Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy.

BACKGROUND: Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets. AIMS: This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes. METHODS: All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined. RESULTS: Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001). CONCLUSION: Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.

Identifying cancer driver genes in individual tumours.

Cancer is a heterogeneous disease with a strong genetic component making it suitable for precision medicine approaches aimed at identifying the underlying molecular drivers within a tumour. Large scale population-level cancer sequencing consortia have identified many actionable mutations common across both cancer types and sub-types, resulting in an increasing number of successful precision medicine programs. Nonetheless, such approaches fail to consider the effects of mutations unique to an individual patient and may miss rare driver mutations, necessitating personalised approaches to driver-gene prioritisation. One approach is to quantify the functional importance of individual mutations in a single tumour based on how they affect the expression of genes in a gene interaction network (GIN). These GIN-based approaches can be broadly divided into those that utilise an existing reference GIN and those that construct de novo patient-specific GINs. These single-tumour approaches have several limitations that likely influence their results, such as use of reference cohort data, network choice, and approaches to mathematical approximation, and more research is required to evaluate the in vitro and in vivo applicability of their predictions. This review examines the current state of the art methods that identify driver genes in single tumours with a focus on GIN-based driver prioritisation.

Concurrent cholecystoduodenal fistula and primary aortoenteric fistula.

Bilioenteric fistulae are a rare complication and can pose a diagnostic challenge owing to non-specific symptomology. When occurring with an aortoenteric fistula, it represents a rare and potentially life-threatening disease state. We present the case of a 77-year-old gentleman initially treated as presumed ascending cholangitis. This was complicated by upper gastrointestinal bleeding secondary to an aortoenteric fistula and cholecystoduodenal fistula.

The efficacy of training insertion skill on a physical model colonoscopy simulator.

Background and study aims: Prior research supports the validity of performance measures derived from the use of a physical model colonoscopy simulator - the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd., Kyoto, Japan) - for assessing insertion skill. However, its use as a training tool has received little research attention. We assessed the efficacy of a brief structured program to develop basic colonoscope insertion skill through unsupervised practice on the model. Participants and methods: This was a training study with pretesting and post-testing. Thirty-two colonoscopy novices completed an 11-hour training regime in which they practiced cases on the model in a colonoscopy simulation research laboratory. They also attempted a series of test cases before and after training. For each outcome measure (completion rates, time to cecum and peak force applied to the model), we compared trainees' post-test performance with the untrained novices and experienced colonoscopists from a previously-reported validation study. Results: Compared with untrained novices, trained novices had higher completion rates and shorter times to cecum overall (Ps < .001), but were out-performed by the experienced colono-scopists on these metrics (Ps < .001). Nevertheless, their performance was generally closer to that of the experienced group. Overall, trained novices did not differ from either experience-level comparison group in the peak forces they applied (P > .05). We also present the results broken down by case. Conclusions: The program can be used to teach trainees basic insertion skill in a more or less self-directed way. Individuals who have completed the program (or similar training on the model) are better prepared to progress to supervised live cases.

Applying heuristic evaluation to observation chart design to improve the detection of patient deterioration.

A key goal for patient safety is to improve the early recognition and management of patients whose conditions deteriorate whilst in hospital. Paper-based observation charts are the main means of recording and monitoring patients' physiological stability, yet observations (e.g., blood pressure, heart rate, and respiratory rate) are not always correctly recorded or appropriately acted upon. No prior published study has applied usability heuristics to systematically compare the usability of multiple observation chart designs. In this study, five evaluators with human factors, applied psychology, or medical expertise inspected 25 observation charts for usability problems. Every chart was found to have substantial usability problems, potentially affecting the ability of hospital staff to accurately record observations or recognize patient deterioration. We proposed a new observation chart design, which avoids many of the previously observed usability problems.

Designing observation charts to optimize the detection of patient deterioriation: reliance on the subjective preferences of healthcare professionals is not enough.

AIM: Observation charts are critical to detecting patient deterioration. Research suggests their design has a dramatic impact on user performance in terms of failure rates for detecting abnormal vital signs and how quickly users can interpret recorded observations. In this study, we examined the design preferences of professional chart users to assess their alignment with objective performance data. In addition, we tested the assumptions of prior knowledge that chart designers appear to have made about chart users. METHODS: We conducted an online survey of health professionals (n=347). Participants answered questions about their observation chart design preferences in general, and were randomly assigned to evaluate one of nine specific charts. RESULTS: Chart users' preferences for design features were not always consistent with objective performance data. While some views concurred with empirical findings (e.g., participants preferred to plot observations on a graph with graded colouring, where the colours corresponded with degrees of abnormality), others did not (e.g., participants preferred plotting blood pressure and pulse together on the same chart area, which the objective data suggest is problematic). Additionally, a substantial proportion of respondents were unfamiliar with some of the assumed knowledge required to interpret many charts (e.g., particular abbreviations). CONCLUSIONS: It is dangerous to rely solely on subjective opinions - even those of experienced health professionals - when developing patient observation charts, as optimal design may be counterintuitive and some preferences may merely reflect familiarity. Objective performance data is also required. In addition, the level of assumed knowledge required to use a chart should be minimized.

Assessing the realism of colonoscopy simulation: the development of an instrument and systematic comparison of 4 simulators.

BACKGROUND: No useful comparative data exist on the relative realism of commercially available devices for simulating colonoscopy. OBJECTIVES: To develop an instrument for quantifying realism and provide the first wide-ranging empiric comparison. DESIGN: Repeated measures, observational study. Nineteen experienced colonoscopists completed cases on 4 colonoscopy simulators (AccuTouch, GI Mentor II, Koken, and Kyoto Kagaku) and evaluated each device. SETTING: A medical simulation center in a large tertiary hospital. MAIN OUTCOME MEASURES: For each device, colonoscopists completed the newly developed Colonoscopy Simulator Realism Questionnaire (CSRQ), which contains 58 items grouped into 10 subscales measuring the realism of different aspects of the simulation. Subscale scores are weighted and combined into an aggregated score, and there is also a single overall realism item. RESULTS: Overall, current colonoscopy simulators were rated as only moderately realistic compared with real human colonoscopy (mean aggregated score, 56.28/100; range, 48.39-60.45, where 0 = "extremely unrealistic" and 100 = "extremely realistic"). On both overall realism measures, the GI Mentor II was rated significantly less realistic than the AccuTouch, Kyoto Kagaku, and Koken (P < .001). There were also significant differences between simulators on 9 subscales, and the pattern of results varied between subscales. LIMITATIONS: The study was limited to commercially available simulators, excluding ex-vivo models. The CSRQ does not assess simulated therapeutic procedures. CONCLUSIONS: The CSRQ is a useful instrument for quantifying simulator realism. There is no clear "first choice" simulator among those assessed. Each has unique strengths and weaknesses, reflected in the differing results observed across 9 subscales. These findings may facilitate the targeted selection of simulators for various aspects of colonoscopy training.

Malignant Range Elevation of Serum Chromogranin A due to Inadvertent Use of Proton Pump Inhibitor in a Subject with Pancreatic Incidentaloma.

We present a case of highly elevated tenfold rise of serum chromogranin A in a young, morbidly obese, hypertensive female being investigated for pancreatic mass, weight loss, and elevated ESR. Following extensive noninvasive investigations, an ultrasound-guided pancreatic biopsy confirmed benign haemorrhagic cyst. A clue to the etiology of the hyperchromogranin A was the elevated serum gastrin level leading to suspicion of proton pump inhibitor administration confirmed by admittance to its use. Withdrawal of the medication led to dramatic resolution of the neuroendocrine tumor marker.

High prevalence of sessile serrated adenomas with BRAF mutations: a prospective study of patients undergoing colonoscopy.

BACKGROUND & AIMS: Sporadic colorectal cancers with a high degree of microsatellite instability are a clinically distinct subgroup with a high incidence of BRAF mutation and are widely considered to develop from serrated polyps. Previous studies of serrated polyps have been highly selected and largely retrospective. This prospective study examined the prevalence of sessile serrated adenomas and determined the incidence of BRAF and K-ras mutations in different types of polyps. METHODS: An unselected consecutive series of 190 patients underwent magnifying chromoendoscopy. Polyp location, size, and histologic classification were recorded. All polyps were screened for BRAF V600E and K-ras codon 12 and 13 mutations. RESULTS: Polyps were detected in 72% of patients. Most (60%) were adenomas (tubular adenomas, tubulovillous adenomas), followed by hyperplastic polyps (29%), sessile serrated adenomas (SSAs; 9%), traditional serrated adenomas (0.7%), and mixed polyps (1.7%). Adenomas were more prevalent in the proximal colon (73%), as were SSAs (75%), which tended to be large (64% >5 mm). The presence of at least one SSA was associated with increased polyp burden (5.0 vs 2.5; P < .0001) and female sex (P < .05). BRAF mutation was rare in adenomas (1/248 [0.4%]) but common in SSAs (78%), traditional serrated adenomas (66%), mixed polyps (57%), and microvesicular hyperplastic polyps (70%). K-ras mutations were significantly associated with goblet cell hyperplastic polyps and tubulovillous adenomas (P < .001). CONCLUSIONS: The prevalence of SSAs is approximately 9% in patients undergoing colonoscopy. They are associated with BRAF mutation, proximal location, female sex, and presence of multiple polyps. These findings emphasize the importance of identifying and removing these lesions for endoscopic prevention of colorectal cancer.