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INTRODUCTION Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE. METHODS After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored. RESULTS A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P

Introduction Leadership is an area of education and training that is critical to the development of medical providers as health care professionals, yet few medical school curricula offer formal training in this area. Methods We designed and implemented a course to develop and enhance the leadership and teamwork skills of first-year medical students to better prepare them for medical practice. Following a systematic literature review to identify leadership core competencies, the Leadership in Medicine Optional Enrichment Elective (OEE) was developed in accordance with the University of Massachusetts Medical School's course guidelines. The elective included six interactive sessions to advance skills in the areas of recognizing and utilizing effective leadership styles, communication within the health care team, giving and receiving feedback, delegating responsibilities, and direction setting. We designed a robust, evidence-based, scholarly evaluation plan for the OEE that was integral to ongoing quality improvement of the course. Results Outcomes were assessed in alignment with the Kirkpatrick method of standardized evaluation. A total of 26 participants completed the course. At completion, participants demonstrated learning and advancement of skills in all five leadership domains. Furthermore, participants found meaning in the course and planned to utilize their skills in future medical practice. Discussion The development, implementation, and evaluation of this program can serve as a model for future course development, and the program can be adapted and implemented by other institutions in an effort to address the learning gap regarding leadership education.

Background Neuroendocine tumors (NETs) or carcinoids arise at many different sites of the gastrointestinal tract. The small intestine is the most common site for NETs. Diagnosing small bowel carcinoids remains challenging given their non-specific presentations and the overall low incidence of small bowel tumors. Video capsule endoscopy (VCE) has significanly improved our ability to detect small bowel malignancies. We explore the value of VCE in the initial workup and management of a series of small bowel carcinoid patients. Methods We retrospectively analyzed adult patients undergoing surgical management for small bowel lesions from July 2005 to September 2015 at a tertiary care center. Patient characteristics, presenting symptomatology, diagnostic workup and surgical management were analyzed among patients with histologically confirmed small bowel carcinoid tumors. Results Our study identified 16 patients treated surgically for small bowel carcinoids. The majority of patients (87.5%) presented with either occult gastrointestinal bleeding or anemia. Most patients (87.5%) were initially evaluated with various endoscopic and imaging modalities before all ultimately undergoing surgery. Seventy-five percent of patients had a VCE, with 83.3% (10/12) having positive findings that correlated with intraoperative findings compared to 62.5% (5/8) with computed tomography scan, 21.4% (3/14) with colonoscopy, 44% (4/9) with deep enteroscopy, and 0% (0/9) with esophagogastroduodenoscopy (EGD). Conclusions In the absence of any contraindications, VCE is an effective endoscopic modality in the diagnostic workup of small bowel NETs. Furthermore, positive VCE findings appear to highly correlate with surgical findings, thus suggesting a valuable role for VCE in the initial surgical assessment of patients with small bowel NETs.

We present a case of a young lady with extreme involuntary weight loss and alarming constitutional symptoms found ultimately to be all due to a single medication’s side effects. The objective of this case report is to alert physicians, especially in a primary care setting, that the side effects of a medication used mostly in a highly specialized field of neurology, sodium oxybate (SXB), can cause extreme involuntary weight loss in addition to chronic night sweats and symptoms of clinical depression.

The diagnosis of small-bowel tumors is challenging due to their low incidence, nonspecific presentation, and limitations of traditional endoscopic techniques. In our study, we examined the utility of the mucosal protrusion angle in differentiating between true submucosal masses and bulges of the small bowel on video capsule endoscopy. We retrospectively reviewed video capsule endoscopies of 34 patients who had suspected small-bowel lesions between 2002 and 2017. Mucosal protrusion angles were defined as the angle between the small-bowel protruding lesion and surrounding mucosa and were measured using a protractor placed on a computer screen. We found that 25 patients were found to have true submucosal masses based on pathology and 9 patients had innocent bulges due to extrinsic compression. True submucosal masses had an average measured protrusion angle of 45.7 degrees &plusmn, 20.8 whereas innocent bulges had an average protrusion angle of 108.6 degrees &plusmn, 16.3 (p &lt, 0.0001, unpaired t-test). Acute angle of protrusion accurately discriminated between true submucosal masses and extrinsic compression bulges on Fisher&rsquo, s exact test (p = 0.0001). Our findings suggest that mucosal protrusion angle is a simple and useful tool for differentiating between true masses and innocent bulges of the small bowel.

Summary: The rupture of an Echinococcus granulosus hydatid cyst in the spleen due to trauma is a rare event. In this case report we describe the case of a 39-year-old Lebanese male victim of a motor vehicle accident with a ruptured solitary splenic hydatid cyst discovered by CT scan and excised during exploratory laparotomy.Echinococcosis or hydatid disease is a parasitic infestation by the Echinococcus genus of tapeworm. The eggs of E. granulosus, a species of Echinococcus, are fecal-orally transmitted to human hosts, most often from dog feces, and manifest as cystic lesions termed hydatid. E. granulosus most commonly affects the liver (75%), lungs (15%), and rarely the spleen (2–5%) [1,2]. E. granulosus is particularly endemic to cattle rearing areas of the Middle East. Infected patients most commonly present with vague abdominal pain, as a result of mass effect or spontaneous rupture of the cyst. Nevertheless, patient presentation may be due to traumatic rupture of a hydatid cyst; however, this is very rare. Herein we report a case of traumatic rupture of a solitary splenic hydatid cyst in a 39-year-old male following a motor vehicle crash, managed following the Advanced Trauma Life Support (ATLS) protocol. Keywords: Echinococcus, Hydatid, Trauma, Splenectomy, Cysts, Surgery

Aurora-B is the kinase subunit of the Chromosome Passenger Complex (CPC), a key regulator of mitotic progression that corrects improper kinetochore attachments and establishes the spindle midzone. Recent work has demonstrated that the CPC is a microtubule-associated protein complex and that microtubules are able to activate the CPC by contributing to Aurora-B auto-phosphorylation in trans. Aurora-B activation is thought to occur when the local concentration of Aurora-B is high, as occurs when Aurora-B is enriched at centromeres. It is not clear, however, whether distributed binding to large structures such as microtubules would increase the local concentration of Aurora-B. Here we show that microtubules accelerate the kinase activity of Aurora-B by a ‘‘reduction in dimensionality.’’ We find that microtubules increase the kinase activity of Aurora-B toward microtubule-associated substrates while reducing the phosphorylation levels of substrates not associated to microtubules. Using the single molecule assay for microtubule-associated proteins, we show that a minimal CPC construct binds to microtubules and diffuses in a one-dimensional (1D) random walk. The binding of Aurora-B to microtubules is salt-dependent and requires the C-terminal tails of tubulin, indicating that the interaction is electrostatic. We show that the rate of Aurora-B auto-activation is faster with increasing concentrations of microtubules. Finally, we demonstrate that microtubules lose their ability to stimulate Aurora-B when their C-terminal tails are removed by proteolysis. We propose a model in which microtubules act as scaffolds for the enzymatic activity of Aurora-B. The scaffolding activity of microtubules enables rapid Aurora-B activation and efficient phosphorylation of microtubuleassociated substrates., PLoS ONE, 9 (2), ISSN:1932-6203

A 43-year-old woman was the driver in a car crash versus a tree. After a prolonged extrication, she was taken to a local community hospital. Her injuries on clinical examination included an abdominal wall defect with small bowel evisceration and multiple orthopedic extremity injuries. She was intubated at the community hospital for altered mental status. The patient was then sent by air transport to our level I trauma center for further management. On arrival at the trauma bay, 3 hours after the injury, her pulse was 125 bpm and her blood pressure was 100/56 mm Hg. Her Glasgow Coma Scale was 3 T during the initial trauma bay assessment. Physical examination was notable for a left lower quadrant laceration that revealed an eviscerated small bowel. 1. Perform abdominal imaging and close the defect if no intra-abdominal injury is detected? 2. Proceed to the operating room (OR) for prompt exploratory laparotomy and surgical repair with or without mesh? 3. Proceed to the OR for exploratory laparotomy and component separation repair of the abdominal wall? ### Correct answer: B CT scans of the head, cervical spine, chest, abdomen and pelvis (figure 1) were performed to determine if intracranial hemorrhage, aortic injury or cervical and thoracolumbar …

The direct observation of single kinesins and microtubule-associated proteins (MAPs) has become a core tool for cytoskeleton research. We outline several variations to the core experiment that allow the researcher to explore structural and biophysical mechanisms underlying kinesin motility and MAP function.