainees to develop confidence and competence in this procedure. We aimed to determine the impact of a simulation-based educational intervention on trainee technical skill and procedural attitudes in simulated PEG tube placement. METHODS: Gastroenterology fellows were invited to participate in the study. Baseline procedural attitudes toward PEG tube placement (self-confidence, perceived skill level, perceived level of required supervision) were assessed before simulation training using a Likert scale. Baseline technical skills were assessed by video recording-simulated PEG tube placement on a PEG tube simulator with scoring using a procedural checklist. Fellows next underwent individualized simulation training and repeated simulated PEG tube placement until greater than 90% of checklist items were achieved. Procedural attitudes were reassessed directly after the simulation. Technical skill and procedural attitudes were then reassessed 6 to 12 weeks later (delayed posttraining). RESULTS: Twelve fellows completed the study. Simulation training led to significant improvement in technical skill at delayed reassessment (52.9 ± 14.3% vs. 78.0 ± 8.9% correct, P = 0.0002). Simulation training also led to significant immediate improvements in self-confidence (2.1 ± 0.7 vs. 3.1 ± 0.3, P = 0.001), perceived skill level (2.2 ± 1.0 vs. 4 ± 1.1, P < 0.001), and perceived level of required supervision (2.2 ± 0.9 vs. 3.2 ± 0.6, P = 0.003). CONCLUSIONS: Simulation training led to sustained improvements in gastroenterology fellows' technical skill and procedural attitudes in PEG tube placement. Incorporation of simulation curricula in gastroenterology fellowships for this infrequently performed procedure should be considered.

Nutrition in the management of gastrointestinal diseases and disorders: the evidence for the low FODMAP diet.

A growing interest from both physicians and patients is fueling research in the interaction of symptoms related to irritable bowel syndrome (IBS) and diet, particularly the low FODMAP diet. Recent studies further define the role of these short-chain fermentable carbohydrates on IBS symptoms and their effects in different parts of the gastrointestinal tract. Mounting evidence supports the use of a low FODMAP diet in the clinical setting, but this dietary approach is not without potential drawbacks. This review illustrates the mechanisms by which the low FODMAP diet leads to improvement in IBS symptoms, summarizes the available clinical evidence, and offers practical advice regarding implementation of this dietary strategy.

Risk for Overall Infection with Anti-TNF and Anti-integrin Agents Used in IBD: A Systematic Review and Meta-analysis.

BACKGROUND: The overall risk for infection with contemporary biological agents in treating Crohn's disease (CD) and ulcerative colitis (UC) has not been systematically assessed. METHODS: We performed a PubMed and Cochrane database literature search to evaluate randomized, placebo-controlled trials of biologics in treating UC and CD. Meta-analysis was performed using a DerSimonian and Laird random effects model. We determined relative risk (RR) of harm against placebo; number needed to harm (NNH) was reported when appropriate. Heterogeneity and publication bias were assessed. RESULTS: Fourteen trials (6 UC and 8 CD) evaluating 5107 patients were included. For anti-tumor necrosis factor agents used in the treatment of UC, golimumab {NNH of 9.3, RR = 1.4 (95% confidence interval [CI], 1.04-1.8)} and pooled studies of infliximab and adalimumab (NNH = 17.2, RR = 1.2 [95% CI, 1.0-1.3]) had a statistically significant higher risk for any infection versus placebo. Risk was not significantly increased in anti-tumor necrosis factor trials in CD (RR = 1.1 [95% CI, 0.8-1.5]). By contrast, anti-integrin agents in UC (RR = 1.0 [95% CI, 0.9-1.2]) or CD (RR = 1.1 [95% CI, 0.97-1.3]) did not confer a statistically significant excess risk of infection versus placebo. CONCLUSIONS: Anti-tumor necrosis factor therapy but not anti-integrin therapy is associated with a greater infection risk than placebo in treating UC. Neither class of therapy is associated with increased infection risk over placebo in treating CD. Our findings can help guide patient-centered discussions regarding the risk for infection with biological agents.

Protecting the airway and the physician: Aspects of litigation arising from tracheotomy.

BACKGROUND: In recent decades, medical malpractice costs have increased and have led to a change in the way physicians practice medicine. Tracheotomies are cases in which complications have a high risk of morbidity and mortality and the potential for litigation. METHODS: The Westlaw legal database was used to gather data on 43 jury verdicts and settlements from 1987 to 2013. Various factors included outcome, defendant specialty, and the reason for litigation. RESULTS: Median settlements were $500,000 and median verdict awards were $2,000,000. Postoperative negligence was alleged most often (81%) followed by intraoperative negligence (27.9%) and permanent injury (18.6%). Otolaryngologists were named as defendants most often (25.6%), with nurses named second most often. Pediatric cases had significantly higher awards and were more often named in favor of the plaintiff. CONCLUSION: An awareness of tracheotomy malpractice litigation has the potential to both help physicians avoid future litigation and improve patient safety.