Diffuse Large B-Cell Lymphoma: Clinical Presentation and Treatment Outcomes From the OncoCollect Lymphoma Registry.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) is the commonest subtype of lymphoma, standard CHOP was the treatment of choice, 42% of patients received rituximab, and 29% of patients were lost to follow-up during therapy, were reported in a study that collected retrospective data at 13 public and private hospitals for patients diagnosed with lymphoma between January 2005 and December 2009. The OncoCollect Registry was set up in 2017 to address the challenges in the collection of retrospective data through chart review, recording access to anthracycline and rituximab-based treatment, and to study outcomes and any improvement in the patient follow-up. METHODOLOGY: The OncoCollect Lymphoma group registry was set up at a national level with 9 participating centers. Lymphoma patients registered at these centers between 2011 and 2017 were included. The clinical features, prognostic stratification, associated comorbidities, response to first-line treatment, and 3-year outcomes of adult patients with DLBCL were analyzed. RESULTS: Of the 5,886 lymphoma patients registered in the OncoCollect registry, 2,581 (44%) had DLBCL. A total of 1,961 were evaluable for frontline therapy. The median age at presentation was 57 years. Gender ratio was 1.6:1. At presentation, 43% were early stage, 70% had low and low intermediate IPI, 53% had extranodal disease, and 30.9% had one or more comorbidities (data available for 1,136 patients). The commonest extra nodal site was gastro-intestinal (23.98%) followed by head and neck (19.24%). The overall response rate was 79.29%. Complete remission was seen in 61.75%, partial response in 17.5%, stable disease in 4.3%, and progression in 7.9%. Patients who received anthracycline-based therapy (86.7%) and rituximab-based therapy (83.7%) had a 3-year event-free survival (EFS) of 69.67% and 68.48%, respectively. With a median follow-up of 33 months, the 3-year overall Survival (OS) and EFS were 75.37% and 66.58%, respectively. CONCLUSIONS: DLBCL remains the commonest (44%) lymphoma subtype and is curable with standard anthracycline- and rituximab-based therapies. The availability of rituximab has increased the proportion of patients receiving standard chemoimmunotherapy.

Fracture risk assessment in older adults using a combination of selected quantitative computed tomography bone measures: a subanalysis of the Age, Gene/Environment Susceptibility-Reykjavik Study.

Bone mineral density (BMD) and geometric bone measures are individually associated with prevalent osteoporotic fractures. Whether an aggregate of these measures would better associate with fractures has not been examined. We examined relationships between self-reported fractures and selected bone measures acquired by quantitative computerized tomography (QCT), a composite bone score, and QCT-acquired dual-energy X-ray absorptiometry-like total femur BMD in 2110 men and 2682 women in the Age, Gene/Environment Susceptibility-Reykjavik Study. The combined bone score was generated by summing gender-specific Z-scores for 4 QCT measures: vertebral trabecular BMD, femur neck cortical thickness, femur neck trabecular BMD, and femur neck minimal cross-sectional area. Except for the latter measure, lower scores for QCT measures, singly and combined, showed positive (p < 0.05) associations with fractures. Results remained the same in stratified models for participants not taking bone-promoting medication. In women on bone-promoting medication, greater femur neck cortical thickness and trabecular BMD were significantly associated with fracture status. However, the association between fracture and combined bone score was not stronger than the associations between fracture and individual measures or total femur BMD. Thus, the selected measures did not all similarly associate with fracture status and did not appear to have an additive effect on fracture status.

Factors associated with the process of adaptation among Pakistani adolescent females living in United States.

This study explored post-migration experiences of recently migrated Pakistani Muslim adolescent females residing in the United States. In-depth, semi-structured interviews were conducted with thirty Pakistani Muslim adolescent females between the ages of 15 and 18 years living with their families in Houston, Texas. Data obtained from the interviews were evaluated using discourse analysis to identify major reoccurring themes. Participants discussed factors associated with the process of adaptation to the American culture. The results revealed that the main factors associated with adaptation process included positive motivation for migration, family bonding, social support networks, inter-familial communication, aspiration of adolescents to learn other cultures, availability of English-as-second-language programs, participation in community rebuilding activities, and faith practices, English proficiency, peer pressure, and inter-generational conflicts. This study provided much needed information on factors associated with adaptation process of Pakistani Muslim adolescent females in the United States. The results have important implications for improving the adaptation process of this group and offer potential directions for intervention and counseling services.

Esophageal adenocarcinoma versus squamous cell carcinoma: retrospective hospital-based analysis of a 12-year temporal trend.

There is a paucity of literature from the Indian subcontinent looking at the prevalence of esophageal cancer by histological type. In our study, we ascertained the relative proportion and location of adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the esophagus at a referral hospital in Mumbai, India over a 12-year period to assess whether a time-trend existed. A retrospective analysis was carried out on patients who were diagnosed with and/or treated for esophageal cancer at the P D Hinduja Hospital and Research Centre in Mumbai between January 1, 2000 and December 31, 2011. Data were procured from histopathology and oncology registers of the institute, the database of the Gastroenterology consultants, the Endoscopy Department records and from the Medical Records Department. Of the 445 cases of esophageal cancer with known histology, 104 (23 %) were AC and 314 (71 %) were SCC. Over the 12-year period, the proportions of AC compared to SCC did not show a statistically significant temporal change (p = 0.145). AC comprised nearly a quarter of esophageal carcinoma in Mumbai. There has been no significant change in the number and proportion of AC and SCC in the 12-year period.

Hazard of recurrence among women after primary breast cancer treatment--a 10-year follow-up using data from SEER-Medicare.

BACKGROUND: Few studies have used SEER-Medicare data to describe recurrence of breast cancer after primary treatment for U.S. women. METHODS: We used SEER-Medicare data to estimate the annual hazard rate (HR) of recurrence for women with breast cancer between 1991 and 1997 with 10 years of follow-up. The Kaplan-Meier method was used to derive the HR. Multivariate Cox proportional hazards model was used to estimate the relative hazard of the recurrence-associated prognostic factors. RESULTS: Of 20,027 women, 36.8% had recurrence within 10 years, with most of these recurrences (81.9%) occurring within 5 years after diagnosis. Women with stage III cancer showed the highest HR peak and largest magnitude than women with stage I or II disease (both P < 0.01) within the first 5 years. Women with negative tumor hormone receptor status had a higher peak hazard of developing recurrence within the first 5 years (P < 0.01), but the hazards were remarkably lower beyond 5 years of follow-up than in women with positive or unknown hormone receptor status (P > 0.05). Women with poorly differentiated histologic grade tumors showed higher HR in the first 5 years than women with other grades after primary treatment (both P < 0.01). The increased risk of recurrence of breast cancer was associated with advanced stage, moderate and poorly differently grades, and negative hormone receptor status (all P < 0.01). CONCLUSION: The HRs of the recurrence are dynamic over 10 years and are markedly determined by prognostic factors at diagnosis. IMPACT: Our study suggests that the optimal follow-up may differ among women.

Causes of hospitalization and perceived access to care among persons newly diagnosed with HIV infection: implications for HIV testing programs.

There has been little research on the causes of hospitalization when patients are first diagnosed with HIV in the hospital. Reduced access to care could partially explain inpatient diagnosis. We sought to determine if the patients diagnosed as inpatients are hospitalized due to a HIV-related cause versus some other causes, to compare access to care of patients diagnosed with HIV in hospital and outpatient settings, and to determine factors associated with access to care. Participants were newly diagnosed with HIV and recruited between January 2006 and August 2007. The reason for hospitalization was classified as HIV-related, other infectious cause, noninfectious cause, or miscellaneous cause. Access to care was self-reported using a six-item scale and scores were compared with the t test. Multivariate linear regression determined factors associated with improved access to care. Of 185 participants in the study, 78 were diagnosed in hospital and 107 in outpatient settings. Thirty-two percent of participants were female, 90% were racial/ethnic minority, 45% had no high school diploma, and 85% were uninsured. HIV-related conditions accounted for 60% of admissions, followed by non-infectious causes (20%) and other infectious causes (17%). Inpatients did not report less access to care than patients diagnosed while outpatients. Multivariate analysis demonstrated improvement in access to care with better health insurance (p = 0.01) and greater education (p = 0.08). HIV-related preventable conditions account for many hospitalizations when patients are first diagnosed with HIV. While socioeconomic factors are associated with perceived access to care, persons diagnosed in the inpatient setting do not report lower perceived access to care than persons diagnosed as outpatients, suggesting other barriers to earlier diagnosis.

Diagnostic accuracy of EUS in differentiating mucosal versus submucosal invasion of superficial esophageal cancers: a systematic review and meta-analysis.

BACKGROUND: The prognosis of esophageal cancer (EC) depends on the depth of tumor invasion and lymph node metastasis. EC limited to the mucosa (T1a) can be treated effectively with minimally invasive endoscopic therapy, whereas submucosal (T1b) EC carries relatively high risk of lymph node metastasis and requires surgical resection. OBJECTIVE: To determine the diagnostic accuracy of EUS in differentiating T1a EC from T1b EC. DESIGN: We performed a comprehensive search of MEDLINE, SCOPUS, Cochrane, and CINAHL Plus databases to identify studies in which results of EUS-based staging of EC were compared with the results of histopathology of EMR or surgically resected esophageal lesions. DerSimonian-Laird random-effects model was used to estimate the pooled sensitivity, specificity, and likelihood ratio, and a summary receiver operating characteristic (SROC) curve was created. SETTING: Meta-analysis of 19 international studies. PATIENTS: Total of 1019 patients with superficial EC (SEC). INTERVENTIONS: EUS and EMR or surgical resection of SEC. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of EUS in accurately staging SEC. RESULTS: The pooled sensitivity, specificity, and positive and negative likelihood ratio of EUS for T1a staging were 0.85 (95% CI, 0.82-0.88), 0.87 (95% CI, 0.84-0.90), 6.62 (95% CI, 3.61-12.12), and 0.20 (95% CI, 0.14-0.30), respectively. For T1b staging, these results were 0.86 (95% CI, 0.82-0.89), 0.86 (95% CI, 0.83-0.89), 5.13 (95% CI, 3.36-7.82), and 0.17 (95% CI, 0.09-0.30), respectively. The area under the curve was at least 0.93 for both mucosal and submucosal lesions. LIMITATIONS: Heterogeneity was present among the studies. CONCLUSION: Overall EUS has good accuracy (area under the curve ≥0.93) in staging SECs. Heterogeneity among the included studies suggests that multiple factors including the location and type of lesion, method and frequency of EUS probe, and the experience of the endosonographer can affect the diagnostic accuracy of EUS.

Trends in colorectal cancer incidence by anatomic site and disease stage in the United States from 1976 to 2005.

OBJECTIVE: The objectives of the current study were to examine the trends in incidence rates of subsite-specific colorectal cancer at all stages in a large US population and to explore the impact of age and sex on colorectal cancer incidence. METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) 9 registries. Colorectal cancer incidence was divided into 3 anatomic subsite groupings: proximal colon, distal colon, and rectum. Incidence rates and relative risk were calculated using the SEER*Stat software provided by the National Cancer Institute. RESULTS: From 1976 to 2005, age-adjusted incidence of proximal colon, distal colon, and rectal cancers per 100,000 population have steadily decreased from 22.5, 18.8, and 19.2 to 21.1, 11.7, and 13.6, respectively, contributing to the overall decline in the incidence of colorectal cancer from 60.5 to 46.4. Distal colon cancer had the greatest incidence decline (-37.79%), whereas the most minimal change in the incidence rates occurred for proximal colon cancer (-6.37%) because of increased incidence rates of ascending colon (24.8%) and hepatic flexure (21.3%) over 30 years. The steadily increased proportion of proximal colorectal cancer subsites was observed in both men and women starting at age 50 although women experienced a greater increase than did men. CONCLUSIONS: Overall incidence rate of colorectal cancer decreased over the past 3 decades. The percent of ascending colon and hepatic flexure cancers diagnosed at early stages (localized and regional) increased. The finding on sex difference over years suggests that great attention should be paid in the future studies to male and female disparities.

Enlarged tracheoesophageal puncture after total laryngectomy: a systematic review and meta-analysis.

BACKGROUND: Enlargement of the tracheoesophageal puncture (TEP) is a challenging complication after laryngectomy with TEP. We sought to estimate the rate of enlarged puncture, associated pneumonia rates, potential risk factors, and conservative treatments excluding complete surgical TEP closure. METHODS: A systematic review was conducted (1978-2008). A summary risk estimate was calculated using a random-effects meta-analysis model. RESULTS: Twenty-seven peer-reviewed manuscripts were included. The rate of enlarged puncture and/or leakage around the prosthesis was reported in 23 articles (range, 1% to 29%; summary risk estimate, 7.2%; 95% confidence interval [CI], 4.8% to 9.6%). Temporary removal of the prosthesis and TEP-site injections were the most commonly reported conservative treatments. Prosthetic diameter (p = .076) and timing of TEP (p = .297) were analyzed as risk factors; however, radiotherapy variables were inconsistently reported. CONCLUSION: The overall risk of enlarged puncture seems relatively low, but it remains a rehabilitative challenge. Future research should clearly establish risk factors for enlarged puncture and optimal conservative management.

TPMT and DPD polymorphisms: Efficient screening method for Indian patients considering taking Thiopurine and 5-FU drugs.

INTRODUCTION: Development of DNA-based tests for TPMT/DPD polymorphisms can help clinicians and patients to make important decisions about cancer treatment. Also, due to lack of Indian data, we aimed at the development and validation of these tests in Indian patients. MATERIALS AND METHODS: Molecular assays were used for identifying TPMT/DPD variations; validated by DNA sequencing. RESULTS: Molecular assays have been used for screening TPMT*2, *3A, *3B, *3C alleles and IVS14+1(G-->A) in DPD gene. A patient, exhibiting neutropenia on 6-MP was observed to be G460A-homozygote, while, two Acute Lymphoblastic Leukemia (ALL) patients with side-effects exhibited wild-type alleles. Two patients showing 6-MP side-effects and responding well to the same drug at later stage also carried wild-type alleles. DISCUSSION: G460A homozygosity in a patient allowed clinicians to stop 6-MP treatment, improving patient's health status. Two ALL patients showing side-effects were wild-type, indicating presence of unidentified rare variations. Two patients with wild-type allele showed side-effects during 6-MP treatment, but responded well to same drug at later stage, suggesting side-effects to be attributable to multiple biological and environmental processes. Absence of IVS14+1(G-->A) in DPD gene will not exclude possibility of another mutation. CONCLUSION: Molecular assays for determining common TPMT/DPD variations, can provide accurate diagnosis and efficient therapies in future clinical studies.

Histopathologic correlation of endoscopic ultrasound findings of chronic pancreatitis in human autopsies.

OBJECTIVES: To provide histologic correlation of endoscopic ultrasound (EUS) findings believed to represent chronic pancreatitis (CP). METHODS: Eighteen postmortem pancreatic specimens in patients dying of all causes were examined in vitro by EUS for features of CP: (1) echogenic foci, (2) hypoechoic foci, (3) echogenic main pancreatic duct (MPD), (4) accentuated lobular pattern, (5) cysts, (6) irregular MPD, (7) dilated MPD, (8) side branch dilation, and (9) calculi. The pancreata were then examined by 2 pathologists (blinded to the EUS/clinical findings) for histopathologic features of CP. RESULTS: Six specimens were autolyzed, and in 1 specimen, MPD could not be seen by EUS. In the other 11 patients, 10 had evidence of CP by EUS (> or =3 features) and by histopathologic examination (> or =2 features). One patient did not have CP by both EUS and histologic examination. CONCLUSIONS: Endoscopic ultrasound accurately detected CP, when compared with histopathologic examination. The presence of 3 or more features of CP correlates with the histologic diagnosis of CP, however, up to 3 features are frequently present in elderly patients dying of all causes. Future studies should address the clinical relevance and the specificity of EUS findings of CP in the older population.

Effect of spaceflight on ability of monocytes to respond to endotoxins of gram-negative bacteria.

Astronauts live and work in relatively crowded, confined environments on the Space Shuttle and the International Space Station. They experience a unique set of stressors that contribute to a diminishment of many immune responses. This study investigated the ability of the shuttle crew members' monocytes to respond to gram-negative endotoxin that they could encounter during infections. Blood specimens were collected from 20 crew members and 15 control subjects 10 days before launch, 3 to 4 h after landing, and 15 days after landing and from crew members during their annual medical examination at 6 to 12 months after landing. When challenged with gram-negative endotoxin, the crew member's monocytes collected at all three time points produced lower levels of interleukin-6 (IL-6) and IL-1beta and higher levels of IL-1ra and IL-8 compared to those of control subjects. Cytokines were assessed by measuring the number of cells positive for intracellular cytokines. These values returned to normal 6 to 12 months after landing, except for IL-1ra, which was still higher (five- to sixfold) than in controls. This phenomenon was accompanied by an increased expression of Toll-like receptor 4 and decreased expression of CD14 on the crew members' monocytes at all time points. There were also increased levels of the lipopolysaccharide binding protein in the plasma of the crew members 3 to 4 h and 15 days after landing. This study shows that spaceflight-associated factors (in-flight and preflight) modulate the response of monocytes to gram-negative endotoxins.

Optimal frequency of imiquimod (aldara) 5% cream for the treatment of external genital warts in immunocompetent adults: a meta-analysis.

BACKGROUND: Postmarketing research has explored the optimal application schedule of imiquimod 5% cream for treatment of external anogenital warts. OBJECTIVES: We systemically reviewed the published literature on the efficacy and safety of the medication when applied either by a three times per week or once-daily regimen for 16 weeks. METHODS: MEDLINE (1966 to Feb 10, 2007), Scopus (1996 to Feb 10, 2007), and Cochrane Library (Issue 1, 2007) databases were searched for randomized trials on the medication. Primary efficacy outcome was the proportion of patients completely cleared of warts by end of treatment. Two primary safety outcomes were as follows: (a) proportion of patients who withdrew and (b) proportion of patients who required at least one rest period from treatment because of drug-related adverse events. RESULTS: Six studies were selected for subgroup analysis of circumcised men, uncircumcised men, and women. The once-daily compared to three times per week regimen did not improve treatment efficacy in any of the 3 subgroups (P <0.05), but resulted in greater incidence and severity of local skin reactions. There was no difference in medication-related withdrawals between the 2 regimens, although significantly more women and uncircumcised men required at least one rest period with the once-daily than the three times per week treatment schedule (P <0.05). CONCLUSIONS: The optimal application schedule of imiquimod 5% cream for external anogenital warts is three times per week.

Pure versus mixed electrosurgical current for endoscopic biliary sphincterotomy: a meta-analysis of adverse outcomes.

BACKGROUND: Endoscopic biliary sphincterotomy (ES) can cause bleeding, pancreatitis, and perforation. This has, in part, been attributed to the type of electrosurgical current used for ES. No consensus exists on the optimal type of electrosurgical current for ES to maximize safety. OBJECTIVE: To compare the rates of complications in patients undergoing ES via pure current versus mixed current. DESIGN: A systematic review of published, prospective, randomized trials that compared pure current with mixed current for ES. PATIENTS: Patients undergoing ES, with random assignment to either current group. INTERVENTIONS: Data were standardized for pancreatitis and postsphincterotomy bleeding. There were insufficient data to analyze perforation risk. A random-effects model was used. MAIN OUTCOME MEASUREMENTS: Bleeding, pancreatitis, and perforation. RESULTS: A total of 804 patients from 4 trials that compared pure current to mixed current were analyzed. The aggregated rate of pancreatitis was 3.8%, 95% confidence interval (CI) 1.0%-6.6%, for the pure-current group versus 7.9%, 95% CI 3.1%-12.7%, for the mixed-current group; the difference was not statistically significant. The rate of bleeding (all severity groups) for the pure-current group was 37.3% (95% CI 27.3%, 47.3%), which was significantly higher than that of the mixed-current group (12.2% [95% CI 4.1%, 20.3%]). Mild bleeding was significantly more frequent with pure current (28.9% [95% CI 16.3, 41.4]) compared with mixed current (9.4% [95% CI 2.1%, 16.8%]). LIMITATIONS: Variables, including endoscopist skill and cannulation difficulty, were difficult to measure. CONCLUSIONS: The rate of pancreatitis in patients who underwent ES when using pure current was not significantly different from those when using mixed current. Pure current was associated with more episodes of bleeding, primarily mild bleeding. Data were insufficient to analyze the perforation risk.

Pakistani Ismaili Muslim adolescent females living in the United States of America: stresses associated with the process of adaptation to U.S. Culture.

This study examines correlates of sociopsychological post-migration depression in Pakistani Ismaili Muslim adolescent females residing in the United States using quantitative information obtained through a questionnaire. Analysis of the questionnaire included descriptive statistics, Pearson product moment correlation coefficients, and multiple regression to describe a final model of risk factors related to depression in these adolescents. Longer periods of stay in the United States, young age at migration, and speaking more English were associated with low sociopsychological stress scores. Adolescents who reported a longer period of stay in the United States and lower levels of sociopsychological stress were less likely to be depressed.

Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors.

BACKGROUND: American Society for Gastrointestinal Endoscopy (ASGE) EUS training and credentialing guidelines exist, but the capability of U.S. GI fellowships to meet these guidelines has not been assessed. OBJECTIVE: To ascertain the capability of U.S. GI fellowship programs to meet ASGE guidelines for EUS training in the context of 3-year and advanced GI fellowships. METHODS: U.S. GI fellowship programs were surveyed for the presence or the absence, type, and extent of EUS training. Demographics regarding the programs and the program directors were obtained. MAIN OUTCOME MEASUREMENTS: Data on the annual total EUS volume and data on EUS performed by 3-year and/or advanced-year fellows were collected and analyzed. RESULTS: Ninety-one of 142 contactable GI programs responded (64%); 72% of programs performed >200 EUS/y and thus could train >or=1 EUS trainee/y. For 3-year GI fellows, 55% received less than 3 months of training, with 43% not receiving actual "hands-on" EUS experience, and 61% not learning EUS-guided FNA. The median EUS performed by 3-year fellows was 50 (0-350). Programs that offer advanced endoscopy fellowship had a median advanced-trainee EUS volume of 200 procedures (range, 50-1100 procedures). Of advanced fellows, 20% failed to receive "hands-on" training and 52% performed <200 procedures. We observed a significant difference in the median EUS volume performed by 3-year versus advanced-year fellows (P<.001). Program director variables did not correlate with training EUS volumes. CONCLUSIONS: The majority of U.S. GI fellowship programs have established the EUS volume to train at least 1 EUS fellow, per ASGE guidelines; however, most 3-year and many advanced fellows are currently receiving insufficient EUS training.

EUS vs MRCP for detection of choledocholithiasis.

BACKGROUND: Numerous published studies have shown the high diagnostic performance of both EUS and MRCP compared with ERCP for the detection of choledocholithiasis. DESIGN: We undertook a systematic review of all published randomized, prospective trials that compared EUS with MRCP with the primary aim being to compare the overall diagnostic accuracy for the detection of choledocholithiasis in patients with suspected biliary disease. METHODS: A MEDLINE review was performed. We identified 5 randomized, prospective, blinded trials comparing MRCP and EUS for the detection of choledocholithiasis, with subsequent ERCP or intraoperative cholangiography as a criterion standard. The study-specific variables for EUS and MRCP for choledocholithiasis were calculated from the data, and analyses were performed by using aggregated variables (sensitivity, specificity, positive and negative predictive values, and likelihood ratios). RESULTS: The pooled data set consisted of 301 patients. The aggregated sensitivities of EUS and MRCP for the detection of choledocholithiasis were 0.93 and 0.85, respectively, whereas their specificities were 0.96 and 0.93, respectively. The aggregated positive predictive values for EUS and MRCP were 0.93 and 0.87, respectively, with the corresponding negative predictive values of 0.96 and 0.92, respectively. Positive likelihood ratios were >10 for both tests, and corresponding negative likelihood ratios approached 0.10 for both tests. No statistically significant differences between EUS and MRCP were found in our analysis. CONCLUSIONS: EUS and MRCP have high diagnostic performance overall. Our analysis showed no statistically significant difference between the modalities. We recommend taking into consideration other factors, such as resource availability, experience, and cost considerations in deciding between these 2 tests.

EUS training and practice patterns among gastroenterologists completing training since 1993.

BACKGROUND: EUS training and practice patterns vary widely. The aim of this study was to assess EUS training methods, volumes, and practice patterns, and to obtain subjective assessment of endoscopic competence from endosonographers. METHODS: A survey was sent to over 1400 U.S. and international gastroenterologists who completed training since 1993. We assessed demographics, whether EUS is performed, how EUS training was obtained, and volume and type of EUS procedures performed in training and at present. Subjective assessment of adequacy of training was also obtained. RESULTS: A total of 157 physicians responded, including 76 EUS performers, of whom 67% completed advanced endoscopy fellowship, 14% were EUS trained during GI fellowship, and 19% learned via other means. EUS performers were subgrouped into those who had and had not completed advanced endoscopy fellowship, and those within and outside of an academic practice. There were significant associations between the number of upper EUS, pancreaticobiliary, and EUS-guided FNAs performed during training (p < 0.001 for all 3 groups) and completion of advanced endoscopy fellowship. Physicians in academic practice performed more EUS and FNAs per month than physicians in other types of practice (p values <0.001 and 0.001, respectively); 93.3% of respondents felt they received adequate instruction in diagnostic EUS, regardless of type of training; 88.9% of EUS performers felt they received adequate instruction in performing FNA. CONCLUSIONS: Most EUS performers are in academic practice. Those with advanced training obtained higher training volumes and perform higher volumes of EUS. The majority of respondents felt well trained regardless of training type and the number of procedures performed during training. This is the first analysis to assess these aspects of EUS training and practice.

Substitution of liothyronine at a 1:5 ratio for a portion of levothyroxine: effect on fatigue, symptoms of depression, and working memory versus treatment with levothyroxine alone.

OBJECTIVE: To attempt to confirm a previous report of superior effectiveness of using two thyroid hormones rather than one hormone to treat hypothyroidism. METHODS: This trial attempted to replicate prior findings, which suggested that substituting 12.5 microg of liothyronine (LT(3)) for 50 microg of levothyroxine (LT(4)) might improve mood, cognition, and physical symptoms in patients with primary hypothyroidism. Additionally, this trial aimed to extend the previous findings to fatigue and to assess for differential effects in subjects with low fatigue and high fatigue at baseline. A randomized, double-blind, two-period, crossover design was used. At an endocrinology and diabetes clinic, 30 adult subjects with primary hypothyroidism stabilized on LT(4) were recruited. Patients randomly assigned to treatment sequence 1 received their standard LT(4) dose in one capsule and placebo in another. Patients assigned to sequence 2 received their usual LT(4) dose minus 50 microg in one capsule and 10 microg of LT(3) in the other. At the end of the first 6 weeks, subjects were crossed over to receive the other treatment. Carryover and treatment effects were assessed by t tests. RESULTS: Of the 30 enrolled study subjects, 27 completed the trial. The mean LT(4) dose was 121 +/- 26 microg/day at baseline. No significant differences in fatigue and symptoms of depression were found between treatments. Measures of working memory were unchanged. During substitution treatment, the free thyroxine index was reduced by 0.7 (P<0.001), total serum thyroxine was reduced by 3.0 microg/dL (P<0.001), and total serum triiodothyronine was increased by 20.5 ng/dL (P = 0.004). CONCLUSION: With regard to the outcomes measured, substitution of LT(3) at a 1:5 ratio for a portion of baseline LT(4) yielded no better results than did treatment with the original dose of LT(4) alone.