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Talreja J.P.,University of Virginia | Sethi A.,Columbia University | Jamidar P.A.,Yale University | Singh S.K.,Boston University | And 8 more authors.
Digestive Diseases and Sciences | Year: 2012

Background: Probe-based confocal laser endomicroscopy (pCLE) has enabled in vivo histopathology by obtaining high resolution images of the mucosal layers of the gastrointestinal tract. For indeterminate bile duct strictures, biopsy, cytologic brushing and needle aspiration have low levels of diagnostic accuracy. Aim: The objective of this multi-center pilot study was to assess the interobserver agreement in interpretation of pCLE imaging. Methods: Twenty-five de-identified pCLE video clips of indeterminate biliary strictures were sent to 6 observers at 5 institutions. Miami Classification was used to standardize image interpretation. Seven variables were assessed for interobserver agreement using the Fleiss kappa statistic which included: presence of thick (>20 μm) or thin (<20 μm) dark or white bands, dark clumps, epithelium including glandular structures, interstitial fluorescein leakage, ease of interpretation, and final diagnosis. Based on operator experience, observers were categorized into 3 categories of experience (Category 1: 0-10; Category 2: 11-20; Category 3: >21 cases). Results: Upon stratification, Category 1 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.277, κ = -0.079, κ = -0.025, κ = -0.066, κ = 0.128, κ = 0.088), and for the final diagnosis variable, the agreement was slight (κ = 0.033). Category 2 and 3 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.211, κ = 0.181, κ = 0.347, κ = 0.238, κ = -0.050, κ = 0.092), and for the final diagnosis variable, the agreement was slight (κ = 0.195). Conclusion: The overall interobserver agreement for pCLE image interpretation in indeterminate biliary strictures ranges from poor to fair. Interpretation criteria as well as training require further standardization toward improving inter-rater reliability. © 2012 Springer Science+Business Media, LLC.

Kamine T.H.,Newton Wellesley Hospital | Barron R.J.,Brown University | Lesicka A.,Newton Wellesley Hospital | Galbraith J.D.,BIDMC | And 2 more authors.
American Journal of Surgery | Year: 2013

Background: On July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) eliminated 30-hour call in an attempt to improve resident wakefulness. We surveyed interns on the Newton Wellesley Hospital (NWH) surgery service before and after the transition from Q4 overnight call to a night float schedule. Methods: For 15 weeks, interns completed weekly surveys including the Epworth Sleepiness Scale (ESS). The service changed to a night float schedule after 3 weeks (ie, first to 3-4 and then to 6 nights in a row). Results: The average ESS score rose from 9.8 ± 5.2 to 14.9 ± 3.1 and 14.4 ± 4.5 (P =.042) on the 3/4 and 6/1 schedules, respectively. Interns were more likely to be abnormally tired on either night float schedule (relative risk = 2.86; 95% confidence interval, 1.17-6.97, P =.029). Conclusions: The new ACGME work hours increased the ESS scores among interns at NWH and caused interns to be more tired than interns on the Q4 schedule. This is likely caused by the multiple nights of poor sleep without a post-call day to make up sleep. © 2013 Elsevier Inc. All rights reserved.

Boone B.A.,University of Pittsburgh | Zeh H.J.,University of Pittsburgh | Mock B.K.,University of Pittsburgh | Johnson P.J.,University of Pittsburgh | And 5 more authors.
HPB | Year: 2014

Background: The majority of patients with periampullary cancer develop local or metastatic recurrence despite successful negative margin resection. Unfortunately, there are no established therapeutic strategies for managing these patients. The literature on the surgical resection of recurrent disease is limited. Methods: This is a retrospective study evaluating patients who underwent reoperative resection of recurrent periampullary cancer at a single institution between 1990 and 2011. Perioperative outcomes were compared with those of the original primary resections for patients with local recurrence. Kaplan-Meier curves were used to evaluate survival. Results: Twenty-two patients underwent reoperative resection following the successful primary resection of periampullary cancers. Median survival from the time of reoperation was 28.1 months. A greater survival benefit was seen in patients undergoing reoperative resection with >15 months between the primary resection and recurrence (40.6 months versus 8.2 months; P < 0.05). Complication rates were lower after reoperative resection compared with the primary resection (20% versus 70%). Perioperative characteristics including operative time, estimated blood loss and hospital stay were similar in both the primary and reoperation procedures. Conclusions: Surgical resection of periampullary cancer recurrence is feasible, safe and may offer survival benefits in comparison with alternative treatment modalities. Reoperative resection should be considered, especially in patients in whom the time to recurrence is lengthy. © 2013 International Hepato-Pancreato-Biliary Association.

Driscoll D.F.,Beth Israel Deaconess Medical Center | Silvestri A.P.,BIDMC | Bistrian B.R.,Beth Israel Deaconess Medical Center
Journal of Parenteral and Enteral Nutrition | Year: 2010

Background: United States Pharmacopeial Chapter <729> places a limit on the percentage of large fat globules >5 1/4m, expressed as a PFAT 5 of <0.05% for all native lipid emulsions. Some adult total nutrient admixtures (TNAs) have also remained below this limit for up to 48 hours. In 2003, medium-chain/ long-chain triglyceride (MCT/LCT)-based neonatal TNAs with between 2% and 3% amino acid (AA) concentrations were shown to be similarly stable by the PFAT5 parameter. Stability assessment of neonatal TNAs with AA <2% or ≥3% were tested. Methods: Eight neonatal TNAs with various combinations of AA (1%, 1.5%, 3%, and 4%), glucose (G; 5% and 10%), and MCT/ LCT (ML; 2% and 4%) and standard concentrations of additives were tested in triplicate (n = 24) over 30 hours (immediately after mixing, then at 6, 24, and 30 hours) at 25°C ± 2°C. PFAT5 determinations for all 24 formulations were made in duplicate, immediately after mixing, and then at 6, 24, and 30 hours later. Mean droplet size (MDS) and pH were assessed at the outset and end of the study. Results: The differences in the PFAT5 levels were significant (P <.001) by a 2-way analysis of variance based on formula and time as the independent variables. The TNAs with 1% and 1.5% AA with all Gs and MLs (group 1, n = 12) had PFAT5 levels >0.05% (up to 0.50%) in most samples (68 of 96 samples, or 71% of cases) in the study, whereas in the same TNAs, but made with 3% and 4% AA (group 2, n = 12), 100% of samples (all 96 cases) had PFAT5 levels <0.05% (up to 0.04%), and this difference was significant (P <.001). Pairwise comparisons between groups based on overall values of PFAT5, MDS, and pH showed significant differences between groups for all variables. Conclusions: For neonatal TNAs, AA level is the most sensitive determinant of stability, and the PFAT5 parameter is the most sensitive indicator of stability. © 2010 American Society for Parenteral and Enteral Nutrition.

Bakhru M.R.,University of Virginia | Sethi A.,Columbia University | Singh S.K.,Boston University | Kwon R.S.,University of Michigan | And 7 more authors.
Journal of Clinical Gastroenterology | Year: 2013

BACKGROUND:: Malignant ampullary lesions can be difficult to classify by endoscopy alone. Probe-based confocal laser endomicroscopy (pCLE) permits in vivo assessment of mucosal structures in the gastrointestinal tracts in the real time. AIM:: The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of pCLE of ampullary lesions. METHODS:: Twelve pCLE video clips of ampullary lesions were distributed to 6 gastrointestinal specialists at 5 medical centers, blinded to final pathologic results. Six variables were assessed for interobserver agreement using κ statistics. Variables included an epithelial outer border with irregular thickness, dark epithelium without discernable individual cells, heterogenously distributed elongated crypts, reduced number of goblet cells, neovascularization, and final diagnosis. RESULTS:: The overall interobserver agreement for all observers was poor to slight for all variables (κ=0.02, 0.05, -0.01, 0.04, 0.018) except for the first variable with fair degree of agreement (κ=0.27). On the basis of experience, 3 observers were classified as less experienced, whereas 3 were classified as most experienced. Upon stratification, the less experienced observers had poor interobserver agreement for all variables, except 1. The most experienced observers had poor agreement for 2 variables, slight agreement for 3 variables, and fair agreement for the final diagnosis variable. CONCLUSIONS:: The overall interpersonal agreement on pCLE for ampullary lesions was poor. The interobserver agreement was not substantially improved for experienced raters. Further standardization of pCLE image criteria is needed for ampullary lesions. Standardized training may improve interrater reliability to an acceptable level. Copyright © 2013 by Lippincott Williams & Wilkins.

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