Early experience with cap-assisted endoscopic pancreatic necrosectomy: A technique to enhance safe tissue extraction and decrease interventions.

Background and study aim Endoscopic treatment of walled-off pancreatic necrosis (WOPN) has been established as an alternative to operative intervention for well selected patients for many years. Patients and methods A retrospective database of patients who underwent cap-assisted endoscopic necrosectomy of symptomatic or infected WOPN using the assistance of a sterilized banding cap was constructed. All procedures were performed at a single center between January 2017 and June 2018. Results Eight patients met the inclusion criteria for this study. Contrast computed tomography scan was obtained between the initial percutaneous or trans-gastric access and initial necrosectomy. The WOPN had a median length of 9.5 cm (range 3.2 - 14) and width of 5.3 cm (range 2.8 - 11.6). Median duration of endoscopic debridement was 69 minutes (range 21 - 105). Four of six patients underwent a second debridement with a median duration of 95 minutes (range 16 - 108). No periprocedural adverse events occurred. Follow-up was at 6 months, and there were no additional endoscopic or percutaneous interventions for recurrent pancreatic fluid collections. Conclusion The technique of cap-assisted necrosectomy can allow for safe and efficient method of endoscopically treating WOPN.

The Value of Quick Sepsis-Related Organ Failure Assessment Scores in Patients With Acute Pancreatitis Who Present to Emergency Departments: A Three-Year Cohort Study.

BACKGROUND: Distinguishing sepsis from other inflammatory syndromes continues to be a clinical challenge. The goal of risk stratification tools is to differentiate sepsis from other conditions. We compare the ability of quick sepsis-related organ failure assessment (qSOFA) and systemic inflammatory responses syndrome (SIRS) scores to predict prolonged length of stay (LOS) among patients who presented to the emergency department and hospital ward with acute pancreatitis (AP). METHODS: We compiled a retrospective database of all adult patients hospitalized for AP during 2015 - 2018 at a single tertiary care center. Independent t-tests, Pearson's correlation and multiple regressions were performed with hospital LOS as the dependent variable, versus demographic characteristics and etiology of the pancreatitis as independent variables. Prolonged LOS was defined as > 5 days. RESULTS: The sensitivity and specificity of an SIRS score of 2 or greater for the detection of patients with prolonged LOS were 61% and 80%, respectively. The qSOFA score of 2 or greater corresponded to a diagnosis of significant AP with a specificity of 99% and a sensitivity of 4%. Multiple regression analysis demonstrated that each point increase in an SIRS score is associated with 2.24 days in additional hospital LOS. Interestingly, SIRS scores were found to correlate with the LOS, but not qSOFA. CONCLUSION: The qSOFA is a tool designed to identify patients at high risk of mortality due to sepsis. The data suggest that as with sepsis, patients with AP who are triaged with only qSOFA could be underrecognized and subsequently undertreated. Secondarily, the data suggest that SIRS scoring has the potential to promptly predict how long patients with AP will stay in the hospital.

Economical effect of lumen apposing metal stents for treating benign foregut strictures.

AIM: To evaluate the clinical and economical efficacy of lumen apposing metal stent (LAMS) in the treatment of benign foregut strictures. METHODS: A single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and five-parameter regression analysis. RESULTS: Nine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS (stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall. LAMS was cost effective after two dilations in the Post-surgical stricture subgroup. CONCLUSION: Endoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.

Evaluation of correlations between frequencies of complete denture relines and serum levels of 3 bone metabolic markers: A cross-sectional pilot study.

STATEMENT OF PROBLEM: Continuous bone resorption is the primary reason for complete denture relines. Because resorption rates vary, the frequency at which individuals require relines also varies. Currently, there are no predictors to identify individuals at risk of frequent relines or to guide clinicians in decisions related to relines. PURPOSE: The purpose of this cross-sectional pilot study was to determine the utility of measuring bone metabolic markers (C-terminal telopeptide, osteocalcin, 25-OH hydroxy vitamin D) to predict the frequency of complete denture relines. MATERIAL AND METHODS: One hundred adult participants with complete dentures (either maxillary, mandibular, or both) participated in 1 dental clinic visit involving a dental examination and brief interview to obtain relevant medical and dental history, information on medication/supplement use, and 1 laboratory blood draw for the measurement of bone metabolic markers. Data were analyzed by using the Pearson correlation, independent Student t test, or analysis of variance (α=.05). RESULTS: Significant correlations were found between the frequency of relines and C-telopeptide and osteocalcin levels but not with vitamin D or age. No significant associations with reline frequency and other factors (sex, ethnicity, presence or absence of diabetes, use of calcium and vitamin D supplements) were observed. CONCLUSIONS: Elevated levels of bone turnover markers in individuals with edentulism were associated with increased frequency of denture relines.

A Rare Case of Nephrocolic Fistula Resulting from Radio Frequency Ablation (RFA) of Renal Cell Carcinoma.

Nephrocolic fistula is a rare, abnormal fistulous connection between the urinary system (kidney/ureters) and colon. Different benign and malignant etiologies are implicated in the formation of a nephrocolic fistula. Even though conservative treatment options have been tried recently (especially for benign etiologies), surgical resection has been the treatment of choice and should be pursued if conservative management fails. We report the first case of a nephrocolic fistula after a radiofrequency ablation of a renal cell carcinoma, which required surgical resection after conservative management failed.

"Page Me if You Need Me": The Hidden Curriculum of Attending-Resident Communication.

BACKGROUND: Discrepancies exist between what resident and attending physicians perceive as adequate supervision. We documented current practices in a university-based, categoric, internal medicine residency to characterize these discrepancies and the types of mixed messages that are communicated to residents, as well as to assess their potential effect on resident supervision and patient safety. METHODS: We surveyed residents and attending physicians separately about their current attitudes and behaviors regarding resident supervision. Both groups responded to 2 different measures of resident supervision: (1) 6 clinical vignettes that involved patient safety concerns, and (2) 9 frequently reported phrases communicated by attending physicians to residents before leaving the hospital during on-call admission days. RESULTS: There were clear and substantial differences between the perceptions of resident and attending physicians about when the supervising attending physician should be notified in each of the 6 vignettes. For example, 85% of attending physicians reported they wanted to be notified of an unexpected pneumothorax that required chest tube placement, but only 31% of resident physicians said they would call their attending physician during those circumstances. Common phrases, such as "page me if you need me," resulted in approximately 50% of residents reporting they would "rarely" or "never" call and another 41% reporting they would only "sometimes" call their attending physicians. CONCLUSIONS: Our study found that attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians. Although this discrepancy exists, commonly used phrases, such as "page me if you need me," rarely resulted in a change in resident behavior, and attending physicians appeared to be aware of the ineffectiveness of these statements. These mixed messages may increase the difficulty of balancing the dual goals of appropriate attending supervision and progressive independence during residency training.