Dunleavy, Katie

Abstract Purpose This study explores how new residents experienced the transition to residency, examines factors that made the transition process more or less difficult, and identifies potentially modifiable program features that enhanced or would have enhanced transition experiences. Method The authors conducted a qualitative interview study of postgraduate year (PGY) 1 residents in emergency medicine, family medicine, general surgery, internal medicine, obstetrics and gynecology, pediatric and adolescent medicine, and psychiatry at Mayo Clinic sites in Arizona, Florida, Minnesota, and Wisconsin between December 2020 and March 2021. Open-ended questions explored residents’ transition experiences. Interviews were audio-recorded, transcribed, coded inductively, and analyzed iteratively using general thematic analysis from an epistemologically constructivist perspective. Results Forty-five residents (25 women, 20 men) from 12 programs, 7 specialties, and 4 states participated. PGY-1 residents experienced the transition to residency as a confluence of overlapping and interconnected transitions that unfolded over time, spanned multiple life domains, and generated numerous personal and professional demands. Residents appraised demands based on their effects on patient care, professional growth, and personal well-being and struggled when coincident demands forced tradeoffs among these concerns. Residents who experienced many difficulties during the transition to residency reported high demands (eg, due to transition-related discontinuities, depleted resources from prior transitions or a difficult match experience, structural and systemic barriers, coincident personal or situational stressors) and/or fewer resources (eg, insufficient residency or life skills, limited social support, financial strain). Preparedness and supportive relationships eased the transition process. Residency program features that enhanced or would have enhanced the transition experience included monitoring and limiting overall demands, minimizing unhelpful and harmful demands, calibrating constructive demands, and increasing holistic support. Conclusions Study findings illuminate transition experiences of PGY-1 residents, reveal person-centered considerations to inform ongoing improvement efforts, and identify potentially actionable steps programs can take to improve resident transition experiences.

Lay Summary Oral vancomycin shows promise in treating pouchitis in patients with primary sclerosing cholangitis and ulcerative colitis. In this study, vancomycin helped reduce stool frequency, urgency, and incontinence. More research is needed to confirm its long-term benefits and best treatment practices.

Lay Summary This article looks at how changes in bile acids and gut bacteria might contribute to chronic pouchitis, a condition that can develop after surgical removal of the colon and creation of a J-pouch for people with inflammatory bowel disease. The goal is to better understand pouchitis and find treatments to improve patients’ health.

Abstract Background and Aims Inflammatory bowel disease (IBD) is associated with altered mucus and increased intestinal permeability (IP). Prior reports on permeability in IBD typically used lactulose-to-mannitol ratio (LMR). Food contamination with 12C-mannitol is a significant potential confounder in IP assessment. We aimed to compare small intestinal (SI) and colonic (COL) permeability in IBD, both active (ACT) and in remission (REM), to normal healthy volunteers (NHV). Methods Inflammatory bowel disease activity was based on Simple Endoscopic Score for Crohn’s Disease (SES-CD) and Mayo endoscopy score for ulcerative colitis (UC). We performed 24-hour IP test using 100 mg 13C-mannitol and 1000 mg lactulose with urine collected during 0-2, 2-8, and 8-24 hours. The primary endpoint was mg excretion of 13C-mannitol and lactulose during 2-24 hours reflecting SI and COL permeability. Results Among 17 CD patients, 7 were ACT (SES-CD >6), and 10 REM (SES-CD 0-2). Among 20 UC patients, 10 had ACT (Mayo score 2-3), and 10 REM (Mayo score 0-1). Urinary excretions over 2-24 hours were higher for IBD than NHV: 13C-mannitol (13.8 [IQR 8.8, 18.7] NHV; 18.4 [15.6, 29.9] REM; 19.7 [13.8, 23.6] ACT, P = .003) and lactulose (1.8 [1.3, 3.1] NHV; 3.6 [2.0, 5.0] REM; 3.5 [2.0, 6.6] ACT, P = .006). There was no difference between ACT and REM for any timed urine collection. LMR at 2-24 hours (or 2-8 and 8-24 hours) were not statistically significant between the 3 groups (0.014 [0.010, 0.021] NHV; 0.016 [0.010, 0.023] REM; 0.016 [0.012, 0.038] ACT, P = .237). Conclusions Intestinal permeability is increased in IBD using validated in vivo assay relative to NHV; increased IP in IBD persists during remission.

ABSTRACT Hepatic angiosarcoma is a rare and aggressive liver tumor. We report a case study of an 82-year-old elderly gentleman who presented with failure to thrive and ascites. Initially suspected to be cirrhosis, biopsy results eventually concluded angiosarcoma of the liver. Our patient presented with an infiltrative form, rather than distinct masses, which led to portal hypertension and ascites. The variance in symptomatology and radiology presentations make a diagnosis of hepatic angiosarcoma challenging and require a high index of suspicion.

Abstract Background Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. Methods We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. Results Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. Conclusions In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented.

Abstract Crohn’s disease is a chronic gastrointestinal inflammatory disorder, characterized by episodes of relapsing and remitting flares. As the disease mechanism becomes better elucidated, there is a significant increase in the number of available biologic therapies. This article summarizes and synthesizes current Food and Drug Administration-approved biological therapy for Crohn’s disease and examines the positioning of medical therapy as emerging biologics break onto the market.