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The extent of the photoinitiated linkage isomerization of dicarbonyl(3-cyanomethylpyridine-κN)(η(5)-methylcyclopentadienyl)manganese (4) to dicarbonyl(3-cyano-κN-methylpyridine)(η(5)-methylcyclopentadienyl)manganese (5) was examined by time-resolved infrared spectroscopy on picosecond to microsecond time scales in room temperature isooctane to determine the extent the isomerization occurs as a geminate cage rearrangement. We previously reported that a substantial part of the conversion between 4 and 5 must be a bimolecular reaction between a solvent coordinated dicarbonyl(η(5)-methylcyclopentadienyl)manganese (3) and uncoordinated 3-cyanomethylpyridine. For the purpose of designing a molecular device, it would be desirable for the photoisomerization to occur in a geminate cage reaction, because the faster the isomerization, the less opportunity for side reactions to occur. In this study, assignments of transients are identified by comparison with transients observed for model reactions. Within 100 μs after photolysis of 4 in isooctane, no 5 is observed. Instead, the solvent coordinated 3 is observed within 25 ps after irradiation. The formation of 5 is observed only in the presence of 9 mM 3-cyanomethylpyridine but not until 10-50 μs after irradiation of 4. Within the limits of detection, these results indicate the conversion of 4 to 5 occurs exclusively via a bimolecular reaction of 3-cyanomethylpyridine with solvent coordinated 3 and not a geminate cage reaction between 3-cyanomethylpyridine and the dicarbonyl(η(5)-methylcyclopentadienyl)manganese fragment.

The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and management of cystic pancreatic neuroendocrine tumors (PNETs) is unclear. We aimed to compare clinical/endosonographic characteristics of cystic with solid PNETs, determine diagnostic accuracy of preoperative EUS-FNA, and evaluate recurrence rates after resection.All patients with cystic or solid PNET confirmed by EUS-FNA between 2000 and 2014 were identified. A matched case-control study compared 50 consecutive patients with cystic PNETs with 50 consecutive patients with solid PNETs, matched by gender and age at diagnosis of index cystic PNET. We compared clinical/endosonographic characteristics, assessed diagnostic accuracy of preoperative EUS-FNA for identifying malignancy, and analyzed tumor-free survival of patients with cystic and solid PNETs.Cystic PNETs tended to be larger than solid PNETs (mean 26.8 vs. 20.1 mm, P = 0.05), more frequently nonfunctional (96 % vs. 80 %, P = 0.03), and less frequently associated with multiple endocrine neoplasia type 1 (10 % vs. 28 %, P = 0.04). With surgical pathology as reference standard, EUS-FNA accuracies for malignancy of cystic and solid PNETs were 89.3 % and 90 %, respectively; cystic PNETs were less associated with metastatic adenopathy (22 % vs. 42 %, P = 0.03) and liver metastasis (0 % vs. 26 %, P 0.001). Cystic fluid analysis (n = 13), showed benign cystic PNETs had low carcinoembryonic antigen (CEA), Ki-67 ≤ 2 %, and no loss of heterozygosity. Patients with cystic and solid PNETs had similar recurrence risk up to 5 years after complete resection.Cystic PNETs have distinct clinical and EUS characteristics, but were associated with less aggressive biological behavior compared with solid PNETs. EUS-FNA is accurate for determining malignant potential on preoperative evaluation. Despite complete resection, recurrence is observed up to 5 years following surgery.

Background The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Objectives To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. Design Retrospective cohort study. Setting Tertiary-care referral center. Patients All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. Intervention EUS. Main Outcome Measurements Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. Results We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. Limitation Retrospective design. Conclusions EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations The following recommendations should only be applied after a thorough diagnostic evaluation including a contrast-enhanced computed tomography (CT) scan. Prophylactic colonic stent placement is not recommended. Colonic stenting should be reserved for patients with clinical symptoms and imaging evidence of malignant large-bowel obstruction, without signs of perforation (strong recommendation, low quality evidence). Colonic self-expandable metal stent (SEMS) placement as a bridge to elective surgery is not recommended as a standard treatment of symptomatic left-sided malignant colonic obstruction (strong recommendation, high quality evidence). For patients with potentially curable but obstructing left-sided colonic cancer, stent placement may be considered as an alternative to emergency surgery in those who have an increased risk of postoperative mortality, i.e. American Society of Anesthesiologists (ASA) Physical Status III and/or age >70 years (weak recommendation, low quality evidence). SEMS placement is recommended as the preferred treatment for palliation of malignant colonic obstruction (strong recommendation, high quality evidence), except in patients treated or considered for treatment with antiangiogenic drugs (e.g. bevacizumab) (strong recommendation, low quality evidence)

Climber's Paradise: Making Canada's Mountain Parks, 1906-1974, by PearlAnn Reichwein. Edmonton, University of Alberta Press, 2014. xix, 402 pp. $45.00 Cdn (paper). Beginning and ending with a recognition of her personal connection to the topic, PearlAnn Reichwein provides a rich and absorbing history of the Alpine Club of Canada (ACC), beginning at the organization's birth in Winnipeg in 1906 and ending with the club's conservation work in the 1970s. Rather than providing a groundbreaking account of the history of Canadian national parks, Climber's Paradise, instead, adds another component to the growing body of recent national park history, like the essays in A Century of Parks Canada (Calgary, 2011) that acknowledge national parks as dynamic cultural staging grounds for social, political, and scientific agendas. The study of mountaineering, and its connection to environmental, gender, and other history subfields, has been gaining momentum as seen in volumes like Peter H. Hansen's The Summits of Modern Man: Mountaineering after the Enlightenment (Cambridge and London, 2013). "The history of mountaineering in Canada," Reichwein writes, "is not a unilinear process of sport 'progress' or a 'coming of age,' but a diverse and contested field of ongoing social relations interacting in specific times and places as a dynamic site of culture" (p. xiii). Reichwein immediately situates herself amongst those that view parks as peopled places, places where humankind and nature are intertwined. Mountaineering, Reichwein argues, provides a device by which to examine the way in which humans interact with the environment and create meaning. Reichwein portrays the mountains and the park boundaries that encompass them as both physical and imagined borderlands, a place where differences and identities are created and managed. A constant undercurrent in Climber's Paradise is the ACC'S connection to the evolution of Canadian nationhood. A predominantly western organization, particularly in its first fifty years, the ACC'S activities illustrate the ways in which Canadians and the Canadian government latched onto the sublime western mystique to create a unique Canadian identity. Several aspects of this national identity and the ACC'S involvement in this process are apparent in Reichwein's treatment of the organization's story. Firstly, Reichwein demonstrates how the organization was anglo-centric, promoting "a distinct combination of alpinism and Anglo-Canadian nationalism" (p. 25). An elite organization, the acc and its membership illustrates that park-making in the formative years was largely an elite and whitewashed process. In chapter six, Reichwein briefly touches upon ACC'S relations with aboriginal peoples, but does not give the subject detailed treatment, which is a missed chance to add depth to the narrative. The male/female dynamics within the acc also illuminate the gendered aspects of Canadian identity. The dominance of white, male members in the club and the emphasis on climbing, or conquering, the next peak is reminiscent of the way in which Gail Bederman connects masculinity and race identity to the civilizing process in Manliness and Civilization (Chicago, 1995). …

Background Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV . We compared use of national guideline‐recommended cardiovascular care during office visits among HIV ‐infected versus HIV ‐uninfected adults. Methods and Results We analyzed data from a nationally representative sample of HIV ‐infected and HIV ‐uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline‐recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV ‐infected patients and 226 862 visits by HIV ‐uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV ‐infected versus HIV ‐uninfected adults with aspirin/antiplatelet therapy when patients met guideline‐recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% ( P =0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% ( P HIV ‐infected versus HIV ‐uninfected patients, respectively. Conclusions Physicians generally underused guideline‐recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV ‐infected patients at increased risk—findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV . US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV ‐infected patients receive.

A workshop was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases to address the research gaps and opportunities in pancreatic EUS. The event occurred on July 26, 2017 in 4 sessions: (1) benign pancreatic diseases, (2) high-risk pancreatic diseases, (3) diagnostic and therapeutics, and (4) new technologies. The current state of knowledge was reviewed, with identification of numerous gaps in knowledge and research needs. Common themes included the need for large multicenter consortia of various pancreatic diseases to facilitate meaningful research of these entities; to standardize EUS features of different pancreatic disorders, the technique of sampling pancreatic lesions, and the performance of various therapeutic EUS procedures; and to identify high-risk disease early at the cellular level before macroscopic disease develops. The need for specialized tools and accessories to enable the safe and effective performance of therapeutic EUS procedures also was discussed.

Availability of farmers markets may increase fruit and vegetable consumption among rural residents of the United States. We conducted a community-based marketing campaign, Plate it Up Kentucky Proud (PIUKP), in 6 rural communities over 2 years to determine the association between exposure to the campaign and fruit and vegetable purchases, adjusted for Supplemental Nutrition Assistance Program recipient status. Logistic regression was used to examine the odds of the PIUKP campaign influencing purchases. Awareness of the PIUKP marketing campaign was significantly associated with a willingness to prepare fruits and vegetables at home. Using marketing strategies at farmers markets may be an effective way to improve fruit and vegetable purchases in rural communities.

Background and study aims Data on clinical outcomes of endoscopic drainage of debris-free pseudocysts (PDF) versus pseudocysts containing solid debris (PSD) are very limited. The aims of this study were to compare treatment outcomes between patients with PDF vs. PSD undergoing endoscopic ultrasound (EUS)-guided drainage via transmural stents. Patients and methods Retrospective review of 142 consecutive patients with pseudocysts who underwent EUS-guided transmural drainage (TM) from 2008 to 2014 at 15 academic centers in the United States. Main outcome measures included TM technical success, treatment outcomes (symptomatic and radiologic resolution), need for endoscopic re-intervention at follow-up, and adverse events (AEs). Results TM was performed in 90 patients with PDF and 52 with PSD. Technical success: PDF 87 (96.7 %) vs. PSD 51 (98.1 %). There was no difference in the rates for endoscopic re-intervention (5.5 % in PDF vs. 11.5 % in PSD; P = 0.33) or AEs (12.2 % in PDF vs. 19.2 % in PSD; P = 0.33). Median long-term follow-up after stent removal was 297 days (interquartile range [IQR]: 59 – 424 days) for PDF and 326 days (IQR: 180 – 448 days) for PSD (P = 0.88). There was a higher rate of short-term radiologic resolution of PDF (45; 66.2 %) vs. PSD (21; 51.2 %) (OR = 0.30; 95 % CI: 0.13 – 0.72; P = 0.009). There was no difference in long-term symptomatic resolution (PDF: 70.4 % vs. PSD: 66.7 %; P = 0.72) or radiologic resolution (PDF: 68.9 % vs. PSD: 78.6 %; P = 0.72) Conclusions There was no difference in need for endoscopic re-intervention, AEs or long-term treatment outcomes in patients with PDF vs. PSD undergoing EUS-guided drainage with transmural stents. Based on these results, the presence of solid debris in pancreatic fluid collections does not appear to be associated with a poorer outcome.

Background and study aims: Endoscopic ultrasound – guided celiac plexus block (EUS-CPB) is an established treatment for pain in patients with chronic pancreatitis (CP), but the effectiveness and safety of repeated procedures are unknown. Our objective is to report our experience of repeated EUS-CPB procedures within a single patient. Patients and methods: A prospectively maintained EUS database was retrospectively analyzed to identify patients who had undergone more than one EUS-CPB procedure over a 17-year period. The main outcome measures included number of EUS-CPB procedures for each patient, self-reported pain relief, duration of pain relief, and procedure-related adverse events. Results: A total of 248 patients underwent more than one EUS-CPB procedure and were included in our study. Patients with known or suspected CP (N = 248) underwent a mean (SD) of 3.1 (1.6) EUS-CPB procedures. In 76 % of the patients with CP, the median (range) duration of the response to the first EUS-CPB procedure was 10 (1 – 54) weeks. Lack of pain relief after the initial EUS-CPB was associated with failure of the next EUS-CPB (OR 0.17, 95 %CI 0.06 – 0.54). Older age at first EUS-CPB and pain relief after the first EUS-CPB were significantly associated with pain relief after subsequent blocks (P = 0.026 and P = 0.002, respectively). Adverse events included peri-procedural hypoxia (n = 2) and hypotension (n = 1) and post-procedural orthostasis (n = 2) and diarrhea (n = 4). No major adverse events occurred. Conclusions: Repeated EUS-CPB procedures in a single patient appear to be safe. Response to the first EUS-CPB is associated with response to subsequent blocks.

Pancreatitis is associated with intraductal papillary mucinous neoplasm (IPMN). This association is in part due to inflammation from pancreatic ductal obstruction. Although the correlation between pancreatitis and the malignant potential of IPMN is unclear, the 2012 International Consensus Guidelines (ICG) consider pancreatitis a "worrisome feature." We hypothesized that serum pancreatic enzymes, markers of inflammation, are a better predictor of malignancy than pancreatitis in patients with IPMN.Between 1992 and 2012, 364 patients underwent resection for IPMN at a single university hospital. In the past decade, serum amylase and lipase were collected prospectively as an inflammatory marker in 203 patients with IPMN at initial surveillance and "cyst clinic" visits. The latest serum pancreatic enzyme values within 3 months preoperatively were studied. Pancreatitis was defined according to the 2012 revision of the Atlanta Consensus.Of the 203 eligible patients, there were 76 with pancreatitis. Pancreatitis was not associated with an increased rate of malignancy (P = .51) or invasiveness (P = .08). Serum pancreatic enzymes categorically outside of normal range (high or low) were also not associated with malignancy or invasiveness. In contrast, as a continuous variable, the higher the serum pancreatic enzymes were, the greater the rate of invasive IPMN. Of the 127 remaining patients without pancreatitis, serum pancreatic enzymes outside of normal range (low and high) were each associated with a greater rate of malignancy (P .0001 and P = .0009, respectively). Serum pancreatic enzyme levels above normal range (high) were associated with a greater rate of invasiveness (P = .02).In patients with IPMN without a history of pancreatitis, serum pancreatic enzymes outside of the normal range are associated with a greater risk of malignancy. In patients with a history of pancreatitis, there is a positive correlation between the levels of serum pancreatic enzymes and the presence of invasive IPMN. These data suggest serum pancreatic enzymes may be useful markers in stratification of pancreatic cancer risk in patients with IPMN.

The purpose of this study is to compare CT urography (CTU) with unenhanced CT in the evaluation of upper urinary tracts in adults younger than 50 years with asymptomatic microscopic hematuria.In this study, 1516 CTU examinations were reviewed in adults younger than 50 years. Inclusion criteria were no significant prior urologic disease and asymptomatic microscopic hematuria with at least one urinalysis with greater than or equal to 3 RBCs/high-power field and less than or equal to 50 RBCs/high-power field. Upper urinary tract findings on CTU were classified as malignancy-related or non-malignancy-related hematuria and incidental non-hematuria-related findings. A blinded radiologist reviewed the unenhanced images, recording upper urinary tract findings and recommendations for further contrast-enhanced imaging. The modified Wald equation at a 95% CI, the "Rule of Threes" equation, and binomial distribution were used for malignancy-related findings.Four hundred forty-five examinations in 442 patients met inclusion criteria. CTU reports showed zero malignancy-related hematuria findings, 64 non-malignancy-related hematuria findings (62 renal calculi and two others), and 138 incidental non-hematuria-related findings. Unenhanced CT interpretation had a sensitivity of 100% (64/64) and a specificity of 89.2% (337/378). The theoretic risk of an upper urinary tract malignancy is 0-1.1%.CTU added no additional diagnostic benefit versus unenhanced CT in evaluating the upper urinary tracts of adults younger than 50 years with asymptomatic microscopic hematuria. Using only unenhanced CT can reduce radiation and minimize contrast agent-associated risk, with a less than 1.0% risk of missing upper urinary tract hematuria-related malignancy.

Emotion regulation is hypothesized to be a multifaceted process by which individuals willfully modulate the intensity and direction of emotional response via prefrontally mediated inhibition of subcortical response-related regions of the brain. Here we employ activation likelihood estimation (ALE) meta-analysis of functional magnetic resonance imaging studies to (1) reveal a consistent network of structures active during emotion regulation, (2) identify the target regions inactivated by the willful regulation process, and (3) investigate the consistency of activated structures associated with downregulation and upregulation. Results reveal signal change in bilateral amygdala/parahippocampal gyrus that decreased in downregulated states and increased in upregulated states, while cortical regions including superior frontal gyrus, cingulate, and premotor areas exhibited enhanced activity across all regulation conditions. These results provide consistent evidence for the role of amygdala activity in experienced emotional intensity, where intentional dampening and exaggeration are clearly expressed. However, the execution of emotional upregulation and downregulation may involve distinct subsets of frontocortical structures.

A high signal intensity cleft between the labrum and articular cartilage of the posterior glenoid is commonly visible on MRI and has been suggested to be anatomic variation [3, 10, 23]. The association of a posterior cleft with variations in glenoid morphology or with shoulder instability is unknown. The purposes of this study were to determine if posterior chondrolabral clefts are associated with variations in glenoid morphology, and to determine if they are associated with shoulder instability. Shoulder MRI was performed in 1,264 shoulders, 1,135 male (89.8%), and 129 female (10.2%). A musculoskeletal radiologist blinded to history and outcomes evaluated the MR images for linear high signal intensity at the posterior chondrolabral junction and a rounded or truncated contour of the posterior glenoid. Glenoid version and depth were measured. Patients were followed prospectively for shoulder instability for 4 years. Univariate and multivariate statistical analysis were performed. Posterior chondrolabral cleft was present in 114/1,264. Posterior chondrolabral cleft was associated with a rounded or truncated posterior glenoid. There were 9.5° retroversion in shoulders with a posterior cleft, and 7.7° retroversion in shoulders without a cleft. Shoulders with a posterior chondrolabral cleft were more likely to develop shoulder instability. Posterior chondrolabral clefts are not uncommon on MRI. They are associated with a rounded or truncated posterior glenoid and a small but significant increase in glenoid retroversion. They are associated with shoulder instability.

OBJECTIVE This study aimed to evaluate associations between endoscopic ultrasound (EUS) criteria for chronic pancreatitis (CP) and coexisting pancreatic intraepithelial neoplasia (PanIN) lesions. METHODS Patients with known or suspected CP who underwent pancreatic resection within a year of EUS were selected. Histology slides and EUS images were reviewed for evidence of pancreatic fibrosis. RESULTS Ninety-seven (51 men; mean age, 53 [12] years) underwent EUS within a 1 year or less of EUS. Pancreatic intraepithelial neoplasia lesions were found in 84 (87%) patients. Pancreatic intraepithelial neoplasia 1, 2, and 3 lesions were seen in 71 (83%), 10 (14%), and 1 (2%), respectively. Two patients had more than 1 PanIN grade (one had PanIN 1 and 2 and the other had PanIN 1 and 3). The mean number of EUS criteria for PanIN 1, 2, and 3 lesions were 3.9, 4.5, and 5.5, respectively. The odds ratio for the association between PanIN 2 and hyperechoic foci without shadowing in the pancreas head was 8.5 (P = 0.05). The odds ratio for the association between PanIN 2 and lobularity with honeycombing was 2.7 (P = ns). Advanced PanIN lesions had greater than or equal to 4 EUS criteria for CP. CONCLUSIONS Pancreatic intraepithelial neoplasia lesions were highly prevalent in CP resections. Increasing PanIN grade is observed with increasing fibrosis score and increasing number of EUS criteria for CP.

Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated.From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy.Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively).Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

Gastric variceal bleeding is associated with significant morbidity and mortality and limited endoscopic therapeutic options. The aim of this study was to evaluate the short- and long-term efficacy and safety of endoscopic therapy with 2-octyl-cyanoacrylate in patients with gastric variceal bleeding. A single-center retrospective review of patients receiving endoscopic therapy for gastric variceal hemorrhage. Patient demographics, laboratory, and procedural data were collected. Patients were followed to death, liver transplantation, or last follow-up. Success rates were defined as immediate control of bleeding; early re-bleeding (1–7 days), short-term re-bleeding (1–12 weeks), overall survival, and serious procedure complications. A total of 41 patients (39 with cirrhosis) underwent 54 cyanoacrylate injections during study period. Mean age was 57 and 73 % were males. Twenty-four (58.5 %) patients had failed or were deemed ineligible for transjugular intra-hepatic portosystemic shunt, and 5 % were done for primary prophylaxis. Immediate hemostasis was achieved in five active bleeders. During a median survival time of 117 days, early re-bleeding was seen in 1 (2.4 %), short-term re-bleeding in five patients (12 %), and varices were eradicated in 15 (46.8 %) patients on follow-up. Mean MELD score at the time of the first injection was 17.1 ± 7.8. Mean volume injected was 3.4 cc and median number of varices injected per session was one. Eight patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1), and re-bleeding (2). There were no serious procedure-related complications. Endoscopic cyanoacrylate therapy appears effective and safe for treatment of patients with bleeding from gastric varices or high-risk stigmata.

Objectives This study aimed to correlate endoscopic ultrasound (EUS) criteria and pathology in patients with chronic pancreatitis (CP). Methods Endoscopic ultrasound reports and pathology specimens were reviewed from patients with known or suspected CP who underwent surgery within 1 year of EUS. The following information was abstracted: EUS criteria for CP, corresponding pathology results, and histologic features. The EUS and pathology results were correlated. Results One hundred patients (55 men; mean age, 54 years) underwent a pancreatic resection, median of 50 days (range, 1-363 days). The mean (SD) fibrosis scores in the head and body/tail specimens were 7.9 (3.0) and 6.4 (3.8), respectively (P = 0.02). The main pancreatic duct (MPD) dilation and irregularity were associated with moderate and severe fibrosis. Lobularity with honeycombing was associated with intralobular and interlobular fibrosis. Severe CP was associated with the following: lobularity with honeycombing, hyperechoic foci with shadowing, hyperechoic foci without shadowing, MPD dilation, MPD irregularity, and dilated side branches. Conclusions Endoscopic ultrasound of the pancreas head may be considered in the evaluation of CP. The EUS criteria that were associated with severe CP included the following: lobularity with honeycombing, hyperechoic foci with shadowing, dilated MPD, irregular MPD, and dilated side branches. The importance of pancreatic ductal changes should not be minimized in the evaluation of CP.

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.Retrospective.Academic tertiary referral center.All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.Esophageal stent placement and removal.Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).Retrospective, single-center study.Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Main pancreatic duct (MPD) involvement is a well-demonstrated risk factor for malignancy in intraductal papillary mucinous neoplasm (IPMN). Preoperative radiographic determination of IPMN type is heavily relied upon in oncologic risk stratification. We hypothesized that radiographic assessment of MPD involvement in IPMN is an accurate predictor of pathological MPD involvement. Data regarding all patients undergoing resection for IPMN at a single academic institution between 1992 and 2012 were gathered prospectively. Retrospective analysis of imaging and pathologic data was undertaken. Preoperative classification of IPMN type was based on cross-sectional imaging (MRI/magnetic resonance cholangiopancreatography (MRCP) and/or CT). Three hundred sixty-two patients underwent resection for IPMN. Of these, 334 had complete data for analysis. Of 164 suspected branch duct (BD) IPMN, 34 (20.7 %) demonstrated MPD involvement on final pathology. Of 170 patients with suspicion of MPD involvement, 50 (29.4 %) demonstrated no MPD involvement. Of 34 patients with suspected BD-IPMN who were found to have MPD involvement on pathology, 10 (29.4 %) had invasive carcinoma. Alternatively, 2/50 (4 %) of the patients with suspected MPD involvement who ultimately had isolated BD-IPMN demonstrated invasive carcinoma. Preoperative radiographic IPMN type did not correlate with final pathology in 25 % of the patients. In addition, risk of invasive carcinoma correlates with pathologic presence of MPD involvement.

Background Diagnosis of mucinous pancreatic cysts (MPCs) is challenging due to the poor sensitivity of cytology provided by EUS-guided-FNA (EUS-FNA). Objective To quantify the test characteristics of molecular (DNA) analysis in suspected low-risk MPCs. Design A prospective cohort study performed in between 2008 and 2011. Setting Academic referral center. Patients Consecutive patients who underwent EUS-FNA of suspected MPCs. Intervention EUS-FNA and molecular (DNA) analysis of cyst fluid. Main Outcome Measurements The sensitivity and specificity of molecular analysis in the diagnosis of MPCs using the criterion standard of surgical pathology in resected cysts. Results Patients with suspected MPCs underwent EUS-FNA and cyst fluid DNA analysis. Surgical resection was performed in 48 patients (17%), confirming a mucinous pathology in 38 (79%). In this group, molecular analysis had a sensitivity of 50% and a specificity of 80% in identifying MPCs (accuracy of 56.3%). The combination of molecular analysis with cyst fluid carcinoembryonic antigen (CEA) and cytology resulted in higher MPC diagnostic performance than either one of its individual components, with a sensitivity, specificity, and accuracy of 73.7%, 70%, and 72.9%, respectively. There was no significant difference in accuracy between molecular analysis and CEA/cytology in this group. Limitations Single-center experience. Conclusion Molecular analysis aids in the diagnosis of MPCs when cytology is nondiagnostic or cyst fluid is insufficient for CEA or its level is indeterminate. Our results do not support the routine use of molecular analysis, which should be used selectively after review of imaging findings and cyst fluid studies. Further studies are needed to assess DNA's performance in malignant cysts.

Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies.After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used.Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p0.01).Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.

Background and Aims Endocuff (Arc Medical Design, Leeds, UK) and Endocuff Vision (Arc Medical Design, Leeds, UK) are effective mucosal exposure devices for improving polyp detection during colonoscopy. AmplifEYE (Medivators Inc, Minneapolis, Minn, USA) is a device that appears similar to the Endocuff devices but has received minimal clinical testing. Methods We performed a randomized controlled clinical trial using a noninferiority design to compare Endocuff Vision with AmplifEYE. Results The primary endpoint of adenomas per colonoscopy was similar in AmplifEYE at 1.63 (standard deviation 2.83) versus 1.51 (2.29) with Endocuff Vision (P = .535). The 95% lower confidence limit was 0.88 for ratio of means, establishing noninferiority of AmplifEYE (P = .008). There was no difference between the arms for mean insertion time, and mean inspection time (withdrawal time minus polypectomy time and time for washing and suctioning) was shorter with AmplifEYE (6.8 minutes vs 6.9 minutes, P = .042). Conclusions AmplifEYE is noninferior to Endocuff Vision for adenoma detection. The decision on which device to use can be based on cost. Additional comparisons of AmplifEYE with Endocuff by other investigators are warranted. (Clinical trial registration number: NCT03560128.)

Surface pressure-molecular area (Π-A) isotherms and fluorescence microscopy were used to investigate the interactions between N-stearoyl-glutamic acid (l- and d-) and l-arginine at the air/water interface. N-stearoyl-glutamic acids (C18-Glu) with different chirality (l- and d-) were spread at the air-water interface onto subphases containing varied concentrations of l-arginine at pH 5. The apparent binding affinity of C18-Glu to l-arginine was obtained by fitting the plots of the change in mean molecular area of C18-Glu vs. l-arginine concentration. The thermodynamic properties of the binding events such as binding constant and Gibbs free energy were estimated from the binding curves. We found that N-stearoyl-l-glutamic acid (C18-l-Glu) had a stronger binding affinity to l-arginine as compared to N-stearoyl-d-glutamic acid (C18-d-Glu) at low to moderate surface pressures (below ∼22mN/m). The C18-d-Glu had stronger binding to l-arginine at higher surface pressure. Domains with different shapes in C18-l-Glu and C18-d-Glu monolayers were observed under a fluorescence microscope in situ at the air/water interface. Herein, we present a mechanism for C18-l-Glu and C18-d-Glu interacting with l-arginine at the air/water interface.