Overall, these and past studies dealing with the examination of H

Overall, these and past studies dealing with the examination of H. pylori-derived effects on DCs suggest that local and monocyte-derived DC populations in the gastric mucosa may differ functionally and support conditions for a diverse population of T cells. It will require further studies, but by exploiting the murine model these intricate

relations may be dissectible. Th17 and Treg CD4+ cell subsets have been the focus of many recent immunologic studies on the course of Helicobacter infection. Regulatory T cells are thought to expand and eventually dominate in chronic infection hindering the function of protective T cells. Recent work is substantiating this scenario; for instance, Kindlund et al. [45] showed that eradication of H. pylori reduced Treg numbers, and Jang Everolimus cost et al. [46] reported increased numbers of Tregs in the stomachs of H. pylori-positive gastric cancer patients. Treg differentiation depends on TGF-β but, in the presence of IL-6, TGF-β rather promotes Th17. Th17 cells have become a new focus in this field because of their role in neutrophil recruitment and activation. Th17 thrive in particular when IL-1 and IL-23 are also present [47]. Shi et al. [48] confirmed the latter scenario after H. pylori infection of mice and found that Th17 and Th1 cells contribute to the overall pro-inflammatory T-cell response. Similar to other infection and autoimmune

disease models, Th17 and Th1 cells modulate each other. However, in the study by Shi et al., Th17 cells promoted an inflammatory component and Th1 response that correlated with higher H. pylori colonization when wild-type mice were compared with click here IL-17-deficient or normal mice treated with an anti-IL-17 antibody

just before infection. Similarly, IL-17, when delivered by recombinant 5-Fluoracil in vivo adenovirus just before H. pylori infection, increased inflammation and bacterial load 4 weeks later. These findings are at odds with work by Otani et al. [49], who observed an increase in gastritis and Th1 cytokines in mice treated with anti-IL-17 antibodies 6 months after infection. It also contradicts work by Kao et al. [44] who showed a negative correlation of IL-17 production and H. pylori burden. Complicating the issue further, Algood et al. [50] reported that mice deficient in the IL-17A receptor developed increased inflammation over a 6 -month time scale but also suffered tenfold increased bacterial burdens. Consistent with the model that IL-17 amplifies recruitment of neutrophils, the inflammatory infiltrate contained more lymphocytes, in particular B cells at the expense of granulocytes. In humans, serum levels of IL-17 seem to correlate with severity of disease; for instance, Jafarzadeh et al. [51] found increased levels of IL-17 in duodenal ulcer patients when compared to asymptomatic H. pylori-positive patients. Moreover, genetic typing for IL-17A alleles in over 800 individuals, 300 of which were gastric cancer patients, by Shibata et al.

Overall, these and past studies dealing with the examination of H

Overall, these and past studies dealing with the examination of H. pylori-derived effects on DCs suggest that local and monocyte-derived DC populations in the gastric mucosa may differ functionally and support conditions for a diverse population of T cells. It will require further studies, but by exploiting the murine model these intricate

relations may be dissectible. Th17 and Treg CD4+ cell subsets have been the focus of many recent immunologic studies on the course of Helicobacter infection. Regulatory T cells are thought to expand and eventually dominate in chronic infection hindering the function of protective T cells. Recent work is substantiating this scenario; for instance, Kindlund et al. [45] showed that eradication of H. pylori reduced Treg numbers, and Jang Metformin et al. [46] reported increased numbers of Tregs in the stomachs of H. pylori-positive gastric cancer patients. Treg differentiation depends on TGF-β but, in the presence of IL-6, TGF-β rather promotes Th17. Th17 cells have become a new focus in this field because of their role in neutrophil recruitment and activation. Th17 thrive in particular when IL-1 and IL-23 are also present [47]. Shi et al. [48] confirmed the latter scenario after H. pylori infection of mice and found that Th17 and Th1 cells contribute to the overall pro-inflammatory T-cell response. Similar to other infection and autoimmune

disease models, Th17 and Th1 cells modulate each other. However, in the study by Shi et al., Th17 cells promoted an inflammatory component and Th1 response that correlated with higher H. pylori colonization when wild-type mice were compared with Natural Product Library order IL-17-deficient or normal mice treated with an anti-IL-17 antibody

just before infection. Similarly, IL-17, when delivered by recombinant selleck screening library adenovirus just before H. pylori infection, increased inflammation and bacterial load 4 weeks later. These findings are at odds with work by Otani et al. [49], who observed an increase in gastritis and Th1 cytokines in mice treated with anti-IL-17 antibodies 6 months after infection. It also contradicts work by Kao et al. [44] who showed a negative correlation of IL-17 production and H. pylori burden. Complicating the issue further, Algood et al. [50] reported that mice deficient in the IL-17A receptor developed increased inflammation over a 6 -month time scale but also suffered tenfold increased bacterial burdens. Consistent with the model that IL-17 amplifies recruitment of neutrophils, the inflammatory infiltrate contained more lymphocytes, in particular B cells at the expense of granulocytes. In humans, serum levels of IL-17 seem to correlate with severity of disease; for instance, Jafarzadeh et al. [51] found increased levels of IL-17 in duodenal ulcer patients when compared to asymptomatic H. pylori-positive patients. Moreover, genetic typing for IL-17A alleles in over 800 individuals, 300 of which were gastric cancer patients, by Shibata et al.

Specifically, orexin (OX) A and OXB are peptides with neuronal ce

Specifically, orexin (OX) A and OXB are peptides with neuronal cell bodies primarily localized in the LH (Fig. 1). However, orexin containing INK 128 mouse neurons have been shown to project to the cortex, thalamus, hypothalamus, brainstem (including the locus coeruleus and the raphe nucleus), as well to the gastrointestinal tract.46 Orexin acts on 2 G-protein coupled receptors, OXR1 and OXR2, which have been shown to contribute to the regulation of food intake as well as arousal and pain.47-49 In animal studies, centrally administered orexin increases food intake and has also been shown to reverse the cholecystokinin-induced

loss of appetite. In addition in VAT orexin has been shown to decrease the expression of hormone-sensitive lipase, which suggests that orexin might also modulate adipose tissue metabolism by inhibiting lipolysis.49 In addition to their role in feeding, the orexins

also participate in inflammatory processes. Several animal studies have demonstrated anti-nociceptive properties of the orexins. In mouse and rat models of nociception and hyperalgesia, intravenous OXA has been shown to be analgesic with an efficacy similar to that of morphine in both the hotplate test and carrageenan-induced thermal hyperalgesia tests.48 Similarly, intrathecally administered OXA in rats has been shown to inhibit heat-evoked hyperalgesia as well as to reduce mechanical allodynia.50 Finally, OXA has also been shown to inhibit Bortezomib neurogenic vasodilation as well as TNC neuronal nociceptive responses to electrical stimulation of the dura mater in rats.51,52 However, the orexins may also have a pro-nociceptive role. The orexins have been shown to excite the histaminergic neurons in the tuberomammillary nucleus (which terminates in the dorsal raphe nucleus and periaqueductal grey region), which can attenuate the antinociceptive effects of OXA. Specifically OXA activates histamine receptors, H1 and H2; and intra-cerebro-ventricular (ICV) injections of a histamine

receptor antagonist along with OXA in mice has shown greater antinociceptive PI-1840 effects than ICV OXA alone.47 Furthermore, OXA levels have been shown to be elevated in the cerebrospinal fluid of chronic daily headache sufferers.53 This would suggest that the orexin receptor antagonists, such as ACT-078573 or SB649868, which have been reported to be under development by Actelion and GSK for sleep disorders, could also have a role in migraine therapy.54,55 Thus, although the full role of the orexins and their receptors in migraine is still being determined, the current data suggest that the OXA can modulate neurogenic vasodilation, TNC activation, and pain. In addition, the existing data linking OXA and migraine further support the importance of the regulation of the hypothalamus, in not just feeding, but also pain. Further research evaluating orexin levels during or between migraine attacks is warranted. Adipocytokines.

[2] The patients with CoCC, HCC or classical CHC were more likely

[2] The patients with CoCC, HCC or classical CHC were more likely to have suffered from hepatitis virus B or C infection and liver cirrhosis than the patients with CCC (P < 0.001). The tissue samples were fixed in a 10% formalin solution and embedded in paraffin for histological diagnosis and immunohistochemistry. We used the new WHO classification for the histological diagnosis of CoCC, CCC, HCC and classical CHC.[3] The diagnosis of CCC and the CCC components within classical CHC was

confirmed with Alcian blue histochemical staining for mucin and immunostaining for cytokeratin (CK)7 and epithelial membrane antigen (EMA); HCC and the HCC components of classical CHC were diagnosed using immunostaining for α-fetoprotein (AFP), hepatocyte paraffin 1 and MK-8669 in vivo arginase in addition to histological findings. This study was approved by the Research Ethics Review Board of Teikyo University selleck screening library School of Medicine (no. 08–159). Formalin-fixed paraffin-embedded tissue sections, cut at a thickness of 3 μm, were deparaffinized with xylene and rehydrated with

graded ethanol. Immunohistochemistry was performed using monoclonal and polyclonal antibodies with antigen-retrieval methods, as listed in Table S1, and performed using Dako Autostainer Link 48 (Dako, Glostrup, Denmark). Endogenous peroxidase was quenched with 3% H2O2 in distilled water for 5 min. The slides were incubated with primary antibodies for 30 min at room temperature, and the sections were then stained by a detection method using EnVision FLEX (Dako) according to

the manufacturer’s protocol and counterstained with hematoxylin. Immunostaining for the integrins β6, β4 and α3, fibronectin and laminin was defined as positive when more than 10% of positively stained cells or areas were observed. Moreover, the intensity of integrin β6, β4 and α3 staining was semiquantitatively scored as 0 (negative), 1 (weak), 2 (moderate) Lck or 3 (strong). The percentage of cells staining positively for integrins β6, β4 and α3 was also semiquantitatively scored into five categories: 0 (<10%), 1 (11–25%), 2 (26–50%), 3 (51–75%) or 4 (76–100%). To perform the statistical analysis, the level of positive staining was evaluated by a final score, which was calculated by multiplying the scores of staining intensity by the scores for the percentage of positive cells. Based on the final score for integrin β6, β4 and α3 staining, the cases were grouped as negative for a score of 0, low for 1–2 and high for 3–12. The predominant pattern of positive staining for the integrins and ECM proteins in the hepatic tumors was classified as a cytoplasmic pattern, cell membrane pattern, basal lamina pattern or stromal pattern.

MRI and DWI are helpful in the diagnosis, therapy planning and fo

MRI and DWI are helpful in the diagnosis, therapy planning and follow up of encephalopathic cases with carnitine deficiency. “
“A 27-year-old human immunodeficiency virus—positive man presented with abdominal pain. Computed tomography of the abdomen revealed large right pleural effusion, pericardial effusion and marked ascites with diffuse intra- and extraperitoneal lymphadenopathy. Echocardiography showed severely reduced left ventricular systolic

function. After drainage of pleural and pericardial fluid, the patient developed severe hypotension and hypoxic respiratory failure. Extra- and intracranial neurovascular sonography demonstrated low carotid artery flow volume and dicrotic pulse waveforms in all vessels insonated bilaterally. This case report demonstrates an atypical dicrotic waveform pattern of transcranial Doppler in advanced ventricular dysfunction with shock. APO866 purchase
“Acute aortic dissection is the most common acute aortic condition requiring urgent surgical therapy. Due to INK 128 lack of typical symptoms, it is sometimes difficult to identify acute aortic dissection causing ischemic stroke. We report a case of a patient with acute ischemic stroke who was deemed ineligible for intravenous recombinant tissue plasminogen activator treatment

based on a finding of acute aortic dissection detected by carotid ultrasonography. After urgent aortic replacement surgery, the patient recovered with no neurological deficit. This case underscores the crucial role of carotid ultrasonography for the investigation of possible underlying acute aortic dissection when considering the use of intravenous recombinant 4-Aminobutyrate aminotransferase tissue plasminogen activator therapy for hyperacute stroke. “
“Rotational vertebral artery (VA) occlusion can cause ischemic strokes due to hemodynamic insufficiency and possibly artery-to-artery (A-to-A) embolism. The former is known as bow hunter’s stroke. The latter has been proposed only from indirect evidence. We have described a 7-year-old boy with cerebral infarction associated with A-to-A embolism due to repetitive rotational VA occlusion. He had a mobile mural

thrombus at the VA occlusion site on head rotation. Surgical treatment may effectively prevent recurrences. “
“Guillain-Barre syndrome (GBS) is the rubric encompassing highly variable phenotypic subgroups of acute, postinfectious, immune-mediated peripheral neuropathy. The hallmark of GBS phenomenology is a rapidly progressive ascending lower extremity weakness. GBS taxonomy includes a motor and sensory axonal neuropathy (AMSAN). Nitrous oxide (NO) abuse may create a pattern of neurological dysfunction almost identical to subacute combined degeneration. We report an adult with myeloneuropathy due to NO abuse that mimicked the presenting features of the GBS-subtype AMSAN. “
“Effects of methadone misuse have been rarely described.

The GPRD

is not population-based; therefore, its incidenc

The GPRD

is not population-based; therefore, its incidence estimate represents that of the GPRD and not the general population. Moreover, the code for PSC was not validated, and this poses additional challenges to its validity. These two studies were not fully comparable with the other studies included in the analysis. The incidence of PSC appears to be increasing; however, additional studies are necessary to confirm this observation. This increase in PSC incidence may be a direct result of its link to IBD because recent evidence suggests that the incidence of IBD is still increasing in many regions of the world.26, 29-32 Studies investigating the incidence of PSC with and without IBD may help to resolve this issue; however, the decrease in power when these analyses GSK3235025 are conducted may hinder the finding of statistical evidence. One study reported

time trends in PSC with and without IBD but failed to find a statistically significant increase.9 Additionally, the observed increase may be due to improvements in the diagnostic abilities of physicians and diagnostic tools such as noninvasive imaging (i.e., http://www.selleckchem.com/products/INCB18424.html magnetic resonance cholangiopancreatography).33, 34 Magnetic resonance cholangiopancreatography permits fast and highly accurate imaging of the biliary tree and has been used with increasing frequency as a noninvasive alternative to endoscopic retrograde cholangiopancreatography.33, 35-37 Furthermore, the increasing use of biological therapies (e.g., infliximab) and immunosuppressants (e.g., azathioprine

and methotrexate), particularly in those with IBD,38-40 may have contributed to the greater detection of PSC over time. Biologics and immunosuppressants have been associated with drug-induced liver complications, hepatobiliary disease, and liver toxicity41, 42; therefore, the routine screening of liver function profiles for individuals taking these therapies has increased. Studies investigating the incidence of PSC should consider assessments of diagnostic tool utilization over time. Moreover, this increase in incidence may be a result of biases in observational studies. In particular, the study by Escorsell et al.7 Selleck Depsipeptide had an unrealistically high AAPC of 27%. Many factors likely contributed to the obvious bias of this estimate. The population estimate used to calculate the incidence was taken from the end of the study period. An increase in the study population (i.e., 12 regions in Spain)43 over the time interval would have overestimated the increase in IR. Additionally, because of the retrospective nature of the study and the need for physicians to respond to a questionnaire, the response rate could have been lower for earlier time periods. Finally, detection bias could have been more pronounced at the end of the study period because of the increased availability and use of diagnostic technologies.

The GPRD

is not population-based; therefore, its incidenc

The GPRD

is not population-based; therefore, its incidence estimate represents that of the GPRD and not the general population. Moreover, the code for PSC was not validated, and this poses additional challenges to its validity. These two studies were not fully comparable with the other studies included in the analysis. The incidence of PSC appears to be increasing; however, additional studies are necessary to confirm this observation. This increase in PSC incidence may be a direct result of its link to IBD because recent evidence suggests that the incidence of IBD is still increasing in many regions of the world.26, 29-32 Studies investigating the incidence of PSC with and without IBD may help to resolve this issue; however, the decrease in power when these analyses ABT-263 are conducted may hinder the finding of statistical evidence. One study reported

time trends in PSC with and without IBD but failed to find a statistically significant increase.9 Additionally, the observed increase may be due to improvements in the diagnostic abilities of physicians and diagnostic tools such as noninvasive imaging (i.e., Talazoparib molecular weight magnetic resonance cholangiopancreatography).33, 34 Magnetic resonance cholangiopancreatography permits fast and highly accurate imaging of the biliary tree and has been used with increasing frequency as a noninvasive alternative to endoscopic retrograde cholangiopancreatography.33, 35-37 Furthermore, the increasing use of biological therapies (e.g., infliximab) and immunosuppressants (e.g., azathioprine

and methotrexate), particularly in those with IBD,38-40 may have contributed to the greater detection of PSC over time. Biologics and immunosuppressants have been associated with drug-induced liver complications, hepatobiliary disease, and liver toxicity41, 42; therefore, the routine screening of liver function profiles for individuals taking these therapies has increased. Studies investigating the incidence of PSC should consider assessments of diagnostic tool utilization over time. Moreover, this increase in incidence may be a result of biases in observational studies. In particular, the study by Escorsell et al.7 ever had an unrealistically high AAPC of 27%. Many factors likely contributed to the obvious bias of this estimate. The population estimate used to calculate the incidence was taken from the end of the study period. An increase in the study population (i.e., 12 regions in Spain)43 over the time interval would have overestimated the increase in IR. Additionally, because of the retrospective nature of the study and the need for physicians to respond to a questionnaire, the response rate could have been lower for earlier time periods. Finally, detection bias could have been more pronounced at the end of the study period because of the increased availability and use of diagnostic technologies.

The GPRD

is not population-based; therefore, its incidenc

The GPRD

is not population-based; therefore, its incidence estimate represents that of the GPRD and not the general population. Moreover, the code for PSC was not validated, and this poses additional challenges to its validity. These two studies were not fully comparable with the other studies included in the analysis. The incidence of PSC appears to be increasing; however, additional studies are necessary to confirm this observation. This increase in PSC incidence may be a direct result of its link to IBD because recent evidence suggests that the incidence of IBD is still increasing in many regions of the world.26, 29-32 Studies investigating the incidence of PSC with and without IBD may help to resolve this issue; however, the decrease in power when these analyses Apoptosis Compound Library datasheet are conducted may hinder the finding of statistical evidence. One study reported

time trends in PSC with and without IBD but failed to find a statistically significant increase.9 Additionally, the observed increase may be due to improvements in the diagnostic abilities of physicians and diagnostic tools such as noninvasive imaging (i.e., Ku-0059436 manufacturer magnetic resonance cholangiopancreatography).33, 34 Magnetic resonance cholangiopancreatography permits fast and highly accurate imaging of the biliary tree and has been used with increasing frequency as a noninvasive alternative to endoscopic retrograde cholangiopancreatography.33, 35-37 Furthermore, the increasing use of biological therapies (e.g., infliximab) and immunosuppressants (e.g., azathioprine

and methotrexate), particularly in those with IBD,38-40 may have contributed to the greater detection of PSC over time. Biologics and immunosuppressants have been associated with drug-induced liver complications, hepatobiliary disease, and liver toxicity41, 42; therefore, the routine screening of liver function profiles for individuals taking these therapies has increased. Studies investigating the incidence of PSC should consider assessments of diagnostic tool utilization over time. Moreover, this increase in incidence may be a result of biases in observational studies. In particular, the study by Escorsell et al.7 GBA3 had an unrealistically high AAPC of 27%. Many factors likely contributed to the obvious bias of this estimate. The population estimate used to calculate the incidence was taken from the end of the study period. An increase in the study population (i.e., 12 regions in Spain)43 over the time interval would have overestimated the increase in IR. Additionally, because of the retrospective nature of the study and the need for physicians to respond to a questionnaire, the response rate could have been lower for earlier time periods. Finally, detection bias could have been more pronounced at the end of the study period because of the increased availability and use of diagnostic technologies.

In addition, the currently available liver chemistries, such as s

In addition, the currently available liver chemistries, such as serum alanine aminotransferase (ALT), do not reliably distinguish between mild and transient DILI, which is of no consequence for the patient who can continue to receive the drug safely, versus DILI that will progress to life-threatening injury if drug therapy is not promptly stopped.3 In addition, currently available tests generally cannot distinguish which specific drug is causing the DILI in patients on multiple drug therapy. What is clearly needed are better biomarkers of DILI to help clinicians, as well as provide more meaningful liver safety data in

clinical trials of new drugs. We believe that the peripheral blood (PB) transcriptome may contain information that could address the shortcomings of currently available DILI diagnostic tools. Support for the PB transcriptomic approach comes from several recent findings. In an in-life rat buy Z-VAD-FMK study of eight hepatoxicants, we recently demonstrated that PB cell gene expression can be successfully utilized to detect the presence and severity of toxic responses in the liver.4 In fact, these studies suggested that PB transcriptomic data might be more sensitive to liver injury than traditional clinical tests and therefore able to detect DILI earlier. In addition, the pattern of PB cell transcriptomic response varied across

toxicants, indicating the existence ABT-263 of “signatures” that could be useful in identifying the specific drug responsible for DILI. With specific respect to acetaminophen (APAP), the most common identifiable causative agent of acute liver failure in the US, we have shown that in rats treated with toxic doses, PB transcriptomic signatures, particularly in immune and inflammatory pathways, outperform traditional histological or clinical chemistry 3-mercaptopyruvate sulfurtransferase markers in detecting DILI. Furthermore, by probing human whole blood transcriptomic data from clinical overdose patients with human

orthologs of this rat PB signature, we were also able to differentiate these patients from nonexposed individuals.5 The hypothesis tested in the current study was that a supratherapeutic but not overtly toxic APAP dose would result in readily detectable changes in the human PB transcriptome and that these changes would be qualitatively similar to changes we have demonstrated in rats and humans after toxic doses of APAP.5 ALT, alanine aminotransferase; APAP, acetaminophen; AUC, area under the curve; CBC, complete blood counts; CYP2E1, cytochrome P4502E1; DEGs, differentially expressed genes; DILI, drug-induced liver injury; GSA, gene set analysis; GSH, glutathione; IPA, ingenuity pathways analysis; NAPQI, N-acetyl-p-benzoquinone-imide; PB, peripheral blood. Subjects were healthy volunteers from 18-55 years old weighing 55 to 85 kg and not taking any over-the-counter or prescription medications.

P SAXENA, V KUMBHARI, M EL ZEIN1, A MESALLAM, A ABDELGELIL, JO C

P SAXENA, V KUMBHARI, M EL ZEIN1, A MESALLAM, A. ABDELGELIL, JO CLARKE, AN KALLOO, MA KHASHAB Division of Medicine, Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore MD USA Background: POEM is a novel endoscopic treatment for achalasia and other spastic esophageal disorders (SED). It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. Most published data comes from procedures performed by surgeons in operating rooms. The safety, efficacy, and learning curve of POEM when performed by gastroenterologists in the endoscopy unit are currently unknown. Sotrastaurin ic50 Aims: To 1)

study the safety and efficacy of POEM at one U.S. center where all procedures were performed by one gastroenterologist in the endoscopy unit Methods: Initial training in POEM consisted of observing an expert perform two live POEM procedures followed by performing 10 POEM procedures in a swine model. Dasatinib order All patients who subsequently underwent POEM for treatment of achalasia or SED were included in this retrospective cohort study. Clinical response was defined by improvement of symptoms and decrease in Eckardt score to ≤3. Adverse

events were graded according to the ASGE lexicon’s severity grading system. Results: A total of 35 patients (mean age 46, 21 Female) underwent POEM for treatment of achalasia (type I 1, type II 28, type III 2) or SED (Jackhammer Esophagus 4). POEM was successfully performed in the endoscopy suite and completed in all patients (anterior approach 31, posterior approach 4) with a mean LOP of 119 minutes (range 61–210 min). The mean length of submucosal tunnel was 13 cm (range 9–24). The mean myotomy length was 10 cm (range 7–19 cm. There was significant decrease in Eckhardt score after POEM (8.23 vs. 1.67, p < 0.0001). Overall, clinical

response was those observed in 32 (91%) patients. Symptomatic reflux occurred in 4 patients (11.4%) which was successfully managed with PPI. Post-POEM pH impedance testing was performed in 14 patients; positive in 11 (79%) of whom only 1 was symptomatic. The mean Demeester score was 93.2. The mean LES pressure decreased significantly after POEM (27 vs. 14 mmHg, p < 0.001). A total of 7 complications occurred with 5 complications rated as mild, 2 moderate and none severe. Mucosotomy occurred in 3 (8%) patients and were successfully treated with endoscopic closure, pneumoperitoneum occurred in 2 patients, pneumothorax in 1 and pulmonary embolism in 1 patient. The mean length of hospital stay was 2.2 days (range 1–10). Conclusions: POEM can be effectively and safely performed by experienced gastroenterologists in a tertiary care endoscopy unit. V KUMBHARI, P SAXENA, MH EL ZEIN, M SOLANKI, AN KALLOO, JO CLARKE, MA KHASHAB Department of Medicine and Division of Gastroenterology and Hepatology, John Hopkins Hospital and Medical Institution.