To work or not to work... Before law school: apprehension, confidence, and cynicism among law students

 Most socio-legal scholarship does not examine pre-law school preparation, more specifically, work experience. The recent American economic recession brought many working adults back into the fold of school. With regard to legal education in particular, how might work experience before law school affect students’ perceptions of the profession, themselves, and their career trajectories? And, how do these experiences vary between law schools, and among law students? Drawing on an ethnographic study at two divergently-ranked American law schools between 2009-2011 (the beginnings of the economic crisis), I argue that student work experiences (or lack thereof) before law school matter for their own perceptions of their school and overall career outlook. I typologize those students who transitioned immediately from undergraduate to law school as "conventionals," and those with work experience prior to commencing legal education as "returnees." I find that overall, returnees are more confident about completing law school, yet cynical about legal education, while their conventional counterparts respect the pedagogy but remain apprehensive regarding their career outlook. In this respect, work experience provides a form of "capital." Notably, most immigrant students in this study are conventionals, and I provide some suggestions to better incorporate these students who already feel as if they are posturing in an unfamiliar cultural and professional environment.

Clinical utility of capsule endoscopy in gastrointestinal bleeding

Introduction Capsule endoscopy (CE) is a first-line diagnostic tool for known or suspected small bowel bleeding (SBB), and its use has over time been expanded to include panenteric imaging. It offers advantages over conventional endoscopy in minimal invasiveness and ease of use. However several drawbacks remain including the lack of modalities other than imaging, inability to control or propel the capsule, lesser image quality compared to conventional endoscopy and labour-intensiveness of data interpretation. Aims and objectives This thesis aims to explore the ways in which use of CE can be optimised in the current clinical or “real world” context, focusing on its use in gastrointestinal bleeding and working within current resource and technological limitations. Methods A review and analysis of the existing literature was undertaken, examining the present state of CE technology and identifying current gaps in knowledge. Meta-analyses were undertaken examining the effectiveness of the two main methods of image enhancement in CE: the use of bowel preparation and currently available rudimentary computer-aided diagnosis. The following studies then looked into how to better select patients who should be prioritised for CE examination – a pertinent issue in today’s resource-stretched healthcare systems. A retrospective study was carried out to examine the effects of altering the timing of CE examination in patients referred for likely SBB, using cases carried out at our tertiary care centre over the past decade. Outcomes were compared between patients who had undergone CE following negative bidirectional endoscopies, or negative upper gastrointestinal tract endoscopy only. Furthermore, building on existing work, a second study was undertaken using a prospectively-designed database to collect multicentre data on findings and outcomes in young patients referred for CE with iron deficiency anaemia. This study investigated factors predictive of small bowel neoplasia in this patient group. Finally, the effect of image visualisation quality on diagnostic certainty was investigated. CE images were processed to alter image parameters, and the resulting images presented to an iii international group of expert CE readers in order to determine thresholds for acceptable image quality and the effects of differing image quality in the parameters examined. Results Currently-available image enhancement techniques: (1) Use of bowel preparation: Laxative use did not improve the diagnostic yield of CE with odds ratio (OR) 1.1 for both overall and significant findings when comparing laxative use with pre-procedural fast only. However, subjectively-determined small bowel visualisation quality improved with the use of laxatives (OR 1.60 (95%CI 1.08–2.06)), NNT 14. (2) Use of suspected blood indicator (SBI): The overall sensitivity of SBI for bleeding or potentially bleeding lesions was 0.553, specificity 0.578, DOR 12.354. The sensitivity of SBI for active bleeding was 0.988, specificity 0.646, DOR 229.89. (3) Use of FICE digital image enhancement: Overall, the use of the three FICE modes did not significantly improve image delineation or detection rate in CE. For pigmented lesions only, FICE setting 1 performed better in lesion delineation and detection. Patient selection and CE pathways: The earlier use of CE in inpatients with melena or IDA, no signs of lower gastrointestinal pathology and negative UGIE resulted in shortened hospital stays, significant diagnostic yield from both small bowel and upper gastrointestinal tract, and two-thirds less unnecessary colon investigations without affecting clinical outcomes. In young patients (age <50 years) with IDA and negative bidirectional GI endoscopy, the overall diagnostic yield of CE for clinically significant findings was 32.3%. 5% of our cohort was diagnosed with SB neoplasia; lower MCV and weight loss were associated with higher diagnostic yield for significant SB pathology. Effects of visualisation quality on diagnostic certainty: Poor visualisation quality in all parameters affected mostly neoplastic lesions. Software to increase contrast and sharpen images can improve visualisation quality; smart frame rate adaptation could improve the number of high-quality frames obtained. Thoroughness in small bowel cleansing was found to be most important when there is suspicion of neoplasia. Conclusions The data in this thesis show that CE could be employed earlier in the diagnostic pathway for patients presenting clinically with SBB, as an effective diagnostic and triage tool in the semi acute setting. Although the overall diagnostic yield of CE is lower in younger patients, young patients with IDA and no significant findings on bidirectional endoscopy are also more likely to have significant small bowel findings, and should perhaps be referred preferentially for CE. This would help increase the efficiency of resource utilisation. Of the currently available image enhancement techniques in CE, digital image enhancement and diagnostic tools such as SBI and FICE remain of limited validity; however they show the most promise for vascular lesions and active GI bleeding, which supports their use in the acute to semi-acute setting to improve efficiency of CE reading. Image enhancement with both laxatives and digital means is the most crucial when patients are suspected of having more subtle small bowel findings such as small bowel neoplasia

Thrombin is an effective and safe therapy in the management of bleeding gastric varices:A real-world experience

Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (&lt;5 days from index endoscopy)—26 patients (18%); rebleeding within 30 days—42 patients (29.1%); delayed rebleeding (&gt; 30 days)—11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices

Morpho-functional evaluation of small bowel using wireless motility capsule and video capsule endoscopy in patients with known or suspected Crohn’s disease: pilot study

Background and study aims: SmartPill(®) (Given Imaging Corp.,Yoqneam,Israel) is an ingestible, non-imaging capsule that records physiological data including contractions and pH throughout the gastrointestinal tract. There are scarce data looking at SmartPill(®) assessment of patients with known/suspected small-bowel Crohn’s Disease (CD). This pilot study aims to investigate feasibility and safety of SmartPill(®) to assess gut motility in this group.  Patients and methods: Over 1 year, patients with known/suspected CD, referred for small-bowel capsule endoscopy (SBCE), were invited to participate and 12 were recruited (7 female, 5 male, mean age 44.2 ± 16.6 years). They underwent hydrogen breath test to exclude small-bowel bacterial overgrowth, patency capsule (Agile(®)), and provided stool samples for fecal calprotectin (FC). Patients ingested PillCam(®)SB2 and SmartPill(®) 4 hours apart. Using unpublished data, 33 healthy controls also were identified for the study. P < 0.05 was considered statistically significant. Results: Of the 12 patients enrolled, 10 underwent complete Smartpill(®) examination (1 stomach retention, 1 dropout). Pillcam(®) was complete in 10 (1 dropout, 1 stomach retention). Mean fecal calprotectin was 340 ± 307.71 mcg/g. The study group had longer transit times and lower gut motility index than did the controls. The difference in motility appears to be statistically significant (P < 0.05). Longer transit times for SmartPill(®) (not statistically significant) may have been due to different specifications between the capsules. Limitations included transient Smartpill(®) signal loss (5/10 studies). Conclusions: This is the first pilot to attempt combining SBCE and SmartPill(®) to assess small-bowel CD. Data on motility in CD are scarce. Multimodal information can provide a clearer clinical picture. Despite concerns about capsule retention in CD patients, SmartPill(®) seems safe for use if a patency capsule is employed beforehand

Small bowel malignancy in patients undergoing capsule endoscopy at a tertiary care academic center:Case series and review of the literature

Abstract Background and study aims Small bowel cancer is rare, accounting for &lt; 5 % of all gastrointestinal neoplasms. Capsule endoscopy has become the procedure of choice for non-invasive diagnosis of small bowel diseases. Data on capsule endoscopy diagnosis of small bowel cancer are limited. The objective of the study was to determine the frequency, indications and diagnostic work-up of patients with small bowel malignancy found by capsule endoscopy at a Scottish tertiary center. Patients and methods In this retrospective study, records all patients who underwent small bowel capsule endoscopy at our center over a 10-year period were reviewed for possible malignancy. Further data were gathered on preceding and subsequent investigations, management and outcome of these patients.  Results From 1949 studies, small bowel malignancies were diagnosed in only 7 patients (0.36 %; 2F/5M; median age 50, range 34 – 67). The main indication was iron-deficiency anemia (n = 5). Prior to capsule endoscopy, 6 of 7 patients had bidirectional endoscopies and one had gastroscopy. All prior investigations were normal or nondiagnostic. Two of 7 experienced capsule retention. Five of 7 underwent surgery. Four patients died, giving a 5-year survival rate of 42.9 %. Conclusion Small bowel malignancies diagnosed by capsule endoscopy are rare, and the median age of 50 indicates they are more common in relatively younger patients. Capsule endoscopy is effective at diagnosing a rare malignancy when other imaging modalities have failed.</jats:p

Restoring Core Values: An International Charter for Human Values in Healthcare

Background: The human dimensions of healthcare are fundamental to the practice of compassionate, safe, and ethical relationship-centered care. Attending to the human dimensions improves patient and clinician satisfaction, outcomes and quality of care; however, these dimensions have not received the emphasis necessary to make them central to every healthcare encounter. We established an international collaborative effort to identify and promote the human dimensions of care. Objectives: a) To describe work to date on the International Charter for Human Values in Healthcare; b) To discuss translation of the Charter's universal values into education, research, and practice. Methods: An international working group of expert educators, clinicians, linguists, and researchers identified initial values that should be present in every healthcare interaction. The working group and four additional groups -- National Academies of Practice (NAP) USA, International Conference on Communication in Healthcare, Interprofessional Patient-Centered Care Conference, American Academy on Communication in Healthcare Forum -- identified values for all healthcare interactions and prioritized top values. The NAP group also prioritized top values for interprofessional interactions. Additional data was gathered via a Delphi process and 2 focus groups of Harvard Macy Institute scholars and faculty. Results: Through iterative content analyses and consensus, we identified 5 categories of core human values that should be present in every healthcare interaction: Capacity for Compassion, Respect for Persons, Commitment to Integrity and Ethical Practice, Commitment to Excellence, and Justice in Healthcare. Through further consensus and Delphi methodology, we identified values within each category. Conclusions: The International Charter for Human Values in Healthcare [1] is a cooperative effort to restore core human values to healthcare around the world. Major healthcare and education partners have joined this international effort. We are working to develop methods to translate the Charter's universal values into education (teaching, assessment, curricula), research and practice

Presence of Human Bocavirus 1 in Hospitalised Children with Acute Respiratory Tract Infections in Latvia and Lithuania

Funding Information: This study was supported by Republic of China (Taiwan)-Republic of Latvia-Republic of Lithuania scientific collaboration project, "Establishing of the framework to track molecular epidemiology of Parvoviruses and to correlate sequence variability with different clinical manifestations" (Research Council of Latvia Nr. gr. 6-25/2012/0026, Research Council of Lithuania TAPLLT02/201) and by project Nr. RSU ZP 17/2013 "Epidemiology, pathogenicity of human Bocavirus (HBoV) species and possible association with lower respiratory tract illnesses and acute gastroenteritis in children". We are grateful to Rita Nikitenkiene and Irina Maksimova for technical help. Publisher Copyright: © 2016 by Zaiga Nora-Krūkle. Copyright: Copyright 2016 Elsevier B.V., All rights reserved.Human bocavirus 1 (HBoV1) is a parvovirus recently found to be a possible aetiologic agent of acute respiratory disease in children. We conducted the first clinical and molecular study on this virus in Latvia (LV) and Lithuania (LT). The aim of the study was to determine the occurrence of HBoV1 in respiratory tract samples taken from hospitalised children with acute respiratory tract infections in LV and LT. In total 186 children with age one to 50 months, and who fulfilled criteria of acute respiratory tract infection, including lower respiratory tract infections, with or without fever, were included in this study. A nasopharyngeal aspirate was obtained from each patient on admission. DNA was isolated and polimerase chain reaction (PCR) performed targeting the HBoV1 NS1sequence. HBoV1 positive samples were sequenced and phylogenetic analysis was performed. HBoV1 sequence was detected in 42 (32%) of 130 LV and in 8 (14%) of 56 LT samples. In LV the majority of patients with HBoV1 infection were observed in February while in LT in October. The phylogenetic tree for HBoV1 indicated that isolates of HBoV1 cluster closely and include almost all of the isolates in this study. HBoV1 is common in Latvia and Lithuania and might be a significant pathogen that contributes to acute respiratory tract infections in children.Peer reviewe

Luminally expressed gastrointestinal biomarkers

Introduction: A biomarker is a measurable indicator of normal biologic processes, pathogenic processes or pharmacological responses. The identification of a useful biomarker is challenging, with several hurdles to overcome before clinical adoption. This review gives a general overview of a range of biomarkers associated with inflammatory bowel disease or colorectal cancer along the gastrointestinal tract. Areas covered: These markers include those that are already clinically accepted, such as inflammatory markers such as faecal calprotectin, S100A12 (Calgranulin C), Fatty Acid Binding Proteins (FABP), malignancy markers such as Faecal Occult Blood, Mucins, Stool DNA, Faecal microRNA (miRNA), other markers such as Faecal Elastase, Faecal alpha-1-antitrypsin, Alpha2-macroglobulin and possible future markers such as microbiota, volatile organic compounds and pH. Expert commentary: There are currently a few biomarkers that have been sufficiently validated for routine clinical use at present such as FC. However, many of these biomarkers continue to be limited in sensitivity and specificity for various GI diseases. Emerging biomarkers have the potential to improve diagnosis and monitoring but further study is required to determine efficacy and validate clinical utility

Increasing public venous awareness, graduated compression stockings compliance and scientific data collection through open events on golf courses: A feasibility study

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