Parvimonas micra Bacteremia: A Rare Complication After Esophagogastroduodenoscopy for Upper Gastrointestinal Bleeding.

Parvimonas micra bacteremia is rarely encountered in clinical practice. When it is, patients usually have underlying periodontal disease or colorectal carcinoma. To the best of our knowledge, this is the first case of P. micra bacteremia in a patient without the predisposing risk factors listed above. We postulate that this occurred because of translocation across an interrupted gut-blood barrier in the setting of an acute upper gastrointestinal bleed. We present this case to highlight the importance of identifying and treating P. micra bacteremia because it can prevent commonly encountered sequelae of untreated bacteremia and improve outcomes.

Assessment of the Degree of Variation of Histologic Inflammation in Ulcerative Colitis.

INTRODUCTION: Treatment of ulcerative colitis (UC) now includes mucosal healing. Adoption of histologic end points is hindered by a lack of evidence guiding optimal sampling, interpretation, and reproducibility of results. METHODS: We analyzed biopsy fragments from colonoscopies in 92 patients with UC. Fragments were scored using 6-point histologic inflammatory activity (HIA) scale. Variability was determined using ordinal representations of HIA scores. The most frequently observed score and percentage of biopsy fragments with that score were determined for each biopsy, each segment, and across all 3 segments for each colonoscopy. Mean percentages and 95% confidence intervals (CIs) were calculated. RESULTS: We reviewed 1802 biopsy fragments. The mean percentages of intrasegment biopsy fragments with the same HIA score were 85.5% (95% CI, 80.9% to 92.9%), 79.6% (95% CI, 76.0% to 87.3%), and 82.7% (95% CI, 79.1% to 90.0%) for the rectum, left colon, and right colon, respectively. The mean percentage of intersegment biopsy fragments with the same HIA score was 70.2% (95% CI, 65.7% to 82.5%). The mean percentages of intrabiopsy fragments with the same HIA score were 83.3% (95% CI, 77.6% to 93.5%), 83.6% (95% CI, 80.1% to 89.7%), and 90.2% (95% CI, 87.6% to 94.7%) for the rectum, left colon, and right colon, respectively. All 3 analyses revealed increased variation when a greater degree of histologic inflammation was present in the biopsies (mean HIA score ≥2). CONCLUSIONS: We found minimal variability between degree of inflammation among biopsy fragments within and among different colorectal segments in UC, suggesting that even a single biopsy would adequately reflect the inflammation of the entire colorectum. These findings have significant implications for the use of histology as a clinical target and trial end point in UC.

Recently Graduated Medical Students Lack Exposure to and Comfort with Chronic Liver Diseases.

BACKGROUND: The prevalence of chronic liver disease (CLD) is rising, but it remains unclear if medical school curricula are emphasizing CLD to reflect its growing epidemiology. AIMS: To assess comfort levels and knowledge of CLD among recently graduated medical students METHODS: An anonymous survey was distributed to incoming categorical Internal Medicine (IM) interns at a single academic institution during a 2-year period. The survey consisted of 38 Likert-like questions evaluating comfort levels and self-assessed knowledge for several general medicine and liver diseases, as well as 12 multiple-choice questions to objectively test knowledge. Wilcoxon ranked sum and Fisher's exact test were then used. RESULTS: There was a 100% (n = 65) completion rate. Only 14 (22%) of those surveyed reported exposure to a hepatology rotation in medical school. Highest mean comfort levels (1 = not at all comfortable, 5 = very comfortable) were for managing congestive heart failure (3.59) and chronic obstructive pulmonary disease (3.77). Mean comfort levels for various liver diseases were significantly lower (2.22-3.03, all p < 0.01). Mean self-rated knowledge (1 = no knowledge, 5 = strong knowledge) was also low (2.14-3.13). Although 98% agreed that hepatology is critical to IM training, only 42% agreed that their hepatology education during medical school was adequate. CONCLUSIONS: Recently graduated medical students are less comfortable managing liver diseases compared to other general medical conditions. Only a minority report satisfaction with hepatology education during medical school. These findings suggest that medical curricula need to be modified to better emphasize CLD.

Balloon Tamponade Utilization for Severe Esophagitis Causing Hemorrhagic Shock.

Esophagitis causing upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. We present a case report of two patients with hemorrhagic shock secondary to esophagitis. Both patients underwent esophagogastroduodenoscopy demonstrating severe bleeding pan-esophagitis complicated by hemodynamic instability. Balloon tamponade for hemostasis was performed with resultant hemodynamic improvement. Severe UGIB secondary to esophagitis is difficult to control, with a high risk of complications and limited available endoscopic therapies in extensive mucosal injury. Treatments such as angiography are ineffective due to collateralization and surgery carries high morbidity and mortality. Balloon tamponade provides a rescue option for severe, refractory UGIB secondary to esophagitis.

Mandatory Hepatology Education for Internal Medicine Residents: Long-Term Effects and Implications for Workforce Needs.

We previously created a mandatory, inpatient, hepatology resident curriculum that immediately improved comfort, knowledge, and career interest in chronic liver disease (CLD). The durability of these effects needs to be known to use this intervention to address the hepatologist shortage. Thus, we aimed to assess this curriculum's long-term outcomes on internal medicine (IM) residents' CLD comfort, knowledge, and career interest. From 2015 to 2019 at a single institution, one IM resident was always assigned to the rotation. Similar anonymous assessments were administered to incoming postgraduate year (PGY)-1 residents and graduating PGY-3 residents, including a historic control cohort that graduated in June 2015. At residency completion, the intervention cohort (n = 61) had significantly higher comfort (1, not at all comfortable/strongly disagree; 5, very comfortable/strongly agree) with both hepatology (e.g., hepatitis C, 2.5 vs. 3.3, P < 0.001) and common IM topics (e.g., heart failure, 3.6 vs. 4.8, P < 0.001) but not specialty topics lacking curricula (e.g., inflammatory bowel disease, 2.8 vs. 2.7, P = 0.54). Compared to the historic cohort (n = 27), the intervention cohort was more comfortable in several CLD topics (e.g., cirrhosis, 3.2 vs. 3.8; P = 0.005) and answered more questions correctly (65% vs. 55%; P = 0.04), but career interest was unchanged (1.9 vs. 1.8; P = 0.45). Many residents (33%) would consider a hepatology career if training were separated from gastroenterology. Conclusion: With the completion of a mandatory hepatology curriculum, residents' CLD comfort and knowledge durably improved and exceeded that of historic counterparts. Initial career interest was not sustained, perhaps due to prerequisite gastroenterology training. These findings suggest IM educational initiatives may better address hepatology workforce needs by generating comanagers than by recruiting trainees.

Practical considerations when treating chronic hepatitis E in solid organ transplant recipients.

Hepatitis E virus (HEV) can lead to chronic infections in immunosuppressed patients. The use of ribavirin to treat chronic HEV has been well-established in case reports and guidelines. However, practical approaches to the use of this antiviral treatment in a post-transplant patient, including drug interactions, dosing adjustments, and monitoring parameters, are lacking. Thus, we present our real-world approach to the use of ribavirin to treat chronic HEV in a solid organ transplant recipient.

#LiverTwitter: An Emerging Tool for Liver Education and Research.

#LiverTwitter has emerged as an academic forum that has begun to advance the field of hepatology by disseminating content on chronic liver diseases to a global audience. This article summarizes the content presented in a panel discussion at the 2019 Liver Meeting by highlighting the perspectives of several key types of participants in Twitter: the trainee, the medical educator, the divisional account, the scientific journal, and the passive participant.

Position 1: Transarterial Chemoembolization Should Be the Primary Locoregional Therapy for Unrespectable Hepatocelluar Carcinoma.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-skef a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-interview-mikolajczyk an interview with the author.

A Practical Approach to Polycystic Liver Disease.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/14-5-reading-patel a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/14-5-interview-patel the interview with the author.

The Time Is Now for Mandatory Liver-Focused Clinical Experiences in Medical School.

The national burden of chronic liver disease is steadily increasing and is only expected to worsen with the ongoing obesity and opioid epidemics fueling growth in the prevalence of nonalcoholic fatty liver disease and a resurgence of new hepatitis C infections. Our letter highlights the disparity between the rising prevalence of chronic liver disease and the proportion of medical students who receive exposure to patients with liver disease as part of their medical education. A more comprehensive survey of clerkship directors is needed to further corroborate this data, which may lead to reforms in medical school curricula to better address the expanding burden of chronic liver disease.

Hemolytic Anemia following Stent-Graft Transjugular Intrahepatic Portosystemic Shunt Creation.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is a minimally invasive technique aimed at managing the complications of portal hypertension. Initially performed in the setting of variceal bleeding, the role of TIPS has expanded to treatment of medically refractory ascites, portal hypertensive gastropathy, hepatic hydrothorax, Budd-Chiari syndrome, portal vein thrombus, and hepatorenal syndrome. Potential complications from TIPS are well documented, and include hepatic encephalopathy, hepatic failure, and TIPS dysfunction. Hemolytic anemia is a lesser known complication related to TIPS creation. In this article, a case of hemolytic anemia following TIPS creation using a Viatorr stent-graft in described.

Can reporting more lead to less? The role of metrics in assessing liver transplant program performance.

Appropriate metrics for performance analysis is an active topic of debate within the transplant community. This study explores current proposals on metric expansion as well as potential metrics and prospective collaborations that have not received widespread discussion within the transplant community. The premature introduction of additional, nonvalidated metrics risks behaviors that may undermine donor utilization and patient access to transplantation.