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Turner&#39;s syndrome is the most common chromosomal abnormality and is associated with either complete or partial loss of one X chromosome. The average age at the time of the diagnosis is around 15 years. It is well-established that patients suffer from multiple endocrinal disorders later in life with multisystem involvement. Our case series suggest a need to optimize the transition from pediatric to adult endocrine care in TS patients. It is essential to have a continuous and integrated approach to treating TS patients with a timely referral to the adult endocrine service to improve the quality of life and prevent complications.

AMA Research Challenge 2022

Retrospective analysis of seven TS patients in an outpatient Adult Endocrine Clinic

Turner's syndrome is the most common chromosomal abnormality and is associated with either complete or partial loss of one X chromosome. The average age at the time of the diagnosis is around 15 years. It is well-established that patients suffer from multiple endocrinal disorders later in life with multisystem involvement. Our case series suggest a need to optimize the transition from pediatric to adult endocrine care in TS patients. It is essential to have a continuous and integrated approach to treating TS patients with a timely referral to the adult endocrine service to improve the quality of life and prevent complications.

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Objective: To compare standardized quality measures between telemedicine and office in a largeintegrated health system.
Materials and Methods: This retrospective cohort study compared graded exposure to telemedicine (office-only, blended, and telemedicine-only) across 16 National Quality Forum HEDIS measures from 03/1/2020 - 11/30/2021. A historical 1.5-year (pre-pandemic) quality performance baseline was established across 200+ sites in Pennsylvania. Chi-squared tests determined statistically significant (P
<0.01) differences between exposure groups. Multivariable logistic regression controlled for sociodemographic factors and comorbidities.
Results: There were 523,874 patients meeting inclusion criteria (409,732 office, 112,199 blended, 4,943 telemedicine). Statistically significant performance differences favored blended-telemedicine in 11 of 16 (cardiovascular: blood pressure 7.84%; lipid panel 7.63%; diabetes: HbA1c, 6.06%; nephropathy testing 9.98%; prevention & wellness: cervical cancer 12.98%, breast cancer 17.90%, colon cancer 8.80%, tobacco intervention 13.29%, influenza vaccination 10.39%, pneumococcal vaccination 5.77%; behavioral health: depression screening 5.07%) and favored office-only in 3 of 16 (cardiovascular care: antiplatelet 6.55%, statin 1.75%; pulmonary: antibiotics in bronchitis, 2.08%). There were insignificant differences between office and blended groups for 2 of 16 measures (cardiovascular care: beta blocker 1.08%, P = 0.1741; diabetes: statin 0.93%, P = 0.0406).
Discussion: Telemedicine had a favorable impact on quality performance, especially in quality measures involving testing and preventive care. A blended telemedicine-office approach might promote higher value care. Further study could determine superiority and graded effect of telemedicine in specific clinical scenarios.
Conclusion: This study demonstrates telemedicine’s ability to enhance primary care capacity while sustaining or improving quality performance.

Comparable Quality Between Telemedicine and In-Office Primary Care 

Introduction: Gallbladder cancer is the most common biliary tract cancer and is a fatal malignancy with a 5-year survival rate of only 18%. The Incidence of gallbladder cancer is 0.26% for women and 0.25% for men globally. It is unclear how the burden of this disease differs between nations. Using the Global Burden of Disease (GBD) Study database, we studied the trends in mortality, Incidence, and disability-adjusted life years (DALYs) from gallbladder cancer between 1990-2019 in European Union (EU) 15+ nations, which constitutes a comparable group of countries for observation analyses.

Methods: We extracted data from the GBD Study database between 1990 - 2019 based on the International Classification of Disease, including Age-Standardized Incidence Rates (ASIR), Mortality (ASMR), Mortality-to-Incidence (MIR) ratios, as well as DALYs for gallbladder cancer. Joinpoint regression analysis was carried out for the evaluation of trends. EU15+ countries is a readily comparable group of 19 countries with similar healthcare infrastructure. We also computed the male-to-female ratio to evaluate the difference in burden between the two genders.
Results: ASIR decreased globally (-2.54% males, -20.93% females) as well as for EU15+ countries except for males in Norway +6.1%, Greece+18.1% and Denmark +27.4%. At the same time, Incidence decreased by approximately 8 times in females than in males. ASMRs also decreased globally (-5.42% males, -22.47% females) by approximately 4 times higher in females. Similarly, ASMR decreased for all EU15+ countries except Greece (+14.5%) for males. Along with Incidence and mortality, MIR also decreased globally (-2.96% males, -1.95% females) and for EU15+ countries except for Sweden (+9.7% males, +28.9% females). We also observed a decreasing trend in DALYs globally for both genders (males -9.3%, females -24.2%). Amongst EU15+ countries, DALYS decreased for all countries except for males in Greece (+13.3%). 
Conclusion: Overall, Incidence, mortality, and DALYs due to gallbladder cancer have decreased globally and in most EU15+ countries. However, countries like Greece have shown discordant trends. Interestingly, the burden of gallbladder cancer has significantly decreased for females with a disproportionate decrease for males. Further studies will help evaluate these discordant trends in detail.

A comparison of the burden of gallbladder cancer between the European Union 15+ countries, 1990-2019: estimates from the Global Burden of Disease Study

Background: Liver failure (LF) is associated with a high mortality rate, requiring a liver transplant as the definitive treatment. The Molecular Adsorbent Recirculating System (MARS) is a non-biologic system that removes toxic metabolites from the bloodstream by providing extracorporeal support while waiting for a liver transplant. Conflicting pieces of evidence from multiple studies are present regarding the outcome of MARS therapy. We evaluated the effect of MARS therapy on patients with liver failure by measuring the changes in their laboratory parameters. 

Methods: In this retrospective cohort analysis, we evaluated 44 patients, by comparing relevant laboratory variables measured before and after MARS therapy. Paired t-test was used for statistical analysis. The primary outcome was an improvement in laboratory parameters following MARS therapy. 

Results: Most of our study cohort were females (63.64%) and white (72.72%). The predominant causes of liver failure were NASH (non-alcoholic steatohepatitis) (22.73%) and alcoholism (22.73%). At admission, the mean Child-Pugh score was 11.45 (SD: 1.97), and the mean SOFA (sequential organ failure assessment) score was 10.95 (SD: 3.65). The mean number of MARS sessions was 4.32 (SD: 2.28) and the mean duration for patients on MARS therapy was 4.64 days (SD: 2.44).
Our analysis demonstrates a statistically significant improvement in mean serum bilirubin, ammonia, urea, creatinine, ALT, and AST levels following MARS therapy. The mean model for end-stage liver disease (MELD-Na) scores also significantly improved. 59.09% of our total patient population survived the hospital stay and 40.91% died in hospital, with 73.07% of the survivors eventually receiving a liver transplant. 94.74% of the patients with whom we were able to bridge MARS therapy until liver transplant, had survived through the follow-up period.

Conclusion: Our study findings suggest that MARS improves the liver-failure-associated laboratory parameters and may be effective therapy as a bridge to liver transplant.


A Retrospective Study on the Effect of Molecular Adsorbent Recirculating System in Patients with Liver Failure

Acute Pancreatitis related to COVID-19 Infection. A Systematic Review and Analysis of Data.

Association of Statins with the Onset and Progression of Non-Alcoholic
Fatty Liver Disease in Veterans with Diabetes: A Retrospective Propensity
Score-Matched Cohort Study

Association of Statins with the Onset and Progression of Non-Alcoholic Fatty Liver Disease in Veterans with Diabetes: A Retrospective Propensity Score-Matched Cohort Study

With a 5-year survival rate of just 20%, esophageal cancer is a disease that must have improved early diagnostics and characterization, obtainable at a moderate cost within an endoscopy suite setting.
In an effort to address this need, including enhanced evaluation of diseases of the esophagus and pharynx, we developed and demonstrated on cadavers a new AI-based experimental 3D endoscope, E3D (Esophagoscope-3D), a slender (~1 cm diameter) endoscope capable of obtaining 3D images inside the mouth and esophagus.
Team members from Pensievision, Inc. built the endoscope hardware and wrote the AI-based image processing software, while MUSC team members guided the device’s development to meet clinical requirements and conducted cadaver tests to evaluate feasibility and demonstrate 3D sensitivities. During cadaver testing, E3D successfully accessed the esophagus via the cadaver’s contracted 1 cm diameter esophagus entrance. We were then able to generate the first macroscopic (~2cm field-of-view) 3D image ever to be collected of the esophagus using an imaging endoscope.

Demonstration of AI-Based, 3D-Imaging of the Esophagus Using a Novel Imaging Endoscope

Inflammatory Bowel Disease and its Association with Melanoma and Non-Melanoma Skin Cancers

Background
Inflammatory bowel disease (IBD) is complex, easily misdiagnosed and mismanaged. Multidisciplinary care improves patient outcomes. Yet, few hospitals have a multidisciplinary team approach to IBD care that consistently includes a gastrointestinal expert pathologist. This study aims to quantify the impact an expert pathologist has on a multidisciplinary team in the care of difficult IBD patients.

Methods
A retrospective chart analysis was performed on patients (N=283) discussed at the semi-monthly multidisciplinary IBD conference at Carilion Clinic, from June 1, 2013 through December 31, 2019. Each patient was presented between one and six times at the conference. Data collected: demographics, baseline clinical characteristics, diagnosis before and after conference, reason for diagnostic change, endoscopy findings, medications, surgeries, and if clinical remission was achieved within 6 months after conference.

Results
After the first conference, 42% of patients presented had a diagnostic change: 84% due to expert pathologist interpretation, 12% due to radiology, and 4% due to other reasons. Majority of diagnostic changes after the second (73%), third (67%), and fourth (100%) conferences were also attributed to pathology. Crohn disease was the most common new diagnosis after conference, and indeterminate colitis was the most commonly changed diagnosis. For patients newly diagnosed with ulcerative colitis after conference, most had moderate active colitis (54%), whereas for those newly diagnosed with Crohn disease, colitis severity was distributed similarly between none (22%), mild (26%), moderate (28%), and severe (24%). Approximately 24% to 35% of patients presented had a change in IBD medication, among which ~34% to 40% had a diagnostic change. Following the conference, ~17% to 20% of patients underwent surgical intervention, among which ~12% to 27% had a diagnostic change. A majority of these patients achieved clinical remission within 6 months of the conference.

Conclusion
The majority of diagnostic changes made at the multidisciplinary IBD conference were due to histopathologic re-interpretation. A change in diagnosis at times led to significant modifications in disease management through surgery or medication changes. Multidisciplinary care teams are essential to the best management of complex IBD patients. An expert gastrointestinal pathologist is a critical team member to the discussion of nuances of each patient’s case.



Multidisciplinary Inflammatory Bowel Disease Conference: The Contribution and Impact of Pathology on Patient Care 

Background
Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare form of idiopathic colonic dilation without mechanical obstruction. It typically occurs in elderly patients who have recently been hospitalized or undergone surgery with an incidence rate of about 100 cases per 100,000 hospitalizations every year. Despite neostigmine being the treatment of choice, we highlight the importance of early management and diagnosis. 

Case Presentation
A 76-year-old male with a history of class III obesity, diabetes mellitus, systolic heart failure, and ulcerative colitis well-controlled with sulfasalazine was admitted due to acute lower back pain with radiculopathy to lower extremities after lifting heavy boxes. The hospital course was complicated by developing acute kidney injury. In addition, a gradually enlarging but painless abdominal distension was noted, along with severe constipation. Serum measurements reflected persistent hypokalemia, leukocytosis, and elevated creatinine. Abdominal imaging revealed a markedly dilated colon with a cecal diameter of 12.8 cm but without signs of inflammation or perforation. Although neostigmine, correction of electrolytes, and rectal tube placement initially alleviated his condition, the abdominal distention continued to worsen. On day 16 of his stay, a repeat abdominal computed tomography showed pneumoperitoneum and the patient required emergent surgery. A 4cm perforation was appreciated in the transverse colon resulting in a total colectomy with end ileostomy. The patient recovered without complications after the surgery. 

Discussion
Although the etiology remains unclear, our patient’s advanced age and renal and cardiac comorbidities potentially precipitated the onset of Ogilvie syndrome, causing a perforated colon. The risk of perforation is increased when the cecal diameter is larger than 12cm, and the colonic distension lasts greater than 6 days, both of which were observed in our patient. Management of Ogilvie syndrome is primarily focused on urgent bowel decompression and correction of electrolyte abnormalities. Although neostigmine has been shown to rapidly alleviate Ogilvie syndrome, our patient did not respond accordingly. The mortality rate in Ogilvie syndrome increases with surgical management, regardless of the presence of perforation, and can reach up to 40% following a perforated colon. Therefore, early diagnosis and conservative management of Ogilvie syndrome are important to prevent serious complications.

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Comparable Quality Between Telemedicine and In-Office Primary Care

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