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Pancreatic adenocarcinoma is a leading cause of cancer death. Few patients are candidates for curative resection due to the late stage at diagnosis. While most pancreatic adenocarcinomas are sporadic, approximately 10% have an underlying hereditary basis. Known genetic syndromes account for only 20% of the familial clustering of pancreatic cancer cases. The majority are due to non-syndromic aggregation of pancreatic cancer cases or familial pancreatic cancer. Screening aims to identify high-risk lesions amenable to surgical resection. However, the optimal interval for screening and the management of pancreatic cancer precursor lesions detected on imaging are controversial.

Purpose:The aim of this study was to assess whether differences in frequency and phenotype of APC and MUTYH mutations exist among racially/ethnically diverse populations.Methods:We studied 6,169 individuals with a personal and/or family history of colorectal cancer (CRC) and polyps. APC testing involved full sequencing/large rearrangement analysis (FS/LRA); MUTYH involved “panel testing” (for Y165C, G382D mutations) or FS/LRA performed by Myriad Genetics, a commercial laboratory. Subjects were identified as Caucasian, Asian, African American (AA), or other. Statistical tests included ?2, Fisher’s exact test, analysis of variance, and z approximation.Results:Among participants, 17.5% had pathogenic APC mutations and 4.8% were biallelic MUTYH carriers. With regard to race/ethnicity, 18% were non-Caucasian, with >100 adenomas and younger ages at adenoma or CRC diagnosis (P < 0.0001) than Caucasians. The overall APC mutation rate was higher in Asians, AAs, and others as compared with Caucasians (25.2, 30.9, 24, and 15.5%, respectively; P < 0.0001) but was similar in all groups when adjusted for polyp burden. More MUTYH biallelic carriers were Caucasian or other than Asian or AA (5, 7, 2.7, and 0.3%, respectively; P < 0.0001). Among Caucasians, 5% were biallelic carriers identified by panel testing versus 2% identified by sequencing/large rearrangement analysis (LRA) (P = 0.002). Among non-Caucasians, 3% undergoing panel testing were biallelic carriers versus 10% identified by sequencing/LRA (P < 0.0002).Conclusion:Non-Caucasians undergo genetic testing at more advanced stages of polyposis and/or are younger at CRC/polyp diagnosis. Restricted MUTYH analysis may miss significant numbers of biallelic carriers, particularly in non-Caucasians.Genet Med 17 10, 815–821.

AbstractBackgroundProcedural skill is predicated on knowledge. We used a previously validated test to evaluate the impact of a web-based education program on medical residents' knowledge of 2 advanced medical procedures.MethodsWe enrolled 210 internal medicine residents at 3 residency programs in a randomized, controlled, educational trial. Study participants completed a 20-item, validated online test of their knowledge of central venous and arterial line (CVL and AL, respectively) placement at baseline and after performing their next 2 procedures (test 1 and test 2). Between test 1 and test 2, participants were randomized to online educational material for CVL insertion, AL insertion, both, or neither. The primary outcome of the study was the difference in test scores between test 1 and test 2 by randomization group.ResultsThough residents in the baseline cohort were confident about their knowledge of procedural technique, their mean test scores were low (62 and 58 in the CVL and AL tests, respectively). Baseline test score correlated with the number of prior procedures performed. Sixty-five residents completed all 3 CVL tests, and 85 residents completed all 3 AL tests. Access to the web-based procedure education was associated with a significant improvement in scores for both the CVL test (effect size, d  0.25, P  .01) and AL test (d  0.52, P < .001).ConclusionsWeb-based procedure training improves knowledge of procedures to a significantly greater extent than performing the procedure alone. Web-based curricula can effectively supplement other methods of skill development.

Immune checkpoint inhibitors represent an important advance in cancer treatment, but immune mediated adverse events associated with their use can be severe and life-threatening. Esophagitis dissecans superficialis, a rare condition of the esophagus characterized by diffuse desquamation and sloughing of the superficial esophageal mucosal lining, has not previously been reported with immune checkpoint inhibitor use. The concerning appearance of esophagitis dissecans superficialis may lead oncologists to stop therapy due to concern for toxicity. We present a case report of a patient who developed esophagitis dissecans superficialis after treatment with an immune checkpoint inhibitor that resolved without permanent discontinuation of the immune checkpoint inhibitor.

•Immune check point inhibitors (ICIs) are associated with gastrointestinal toxicity.•ICIs lead to not only gastritis and duodenitis but also esophagitis.•Consider upper endoscopy and biopsies of the esophagus during diagnostic workup.•A potential treatment strategy if steroids are ineffective is to use infliximab.

Presents letters to the editor referencing articles and topics discussed in previous issues. "Europe's 9/11," which focused on the terrorist attacks on the commuter railroad in Madrid, Spain; "Terrorist Target or Not, The Danger is Real," which compared the nuclear disaster at Three Mile Island 25 years ago with today's potential threats; "Howard Dean: The Un-Nader," which focused on the contributions of the former presidential candidate; Others.