Sumant Inamdar

Comparison of Adverse Events for Endoscopic vs Percutaneous Biliary Drainage in the Treatment of Malignant Biliary Tract Obstruction in an Inpatient National Cohort.

IMPORTANCE Nonsurgical biliary drainage in malignant biliary tract obstruction can be performed endoscopically by endoscopic retrograde cholangiopancreatography (ERCP) or by percutaneous transhepatic biliary drainage (PTBD). The published body of literature to support either approach is surprisingly sparse, is conflicting on the preferred approach, and is limited by small studies with heterogeneous groups. OBJECTIVE To evaluate the procedure-related adverse event rate with endoscopic vs percutaneous drainage in patients with malignant biliary tract obstruction. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective analysis from the National Inpatient Sample (NIS) database from 2007 through 2009. Data analysis was performed in 2015. Patients from the NIS database are representative of the US population and are included from both community and tertiary care hospitals in the United States. MAIN OUTCOMES AND MEASURES Procedure-related adverse event rates. RESULTS A total of 7445 patients were included for ERCP and 1690 for PTBD. The overall adverse event rate was 8.6% for endoscopic drainage (640 events) and 12.3% for percutaneous biliary drainage (208 events) (P < .001). When analyzed by type of malignant neoplasm, ERCP was associated with a lower rate of adverse events compared with PTBD for pancreatic cancer (2.9% vs 6.2%; odds ratio [OR], 0.46 [95% CI, 0.35-0.61]; P < .001) and cholangiocarcinoma (2.6% vs 4.2% OR, 0.62 [95% CI, 0.35-1.10]; P = .10). For pancreatic cancer, endoscopic procedures were associated with a lower rate of adverse events regardless of the volume of percutaneous procedures performed by a center. For cholangiocarcinoma, centers that performed a low volume of percutaneous biliary drainage procedures were more likely to have adverse events compared with endoscopic procedures performed at the same center (5.7% vs 2.5%; OR, 2.28 [95% CI, 1.02-5.11]; P = .04). In centers that performed a high volume of percutaneous drainage procedures, rates of adverse events were similar to those of endoscopic adverse events (3.5% vs 3.0%; OR, 1.18 [95% CI, 0.53-2.66]; P = .68). CONCLUSIONS AND RELEVANCE Our results support the finding that endoscopic biliary drainage for malignant biliary obstruction is a first-line intervention. Endoscopic drainage is superior to percutaneous drainage, in regard to adverse event rate, for patients with pancreatic cancer. For patients with cholangiocarcinoma, endoscopic drainage is superior in centers that perform a low volume of percutaneous biliary drainage procedures.

Clinical and Nonclinical Factors Associated With Potentially Preventable Hospitalizations Among Nursing Home Residents in New York State

OBJECTIVE Identify clinical and nonclinical factors associated with potentially preventable ambulatory care sensitive (ACS) hospitalization among nursing home residents. METHODS Residents (n=26,746) of 147 randomly selected nursing homes in New York State. Data included sociodemographics and clinical and nonclinical related factors. Multivariate linear regression quantified the association between potential determinants and ACS hospitalization. RESULTS Four factors significantly associated with reduction in ACS hospitalization included nursing staff trained to communicate effectively with physicians regarding a residents condition (P < .0001), physicians treat residents within the nursing home and admit to hospital as a last resort (P < .0001), provide better information and support to nurses and aides surrounding end-of-life care (P < .0001), and easy access to stat lab results in <4 hours on weekends (P < .0001). Two factors significantly associated with increased ACS hospitalization are: perceived likelihood illness will cause death (P < .0001) and perceived inadequate access to medical history/lab/EKGs (P < .0001). CONCLUSION Preventable ACS hospitalization reduction depends on effective communication between physicians and nursing staff, providing physicians with easy access to stat results in <4 hours on weekends, and easy access to medical records/lab/EKGs. Use of electronic medical records and providing training to nursing staff on how to communicate effectively with physicians and how to articulate about a residents condition may minimize preventable ACS hospitalizations.

Decompensated cirrhosis may be a risk factor for adverse events in endoscopic retrograde cholangiopancreatography

There are limited data regarding the safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis. The current literature consists of small series totalling less than 225 patients.

Weekend vs. Weekday Admissions for Cholangitis Requiring an ERCP: Comparison of Outcomes in a National Cohort

OBJECTIVES:There has been increasing medical literature showing worse outcomes in patients admitted for medical and surgical conditions on the weekend. This has been termed the weekend effect. Little is known whether this weekend effect occurs for patients with cholangitis who require endoscopic retrograde cholangiopancreatography (ERCP), a procedure that requires many resources from the nursing staff, anesthesia, and the endoscopist.METHODS:Retrospective analysis from the National Inpatient Sample (NIS) database from 2009 through 2012. Patient data were abstracted from the database for patients admitted on the weekend and weekday with cholangitis who underwent ERCP. Time to ERCP, length of stay, total cost, and mortality were compared in patients admitted with cholangitis on the weekend vs. weekday who required ERCP. ERCP adverse events were recorded from the weekend vs. weekday as well.RESULTS:Twenty-three thousand six-hundred sixty-one patients were identified in the NIS database who were admitted for cholangitis who required ERCP in the study period, of which 18,106 (76.5%) patients were admitted on the weekday, whereas 5,555 (23.5%) were admitted on the weekend. By 24 h, the weekday group had undergone ERCP more frequently than the weekend group (54.6 vs. 43%; P<0.001). By 48 h, the weekday group had undergone ERCP more frequently than the weekend group (70 vs. 65.4%; P<0.001). By 72 h, both groups had undergone a similar rate of ERCP (79.7 vs. 78.9%; P=0.17). There was no statistical difference between the groups for in-hospital all-cause mortality (2.86 vs. 2.56%; P=0.24), length of stay (6.97 days vs. 6.88 days; P=0.28), or total cost of hospitalization (

Preventable hospitalization among nursing home residents: varying views between medical directors and directors of nursing regarding determinants.

71,552 vs

Targeting neoplasia using volumetric laser endomicroscopy with laser marking

71,469; P=0.94).CONCLUSIONS:Despite a delay in regard to time to ERCP for weekend admissions, there was no weekend effect observed in regard to length of stay, mortality, or total cost of hospitalization. Although biliary drainage with ERCP is important, these results suggest that other factors in the management of cholangitis (e.g., antibiotics and intravenous fluids) contribute to outcomes.

Feasibility of liquid nitrogen cryotherapy after failed radiofrequency ablation for Barrett's esophagus

Objectives: To compare the perception of the determinants of preventable hospitalization among nursing home residents by surveying medical directors (MDs) and directors of nursing (DONs). Methods: A survey (N = 52) was completed in January 2008. Data included resource availability, determinants of hospitalization, and nursing home practice. Multivariate linear regression examined the associations between potential determinants and preventable hospitalization. Results: Four significant determinants perceived by MDs to influence preventable hospitalization: MD/nurse practitioner (NP) access by pager, family preferences, access to medical history and lab/ electrocardiograph (EKG) reports, and physicians better paid to manage acutely ill residents (R 2 = .58). None of these factors were echoed by DONs (R 2 = .15). Whereas DONs perceived stat lab results on weekends were associated with increased hospitalization (p = .03), MDs did not (p = .28). Conclusions: Our analysis showed that communication and consensus are important factors in the hospital transfer decision and that the discord in perceptions among MDs and DONs may complicate interventions to reduce preventable hospitalization.

Learning curve and competence for volumetric laser endomicroscopy in Barrett’s esophagus using cumulative sum analysis

Volumetric laser endomicroscopy (VLE) is a recent advanced imaging technology that allows high resolution microstructure imaging of the esophagus and gastric cardia; it has been increasingly used in Europe and the USA [1–3]. The system has been recently upgraded to include a laser marking device that places cautery marks on the mucosa to provide targets for histology. We report a case of an incidental finding of focal high grade dysplasia targeted using this new technology. A 69-year-old man was referred for advanced imaging and removal of a gastroesophageal junction polyp. The polyp was visualized, using high definition resolution white-light endoscopy (HDR-WLE), on the cardia side of the gastroesophageal junction (▶Fig. 1; ▶Video1). It was a mobile pedunculated polyp with its base at the gastric cardia (Paris classification 0–1p). It is our practice to use VLE for high resolution imaging of mucosal pathology in the esophagus and gastroesophageal junction. We used a 20-mm balloon containing the VLE probe (▶Fig. 2). VLE showed that the polyp of interest did not contain any of the VLE characteristics that have been associated with neoplasia [4, 5]. No atypical glands or abnormal signal intensity were seen. There was however an area at the gastroesophageal junction just proximal to the polyp that contained a cluster of atypical glands that were suspicious for neoplasia (▶Fig. 3). This area appeared normal on HDR-WLE and narrow-band imaging (NBI) so laser marks were placed at the site to mark it for targeting (▶Fig. 4). Endoscopic mucosal resection of the polyp and the VLE-targeted area was performed. Histology of the polyp showed an inflammatory polyp and the VLE-targeted area was consistent with focal high grade dysplasia (▶Fig. 5; ▶Video1). This case demonstrates the capability of VLE to obtain high resolution microstructure imaging of the esophagus and gastroesophageal junction that can aid in the diagnosis of neoplasia.

Endoscopic ultrasound-guided fine-needle aspiration of solid lesions on clopidogrel may not be a high-risk procedure for bleeding: A case series.

Radiofrequency ablation (RFA) for dysplastic Barretts esophagus (BE) is highly effective. RFA failures are infrequent but can be a challenging cohort to manage. There are limited data on the feasibility of liquid nitrogen cryospray ablation for complete eradication of dysplasia (CE‐D) and/or intestinal metaplasia (CE‐IM) after RFA has failed to achieve CE‐IM in patients with dysplastic BE.

Nitrous oxide CryoBalloon therapy of refractory gastric antral vascular ectasia

BACKGROUND AND STUDY AIMS Little is known about the learning curve for image interpretation in volumetric laser endomicroscopy (VLE) in Barretts esophagus (BE). The goal of this study was to calculate the learning curve, competence of image interpretation, sensitivity, specificity, and accuracy of VLE among novice users. METHODS 31 novice users viewed 96 VLE images electronically at three academic institutions after a brief training session. There were 24 images of each histologic type: normal gastric cardia, normal esophageal squamous epithelium, non-neoplastic BE, and neoplastic BE. The users were asked to identify the correct tissue type and level of confidence. The cumulative summation (CUSUM) technique was used to construct a learning curve. RESULTS 22 (71 %) of the physicians achieved VLE interpretation competency during their 96-slide review. Half of the physicians achieved competency at 65 images (95 % confidence interval [CI] 45 - 85). There was a statistically significant association between confidence in diagnosis and selecting the correct histologic tissue type (P < 0.001). The median accuracy for esophageal squamous epithelium, normal gastric cardia, non-neoplastic BE, and neoplastic BE was 96 % (95 %CI 95 % - 96 %), 95 % (95 %CI 94 % - 96 %), 90 % (95 %CI 88 % - 91 %), 96 % (95 %CI 95 % - 96 %). The overall accuracy was 95 % (95 %CI 93 % - 95 %). CONCLUSION The majority of novice users achieved competence in image interpretation of VLE for BE, using a pre-selected image set, with a favorable learning curve after a brief training session. An electronic review of VLE images, prior to real-time use of VLE, is encouraged.