Navin L. Kumar

The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding

INTRODUCTION We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). OBJECTIVE To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS). DESIGN Retrospective cohort study. PATIENTS Adults with a primary diagnosis of UGIB. MAIN OUTCOME MEASUREMENTS PRIMARY OUTCOME inpatient mortality. SECONDARY OUTCOMES composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. RESULTS Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. LIMITATIONS Retrospective, single-center study. CONCLUSION The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience

Introduction Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. Results All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. Conclusion POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Initial management and timing of endoscopy in nonvariceal upper GI bleeding.

Upper GI bleeding (UGIB) from a nonvariceal source is a common cause of hospital admission, accounting for nearly 300,000 hospitalizations per year in the United States alone. The costs to manage patients with UGIB are rising, with in-hospital nationwide expenditures increasing from

Osteoblastoma-like Osteosarcoma of the Cuboid: A Case Report.

3.3 billion in 1989 to

Gastroenterology Fellowship Match: An Inside Look

7.6 billion in 2009. Although the estimated mortality rate has been widely reported to be 5% to 14%, recent evidence suggests that in-hospital mortality has decreased to approximately 2%, most likely because of advances in both medical and endoscopic therapies. The initial management of patients with nonvariceal UGIB includes resuscitation, close hemodynamic monitoring, treatment with a proton pump inhibitor, management of antithrombotics, and, in some patients, blood transfusion. The next step in management is typically endoscopy. Current guidelines recommend that endoscopy be performed within 24 hours of presentation in patients with nonvariceal UGIB. However, the role of more urgent endoscopy, especially with regard to patients presenting with higher-risk bleeding episodes, remains controversial. In this article we review the existing literature on initial management of nonvariceal UGIB and on the timing of endoscopy.

An active learning curriculum improves fellows’ knowledge and faculty teaching skills

Osteosarcoma most commonly arises in the long bones of the skeleton, and rarely develops in the bones of the foot. We describe a patient who presented with left foot pain, whose radiographic evaluation revealed a lytic destructive mass in the cuboid bone. A biopsy showed an osteoblastoma-like variant of osteosarcoma and the patient was treated with preoperative chemotherapy and amputation. Osteosarcoma of the foot is uncommon and the literature reveals that it is often associated with a delay in diagnosis.

Accuracy of Intensive Care Unit Triage and Assessment of Mortality of a Novel Upper Gastrointestinal Bleeding Score (AIMS65)

Gastroenterology (GI) fellowships continue to be highly sought after by internal medicine residents interested in pursuing subspecialty training. Indeed, a recent study published in Digestive Diseases and Sciences reported that GI fellowships had the highest number of applicants per available position among the major subspecialties within internal medicine (IM) [1]. Despite its popularity, applicant characteristics that may influence one’s candidacy for a GI fellowship position are not well described in the literature. From the late 1990s–early 2000s, during which the GI fellowship match was abandoned, studies noted a geographical association between an applicant’s site of IM residency and his or her GI fellowship training. For example, Niederle et al. [2] found that during this era, fellowship programs increasingly relied on internal applicants (e.g., candidates from the same institution’s IM residency program) to fill GI fellowship positions. Following the reinstatement of the match in the US, little is known about how geography influences the application process from the perspective of the applicant and the fellowship program. Of note, a recent study of Canadian residents who matched in a GI fellowship program did find that applicants ranked a suitable location as the most important factor when choosing a training site [3]. Research from other disciplines of medicine has also identified location as an important consideration in the application process—notably from the perspective of program leadership [4, 5]. In a survey study of the pediatric otolaryngology fellowship application process, program directors ranked “prior knowledge of an applicant” as a top consideration in determining an applicant’s candidacy—a factor that would preferentially benefit internal candidates [5]. And thus, the question for GI fellowship applicants and program directors remains—how does the applicant’s site of IM residency training actually impact the application process? In this issue of Digestive Diseases and Sciences, Atsawarungruangkit et al. [6] investigated the potential influence of the geographical location of a US applicant’s residency training program on the results of the GI fellowship match. The authors searched the medical professional network database Doximity for gastroenterologists who graduated from fellowship between 2010 and 2019 and also listed their respective fellowship and IM residency programs. GI physicians were then categorized as internal applicants if they graduated from the same institution for both IM residency and GI fellowship versus external applicants if the two programs differed. The authors also compared the location of a GI physician’s IM residency and GI fellowship in terms of state as well as US Census Bureau-defined division (e.g., Pacific) and region (e.g., West). A total of 1489 GI physicians were included in the study, with nearly 40% identified as internal applicants who matched at the same institution for both IM residency training and GI fellowship. The authors also found that 53% of applicants matched in the same state, 61% matched in the same division, and 72% matched in the same region. The distribution of internal, in-state, in-division, and in-region applicants varied in different locations of the US. The study authors state that an applicant’s geographical site of IM training is a major factor influencing a GI fellowship program’s decision to interview and rank applicants. The findings of this study provide new data regarding the potential influence that the location of an applicant’s IM residency program has in determining his or her GI fellowship program candidacy. The authors successfully gathered data over ten successive fellowship matches on a large sample of GI physicians using a publicly available medical professional network. The study results also intuitively make sense, for many of the reasons outlined in the study. Internal applicants may rotate on the GI service or pursue research projects within the same institution as residents, thereby increasing the familiarity between both applicant and fellowship program. There is also likely increased communication * Navin L. Kumar nlkumar@bwh.harvard.edu

The Impact of Colonscopic Electrocautery on Pacemaker Function

Objectives Traditional didactic lectures are the mainstay of teaching for graduate medical education, although this method may not be the most effective way to transmit information. We created an active learning curriculum for Brigham and Women’s Hospital (BWH) gastroenterology fellows to maximize learning. We evaluated whether this new curriculum improved perceived knowledge acquisition and knowledge base. In addition, our study assessed whether coaching faculty members in specific methods to enhance active learning improved their perceived teaching and presentation skills. Methods We compared the Gastroenterology Training Exam (GTE) scores before and after the implementation of this curriculum to assess whether an improved knowledge base was documented. In addition, fellows and faculty members were asked to complete anonymous evaluations regarding their learning and teaching experiences. Results Fifteen fellows were invited to 12 lectures over a 2-year period. GTE scores improved in the areas of stomach (p<0.001), general gastroenterology (p=0.005), esophagus (p<0.001), and small bowel (p=0.001), and the total score (p=0.001) between pre- and postimplementation of the active learning curriculum. Scores in hepatology, as well as biliary and pancreatic study, showed a trend toward improvement (p>0.05). All fellows believed the lectures were helpful, felt more prepared to take the GTE, and preferred the interactive format to traditional didactic lectures. All lecturers agreed that they acquired new teaching skills, improved teaching and presentation skills, and learned new tools that could help them teach better in the future. Conclusion An active learning curriculum is preferred by GI fellows and may be helpful for improving transmission of information in any specialty in medical education. Individualized faculty coaching sessions demonstrating new ways to transmit information may be important for an individual faculty member’s teaching excellence.

Bone morphogenic protein-7 inhibits progression of chronic renal fibrosis associated with two genetic mouse models

Purpose: Upper gastrointestinal bleeding is associated with a mortality of 3-15%. Previously, using data from more than 60,000 patients, we derived and validated a score to predict mortality in patients with upper gastrointestinal bleeding. Five factors at the time of initial presentation were included in the score: albumin 1.5, altered mental status, systolic blood pressure 65 years (AIMS65). Mortality risk was characterized as low (AIMS65 < 2 risk factors) or high (AIMS65 ≥ 2 risk factors). The aim of the current study was to determine if the AIMS65 risk stratification score can predict the need for intensive care unit (ICU) admission and mortality in a separate patient population. Methods: This was a retrospective cohort study at a tertiary care teaching hospital from 2004-2009. Our hospitals research patient database was queried for ICD-9 codes related to upper GI bleeding. A diagnosis of upper GI bleeding was then confirmed by review of discharge summaries. Patients were excluded if they lacked documentation of the data required to calculate the AIMS65 score or if it could not be determined whether they had been admitted to an ICU. Patients were categorized as low-risk (AIMS65 score < 2) or highrisk (AIMS65 score ≥ 2). The outcomes of interest were triage decision (ICU or medical ward) and in-hospital mortality. Results: A total of 278 patients included. There were 198 patients who were low-risk and 80 who were high-risk based upon their AIMS65 score. Low-risk patients were less likely to be admitted to the ICU compared with high-risk patients (19 versus 51%, p <0.001). Overall mortality was lower among patients with low scores compared with patients with high scores (0.5% versus 21%, p <0.001). Among patients who were admitted to the ICU, 0/38 (0%) low-risk and 13/41 (31.7%) high-risk patients died (p <0.001). Among patients who were not admitted to the ICU, 1/160 (0.6%) lowrisk and 4/39 (10.3%) high-risk patients died (p <0.01). Conclusion: Patients with high AIMS65 scores are more likely to be admitted to an ICU than patients with low scores. In addition, patients with high scores have significantly higher mortality rates. Using the AIMS65 score, we identified high risk patients who died without admission to the ICU. These results suggest that the AIMS65 score, which is easily applied at the time of admission, may be a helpful risk stratification tool to aid with the triage of high-risk patients with upper gastrointestinal bleeding.

Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding.

The Impact of Colonscopic Electrocautery on Pacemaker Function Navin Kumar, Hemant Roy, Alan Zunamon, Eva Gliwa, Mick Meiselman, Michael Goldberg, Tat-Kin Tsang, Randall Brand Background: While some guidelines advocate inactivation of pacemakers prior to use of electrocautery for colonoscopic polypectomy, this is not done by most endoscopists. These recommendations are based upon expert opinion, small non-blinded studies and anecdotal case reports. In order to provide evidencebased insight into this issue, we performed a pilot study analyzing the risk of electrocardiographic abnormalities during cautery. Methods: A total of 19 patients were enrolled in this study. Each patient had rhythm strips run preand post-colonoscopy, when the cecum was reached and during all episodes of cautery use. Continuous ECG rhythm monitoring was also performed during the colonoscopy. The technique (continuous vs. brief, short bursts) of cautery was dependent on the endoscopist preference. The grounding electrode was placed on the patient’’s buttock or thigh. Identified preand post-procedure strips along with either an unidentified cecal (control) or cautery strip were grouped together and evaluated by a cardiologist blinded to the cautery status of the third strip. Results: Eight of the 19 patients underwent a total of 18 polypectomies using electrocautery. No incidence of pacemaker dysfunction or change in cardiac rhythm occurred in the control or cautery groups. All 19 patients tolerated each colonoscopy without any other adverse cardiac events or complications. Conclusion: This study suggests that electrocautery use is safe in patients with pacemakers as along as the electrocautery pad is positioned on the lower part of the body away from the pacemaker. To our knowledge this is the first blinded, prospective trial demonstrating the safety of performing electrocautery during colonoscopy in patients with a pacemaker. If confirmed with larger patient numbers, this would strongly argue for new practice recommendations.