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Introduction. Understanding how educational pathways may influence clinical competence and work responsibilities is important in providing guidance to academic and clinic stakeholders and physical therapists (PTs) on PT career development. The purpose of this paper was to compare perceived clinical competency and job duties between PTs with formal mentored postprofessional clinical education with PTs without formal postprofessional clinical education. Review of Literature. The understanding of self-perceived clinical competence of PTs overall in the United States is limited, especially as related to the impact of postprofessional education. Furthermore, there is limited understanding of the career pathways and development of job duties of PTs in the United States. Subjects. Two thousand three hundred thirty-four PTs in the United States. Methods. An online survey was sent to licensed PTs. This survey included items measuring self-perceived clinical competency and questions related to weekly job responsibilities. Participants were categorized as residency trained, fellowship trained, or non–residency/fellowship trained. Frequency analyses and Kruskal–Wallis tests with pairwise post hoc tests were performed comparing the 3 groups. Results. Residency-trained (P < .007) and fellowship-trained (P < .001) groups demonstrated elements of higher self-perceived clinical competency compared with the non–residency-/fellowship-trained group. Both the residency- and fellowship-trained groups spent less time with patient care and more time with other responsibilities (e.g., teaching, mentoring, and research) (P < .02) during an average workweek. Fellowship-trained PTs (P < .001) spent more time with administrative duties compared with the non–residency-/fellowship-trained group. Discussion and Conclusion. Results from this paper demonstrate that residency- and fellowship-trained PTs have elements of higher self-perceived clinical competency and spend more of their job duties outside of direct patient care compared with PTs who were not residency or fellowship trained. These results may help guide PTs, academic institutions, and employers in planning and achieving specific career paths. [ABSTRACT FROM AUTHOR]

Objective: We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts. Background and Aims: Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results. Methods: An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA (CEACAM5) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n = 108) and validation (n = 77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data. Results: Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41--59%) and lower specificities (56--96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity. Conclusions: PancreaSeqGCwas not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines. [ABSTRACT FROM AUTHOR]

Objective: We evaluated a protocolized endoscopic necrosectomy approach with a lumen-apposing metal stent (LAMS) in patients with large symptomatic walled-off pancreatic necrosis (WON) comprising significant necrotic content, with or without infection. Summary Background Data: Randomized trials have shown similar efficacy of endoscopic treatment compared with surgery for infected WON. Design: We conducted a regulatory, prospective, multicenter single-arm clinical trial examining the efficacy and safety of endoscopic ultrasound -guided LAMS with protocolized necrosectomy to treat symptomatic WON ≥6 cm in diameter with >30% solid necrosis. After LAMS placement, protocolized WON assessment was conducted and endoscopic necrosectomy was performed for insufficient WON size reduction and persistent symptoms. Patients with radiographic WON resolution to ≤ 3 cm and/or 60-day LAMS indwell had LAMS removal, then 6-month follow-up. Primary endpoints were probability of radiographic resolution by 60 days and procedure-related serious adverse events. Results: Forty consecutive patients were enrolled September 2018 to March 2020, of whom 27 (67.5%) were inpatients and 19 (47.5%) had clinical evidence of infection at their index procedure. Mean WON size was 15.0 ± 5.6 cm with mean 53.2% ± 16.7% solid necrosis. Radiographic WON resolution was seen in 97.5% (95% CI, 86.8%, 99.9%) by 60 days, without recurrence in 34 patients with 6-month follow-up data. Mean time to radiographic WON resolution was 34.1 ± 16.8 days. Serious adverse events occurred in 3 patients (7.5%), including sepsis, vancomycin-resistant enterococcal bacteremia and shock, and upper gastrointestinal bleeding. There were no procedure-related deaths. Conclusions: Endoscopic ultrasound-guided drainage with protocolized endoscopic necrosectomy to treat large symptomatic or infected walled-off necrotic pancreatic collections was highly effective and safe. Clinicaltrials.-gov no: NCT03525808. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Introduction.: Mentoring and professional development opportunities influence job and career satisfaction. Review of the Literature.: Job and career satisfaction are multifactorial. The purpose of this study was to compare job and career satisfaction between physical therapists (PTs) who were residency trained and PTs who were neither residency nor fellowship trained and between PTs who were fellowship trained and PTs who were neither residency nor fellowship trained. Subjects.: Licensed PTs in the United States. Methods.: An online survey was distributed asking questions regarding job satisfaction and career satisfaction. Respondents were categorized as completing a residency, fellowship, both, or neither. Responses were respectively summed, then compared between groups: residency versus nonresidency/nonfellowship and fellowship versus nonresidency/nonfellowship. Frequency analyses and Mann–Whitney U tests were performed. Results.: A total of 3,080 survey responses were analyzed. Residency-trained PTs had an overall higher job satisfaction score (P =.03) and higher career satisfaction score (P =.05) when compared with non–residency-trained or non–fellowship-trained PTs. Fellowship-trained PTs reported higher job satisfaction (P <.001) and career satisfaction (P =.001) compared with non–residency-trained or non–fellowship-trained PTs. Residency-trained PTs rated the importance of their work being interesting and learning/improving in their work of greater importance to their job satisfaction compared with non–residency-trained or non–fellowship-trained PTs (P <.05). Whereas, fellowship-trained PTs rated factors such as their jobs being positively challenging, fulfilling, and interesting, having sufficient independence, and were learning/improving in their work of greater importance than non–residency-trained and non–fellowship-trained PTs (P ≤.004). Discussion and Conclusion.: Results from the study support previous evidence that PTs overall have high job/career satisfaction and residency/fellowship training may further enhance job and career satisfaction. Findings provide valuable insight and are relevant to all PTs as well as stakeholders involved in professional and postprofessional physical therapy education and those making hiring decisions and potential employment opportunities. [ABSTRACT FROM AUTHOR]

INTRODUCTION: There are limited data correlating symptoms with reflux episodes during pH studies after peroral endoscopic myotomy. METHODS: Consecutive patients who underwent POEM followed up ≥6 months later by 48-hour ambulatory wireless pH testing off antisecretory therapy were identified. Reflux symptom association was defined as symptom association probability >95%. RESULTS: The most frequent symptoms of heartburn (47.2%), cough (45.1%), and chest pain (39.6%) were associated with a positive reflux symptom association (symptom association probability >95%) in 20.9%, 17.1%, and 19.4%, respectively. DISCUSSION: There is poor correlation between reported symptoms and esophageal acid exposure during pH testing after POEM. [ABSTRACT FROM AUTHOR]

Objectives: Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches. Summary Background Data: Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. Methods: Patients undergoing Endo-TGD and OR-TGD at a single, highvolume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared. Results: Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. ORTGD required 1.1 ± 0.5 and Endo-TGD 3.0 ± 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P = 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 ± 20.8 days) compared to OR-TGD (9.4 6.1 days; P = 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P = 0.04). Conclusions: Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients. [ABSTRACT FROM AUTHOR]

Objective: Incidental pancreatic cysts are often detected during abdominal imaging and require follow-up since some have malignant potential. Endoscopic ultrasound (EUS) is highly sensitive for pancreatic diseases, yet the prevalence of incidental pancreatic cysts discovered with EUS is unknown. The objective of the study was to determine its prevalence by EUS., Methods: A prospective cross-sectional study was conducted. Patients undergoing EUS for nonpancreatic indications and without known pancreatic abnormality were recruited to assess the prevalence of pancreatic cysts and its characteristics. Risk factors were determined by logistic regression., Results: We enrolled 341 patients (mean age, 59 years; 187 females) and found 46 incidental pancreatic cysts (median [range], 5 [2-80] mm) in 32 patients (9.4%). Branch duct intraductal papillary mucinous neoplasm was the most common finding. Seven cysts were larger than 1 cm and 1 adenocarcinoma was discovered. Multivariate logistic regression showed an association between pancreatic cysts and older age (odds ratio, 1.04 per year; 95% confidence interval, 1.01-1.08) and female sex (odds ratio, 3.08; 95% confidence interval, 1.25-7.45)., Conclusions: In our population, the prevalence of incidental pancreatic cyst discovered on EUS was 9.4% and the majority were less than 1 cm. Increasing age and female sex were associated with the development of pancreatic cysts.

Objective: As such, the natural history of MPD-involved IPMN is poorly understood., Background: The high-risk of malignancy associated with main pancreatic duct (MPD)-involved intraductal papillary mucinous neoplasm (IPMN) has been established by surgical series. The International Consensus Guidelines recommend surgical resection of MPD-involved IPMN in fit patients., Methods: A review of a prospectively collected database (1992-2012) of patients with IPMN undergoing primary surveillance was performed. Invasive progression was defined as invasive carcinoma on pathology and/or positive cytopathology. Analyses included univariate, logistic regression, and receiver operating characteristic curve analyses., Results: A total of 503 patients with IPMN underwent primary surveillance, 70 for MPD-involved, mixed-type IPMN. Indications for intensive surveillance of these 70 high-risk patients were comorbidities, patient choice, and early/borderline MPD dilation (42%, 51%, and 7%, respectively). Mean follow-up was 4.7 years. Nine patients (13%) progressed at a mean of 3.5 (range, 1-9) years during follow-up. Univariate analyses yielded weight loss, interval (from isolated branch-duct IPMN) to MPD involvement, diffuse MPD dilation, increase of MPD diameter, absence of extra pancreatic cysts, elevated serum CA19-9 levels, and elevated serum alkaline phosphatase levels as significant. Maximum MPD and/or branch-duct diameter were not significant. In logistic regression, diffuse MPD dilation, serum CA19-9 and serum alkaline phosphatase levels, and absence of extra pancreatic cysts were predictors of invasiveness. The receiver operating characteristic curve indicated that the combination of these 4 factors achieved an accuracy of 98% in predicting progression., Conclusions: Primary surveillance of mixed-type IPMN may be a reasonable strategy in select patients. Diffuse MPD dilation, serum CA19-9, serum alkaline phosphatase, and absence of extrapancreatic cysts predict patients likely to progress during primary surveillance.

Background: Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) has a well-established role in the evaluation of various gastrointestinal (GI) tract disorders in adults. The clinical impact of EUS on the management of the pediatric population remains less clear. This study evaluates the feasibility, safety, and applications of EUS ± FNA in pediatric GI tract disorders., Patients and Methods: Using a prospectively maintained EUS database, all patients 18 years of age or younger referred for EUS at our institution were identified. Retrospective chart review was conducted to document procedure indications, type of anesthesia used, EUS findings, final FNA cytology results, and clinical impact of EUS ± FNA on the subsequent management of pediatric patients., Results: Fifty-eight EUS procedures were performed in 56 patients (35 girls). Median age was 16 years (range 4-18 years). The main indications for EUS were acute or recurrent pancreatitis, abdominal pain of suspected pancreatobiliary origin, suspected biliary obstruction, upper GI mucosal/submucosal lesions, and evaluation of pancreatic abnormalities seen on prior imaging. Sedation used included nurse-administered propofol sedation in 38 (73%), general anesthesia in 9 (17%), and fentanyl with meperidine in 3 (6%). Five therapeutic procedures performed included celiac plexus blocks in 4 and 1 EUS-guided pancreatogram. In 44 (86%) patients, EUS provided a new diagnosis. The procedure was successfully completed in all patients with no reported complications., Conclusions: EUS ± FNA is feasible and safe and makes a significant impact on most pediatric patients. Nurse-administered propofol sedation appears to be safe and well tolerated in this group.

Objective: Determine whether size and other preoperative parameters predict malignant or invasive intraductal papillary mucinous neoplasia (IPMN)., Summary Background Data: From 1991 to 2006, 150 patients underwent 156 operations for IPMN., Methods: Prospectively collected, retrospective review of a single academic institution's experience. All preoperative parameters including a detailed radiologic-based classification of IPMN type, location, distribution, size, number, cytology, and mural nodularity were correlated with IPMN pathology., Results: Malignant IPMN was present in 32% of cases, whereas 19% of cases were invasive. IPMN type and main pancreatic duct diameter were significant predictors of malignant IPMN (P<0.001). Side-branch lesion number was negatively associated with invasive IPMN (P=0.03). Side-branch size, location, and distribution did not predict IPMN pathology. The presence of mural nodules was associated with malignant and invasive IPMN (P<0.001; P<0.02). Atypical cytopathology was significantly associated with malignant and invasive IPMN (P<0.001; P<0.001). Multivariate analysis demonstrated mural nodularity and atypical cytopathology were predictive of malignancy and/or invasion in branch-type IPMN., Conclusions: To lower the rate of invasive pathology, surgery should be recommended for fit patients with main-duct IPMN and for branch-duct IPMN with mural nodularity or positive cytology irrespective of location, distribution, or size.