Darrell M. Gray

Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

The sense of accomplishment you felt as a resident newly-matched into your chosen field of gastroenterology gradually morphs into a combination of excitement, anticipation, and indeed a healthy amount of trepidation, as you inch closer to the start of your fellowship. But fear not. While fellowship is no doubt a character-building experience, presenting unique challenges, it can be effectively navigated with a deliberate approach. This article is intended to serve as a roadmap to guide you in successfully completing your gastroenterology fellowship.

Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome.

Cameron lesions, as defined by erosions and ulcerations at the diaphragmatic hiatus, are found in the setting of gastrointestinal (GI) bleeding in patients with a hiatus hernia (HH). The study aim was to determine the epidemiology and clinical manifestations of Cameron lesions. We performed a retrospective cohort study evaluating consecutive patients undergoing upper endoscopy over a 2-year period. Endoscopy reports were systematically reviewed to determine the presence or absence of Cameron lesions and HH. Inpatient and outpatient records were reviewed to determine prevalence, risk factors, and outcome of medical treatment of Cameron lesions. Of 8260 upper endoscopic examinations, 1306 (20.2%) reported an HH. When categorized by size, 65.6% of HH were small (<3 cm), 23.0% moderate (3-4.9 cm), and 11.4% were large (≥5 cm). Of these, 43 patients (mean age 65.2 years, 49% female) had Cameron lesions, with a prevalence of 3.3% in the presence of HH. Prevalence was highest with large HH (12.8%). On univariate analysis, large HH, frequent non-steroidal anti-inflammatory drug (NSAID) use, GI bleeding (both occult and overt), and nadir hemoglobin level were significantly greater with Cameron lesions compared with HH without Cameron lesions (P ≤ 0.03). Large HH size and NSAID use were identified as independent risk factors for Cameron lesions on multivariate logistic regression analysis. Cameron lesions are more prevalent in the setting of large HH and NSAID use, can be associated with GI bleeding, and can respond to medical management.

Patient Navigation—An Effective Strategy to Reduce Health Care Costs and Improve Health Outcomes

Patient navigation (PN) was formally defined by Freeman in 1990 in response to high breast cancer mortality rates observed among African American women in Harlem, New York.1 It is designed to help patients complete recommended tests , appointments, and treatments by identifying and resolving barriers to care.1 The single-site observational data by Freeman showed the influence of PN on breast cancer mortality rates1; however, randomized trials were needed to truly validate PN. The Patient Navigation Research Program (PNRP), funded by the National Cancer Institute and the American Cancer Society, did exactly this. Both the individual study site results2 and the combined analysis3 demonstrated that PN reduced delays in diagnostic resolution and start of treatment among patients, predominantly minority or underserved, for 4 types of cancer. Unfortunately, the cost analysis, which did not use the same primary outcome as the combined analysis, did not find any cost savings for PN.4 Nonetheless, the PNRP results were influential in the mention of PN in the Patient Protection and Affordable Care Act and the inclusion of PN in the American College of Surgeons Commission on Cancer accreditation process. However, PN is an unfunded mandate. What is needed is evidence on the cost-effectiveness of PN, as well as which model might work best in achieving better cost-benefit and health outcomes. The study by Rocque et al5 in this issue of JAMA Oncology provides some evidence to justify coverage of PN by major insurers and the Centers for Medicare & Medicaid Services, as well as clarity on models of PN. Within The University of Alabama at Birmingham Health System Cancer Community Network, a natural experiment provided the setting to evaluate a lay PN program in terms of health care spending and resource use in a Medicare population. Using propensity score–matched regression analyses to compare the period before PN with the period during PN, the team found that PN saved the health care system an estimated

Attempted Endoscopic Closure of a Pancreaticocolonic Fistula with an Over-The-Scope Clip

19 million per year in inpatient, outpatient, emergency department, hospitalization, and intensive care unit costs. Lay navigators, a less costly and more voluminous workforce compared with nurse navigators, were assigned to patients with cancer throughout the cancer care continuum, from diagnosis to treatment and survivorship or end of life. The successful use of lay navigators in this study complements PNRP data showing that more clinically trained navigators (eg, nurses) tended to be pulled into nonnavigation clinical duties that took time away from PN duties,6 making them less efficient. What do patient navigators do that makes them so important? As described in the article by Rocque et al,5 navigators identify barriers to care that each patient has and help resolve those barriers so that patients can get the care they need on time and adhere to medication regimens to stay out of the emergency department and hospital. In the example of breast cancer, as described by Daly and Olopade,7 PN can address patterns of care, mainly access to timely, appropriate care that is essential to reducing cancer health disparities. In addition, and this point cannot be overemphasized, navigators often have more time to spend with patients than physicians, physician assistants, and nurse practitioners do and are trained in skills that these care professionals may not possess. Therefore, having navigators in the health care team can increase efficiency and address more broad causes for cancer health disparities. With the strong evidence from many well-designed studies of PN, the latest being this large study by Rocque et al,5 there is little doubt that PN is effective in terms of cost savings and health outcomes. Therefore, the Centers for Medicare & Medicaid Services and insurers should cover PN, as directed in the Patient Protection and Affordable Care Act, to help control health care costs and to reduce the burden of cancer, especially in underserved populations.

Toothpick Perforation of the Small Bowel

CONTEXT Spontaneous development of fistulae is an uncommon complication of acute pancreatitis. Until recently, surgical management has been the standard of care. Endoscopic treatment has been described with hemoclips and glue. CASE REPORT We report a case of a gentleman with a history of recurrent episodes of acute pancreatitis who presented with symptoms correlating with the development of a pancreatic-colonic fistula. Closure of the fistula was attempted with an over-the-scope clip. CONCLUSION More evidence is needed to determine criteria for use of over-the-scope clip in closure of GI and pancreatic fistulae.

Insights into insulin resistance, lifestyle, and anthropometric measures of patients with prior colorectal cancer compared to controls: A National Health and Nutrition Examination Survey (NHANES) Study

A 39-year-old male presented to our gastroenterology clinic with a 6 month history of intermittent cramping and sharp bilateral lower quadrant abdominal pain. He reported associated constipation, bloating, infrequent nausea and vomiting, occasional exacerbation of pain with food intake, and a 10 pound weight loss. He had been evaluated by his primary care physician 4 months earlier. At that time, his evaluation was notable for a white blood cell count of 15,000/mm3. Comprehensive metabolic panel and thyroid stimulating hormone were within normal limits and an abdominal x-ray showed a normal bowel gas pattern. At the time of our evaluation in the gastroenterology clinic, he was well-appearing and in no distress. He had no significant past medical history and was not taking any medications. Abdominal examination revealed normoactive bowel sounds, moderate tenderness and mild guarding to palpation in the right lower quadrant without rebound. His white blood cell count was significantly elevated at 25,300/mm3. A computed tomography scan of the abdomen and pelvis showed a linear foreign body extending from the lumen of a distal loop of small bowel through the bowel wall with minimal surrounding inflammation (Figure A, red circle). The patient was taken to the operating room and underwent an exploratory laparotomy which revealed a wooden toothpick perforating the small bowel at both ends of the toothpick with significant surrounding inflammation and adhesions (Figure B). He required lysis of adhesions and small bowel resection with primary stapled anastomosis. Postoperatively, the patient admitted a history of chewing toothpicks and was not aware that he had swallowed a toothpick. However, his wife reported that he often fell asleep with a toothpick in his mouth. Toothpick perforations of the gastrointestinal tract are uncommon, with an incidence of approximately 0.2 per 100,000 persons annually in the U.S.1 but are associated with a high mortality rate of 20–80%.2 The most common site of injury is the duodenum followed by the sigmoid colon and ileum. Imaging studies vary in their sensitivity in detecting toothpicks, but are often inadequate. Definitive diagnosis is most commonly made at the time of surgical exploration. Li et al reported that the duration of symptoms before diagnosis ranged from 1 day to 9 months and that the diagnosis was established by laparotomy in 53% of cases as opposed to imaging studies in 14%.2 This case highlights a rare cause of small bowel injury and the complications and mortality associated with it.

Disparities in breast cancer tumor characteristics, treatment, time to treatment, and survival probability among African American and white women

BACKGROUND Insulin resistance (IR) increases the risk of index colorectal cancer (CRC) development. Limited data exist on IR values, lifestyle, and anthropometric alterations of patients after CRC diagnosis, a population at high risk for CRC recurrence. METHODS This is a retrospective cohort study using the National Health and Nutrition Examination Survey (NHANES), 1999-2010. We identified patients with and without prior CRC above age 50. Our outcomes were lifestyle, anthropometric measures, and IR measured using the triglyceride to high-density lipoprotein ratio and the homeostasis model assessment IR. RESULTS There were 146,841 patients with prior CRC and 26,979,507 without prior cancer (controls) in our cohort. Prior patients with CRC were significantly older than controls (75.8 vs 62.3, P < 0.01), however, there were no significant differences in gender, ethnicity, income, caloric intake, tobacco use or alcohol consumption between both groups. Multivariate analysis revealed no difference between prior patients with CRC and controls in triglyceride to high-density lipoprotein ratio (adjusted percentage change = -2.17; 95% CI: -27.96 to 18.43) or homeostasis model assessment IR (adjusted percentage change = -6.85; 95% CI: -35.74 to 15.90). Despite similar weight at age 25, prior CRC subjects had lower weights compared to controls (at time of NHANES survey, one and 10 years before survey and greatest weight). Furthermore prior CRC subjects gained less weight in the 10 years before survey. CONCLUSION Patients with prior CRC above age 50 have no conclusive evidence of increased IR compared to non-CRC controls. This is possibly due to lesser weight gain in the peri-CRC diagnosis or treatment period. Future efforts should focus on alternate etiologies for the increased CRC recurrence in this high-risk group.

Coeliac disease screening is suboptimal in a tertiary gastroenterology setting

African American (AA) women have a 42% higher breast cancer death rate compared to white women despite recent advancements in management of the disease. We examined racial differences in clinical and tumor characteristics, treatment and survival in patients diagnosed with breast cancer between 2005 and 2014 at a single institution, the James Cancer Hospital, and who were included in the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Cancer Registry in Columbus OH. Statistical analyses included likelihood ratio chi-square tests for differences in proportions, as well as univariate and multivariate Cox proportional hazards regressions to examine associations between race and overall and progression-free survival probabilities. AA women made up 10.2% (469 of 4593) the sample. Average time to onset of treatment after diagnosis was almost two times longer in AA women compared to white women (62.0 days vs 35.5 days, p < 0.0001). AA women were more likely to report past or current tobacco use, experience delays in treatment, have triple negative and late stage breast cancer, and were less likely to receive surgery, especially mastectomy and reconstruction following mastectomy. After adjustment for confounding factors (age, grade, and surgery), overall survival probability was significantly associated with race (HR = 1.33; 95% CI 1.03–1.72). These findings highlight the need for efforts focused on screening and receipt of prompt treatment among AA women diagnosed with breast cancer.Racial disparity: African Americans face delayed treatmentAfrican Americans with breast cancer wait longer to get treated and then live shorter than white women, a US cancer center’s records show. Electra Paskett and her colleagues from Ohio State University in Columbus examined racial differences in tumor characteristics and patient outcomes among the 4,593 women treated for breast cancer at their institution’s affiliated hospitals between 2005 and 2014. They found that the time between diagnosis and treatment onset was longer for African Americans — 62 days compared to 35.5 days for white women. African Americans were also more likely to have harder-to-treat forms of disease and they were less likely to undergo surgery. Even accounting for many of these factors, African American women still had worse outcomes, as measured by survival probability. The findings highlight the need address racial disparities in breast cancer treatment.

The Link Between Clinically Validated Patient Safety Indicators and Clinical Outcomes

Background and aims Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. Methods Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. Results 616 consecutive patients (49±0.6 years, range 16–87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. Conclusions More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.

Morbid Obesity is Associated with Increased Mortality, Surgical Complications, and Incremental Health Care Utilization in the Peri-Operative Period of Colorectal Cancer Surgery

There is a paucity of evidence on the association between clinically validated Patient Safety Indicators (PSIs) and inpatient length of stay, mortality, and 30-day unplanned readmission. The authors perform a retrospective analysis of patient discharges from an academic medical center comprising 6 hospitals from July 2012 to June 2014. Multivariable regression models are used to assess the relationship between length of stay, mortality, and 30-day unplanned readmission and the presence of a clinically validated PSI. Cases flagged with a clinically validated PSI are associated with a statistically greater length of stay, 30-day unplanned readmission, and mortality as compared to cases without a PSI. This study demonstrates a strong association between clinically validated PSIs and patient outcomes. The findings have important implications in policy and practice as health care reform dictates improvement in the experience of care, health of populations, and per capita costs.