We use contingent valuation to estimate hunter and trapper willingness to pay (WTP) for a hypothetical bobcat harvest permit being considered in Indiana. Harvest permits would be rationed, with limits on aggregate and individual harvests. A model of permit demand shows that WTP may be subject to "congestion effects" which attenuate welfare gains from relaxing harvest limits. Intuitively, relaxing limits may directly change an individual's expected harvest and, hence, WTP. Participation may subsequently change, with congestion offsetting welfare increases. These effects may lead to apparent scope insensitivity that may be endemic in the context of rationed goods.

Introduction: Intraductal papillary neoplasms of the bile duct (IPNB) are the rare biliary cousins to the pancreatic intraductal papillary mucinous neoplasms (IPMN). While both mucin-producing and with malignant potential, IPNBs grow within the hepatobiliary tree with a prevalence of 4%-15% of bile duct tumors. Here, we present a rare case of IPNB within the right hepatic and cystic duct. Case Description/Methods: A 53-year-old man with a history of obstructive jaundice presents for ERCP for evaluation of a newly found 1.4 cm T2 isointense soft tissue focus at the proximal right hepatic duct just distal to the confluence of the common hepatic duct seen on MRCP (Figure 1A/B). The mass was associated with a filling defect and an 8 mm dilated CBD and intrahepatic biliary ductal dilation. Cancer antigen markers CA-19-9 and CEA were negative. On ERCP, mucinous material could be seen within the bile duct (Figure 1B). A cholangiogram and cholangioscopy showed evidence of filling defect within the right hepatic duct and cystic duct. The mass was biopsied, and a 10 Fr x 15 cm stent was placed proximal to the right hepatic duct. The biopsy revealed fragments of high-grade glandular dysplasia with features of invasive adenocarcinoma. The patient was, subsequently, sent for evaluation with hepatobiliary surgery for surgical resection of the mass (Figure 1). Discussion: Commonly seen more in Eastern Asian countries with risk factors for hepatolithiasis and chlonorchiasis and within the left intrahepatic duct, IPNB within the right hepatic duct are extremely rare. While accurate diagnosis of IPNBs is difficult as imaging may not always pick up tumors or the presence of mucin, cholangiography and cholangioscopy are mainstay diagnostic techniques to determine disease extent, visualization of the mass, and direct biopsy. Interestingly, only roughly 28% of IPNBs produce mucin and 43%-70.5% of IPNBs are associated with progression to invasive carcinoma or adenocarcinoma. Given the high-risk recurrent hepatobiliary obstruction and risk for malignancy, the mainstay treatment includes biliary stent placement with eventual curative resection. For this case, direct visualization with cholangioscopy was necessary to biopsy the lesion and make the diagnosis. In the absence of stones or cystic lesions and in the presence of mucin, IPNBs should be considered as part of the differential of obstructive jaundice.Figure 1.: A) Visualization of IPNB within the right hepatic duct on cholangioscopy B) Close up visualization of IPNB with mucinous material on cholangioscopy.

Introduction: Incidentalomas have increased as computed tomography has become a highly utilized pillar in the medical care setting (1). Renal masses are no exception, with the standard of diagnosis being biopsy. Percutaneous approach is the mainstay of renal mass biopsy, however, may be technically difficult in setting of obesity or anatomically distant lesion from the skin (2). We present a case of endoscopic ultrasound guided transgastric kidney biopsy with adequate yield. Case Description/Methods: A 73-year-old man suffered from right nephrolithiasis with discovery of an incidental left upper pole renal cortical neoplasm on CT scan. After urologic evaluation, the mass was deemed to have difficult access using a percutaneous approach and was referred to interventional gastroenterology for a transgastric biopsy. Using endoscopic ultrasound, a poorly defined left renal hypoechoic lesion measuring 34x27 mm was visualized (Figure 1). Two core biopsies were taken using a 19 g needle. Tissue aggregate measured 1.2x0.4x0.2 cm and was considered an adequate specimen by our pathologists with the final diagnosis being Type 1 papillary renal cell carcinoma. The postprocedural course was uneventful. Discussion: Percutaneous biopsy of renal masses has long been the gold standard approach. in cases of difficult percutaneous approach due to body habitus, endoscopic ultrasound guided transgastric for left-sided renal and transduodenal for right-sided renal lesions potentially provide a valuable, safe and minimally invasive alternative. References: 1. Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, Brink JA, Baker ME, Federle MP, Foley WD, Francis IR. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 2010;7(10):754-73. 2. Kwong J, May G, Ordon M. Endoscopic ultrasound-guided trans-duodenal fine-needle biopsy of a small renal mass: case report and review of the literature. Afr j Urol 2021;27: 1-4. doi.org:10.1186/s12301-021-00250-x.Figure 1.: Left renal hypoechoic lesion measuring 34x27 mm seen on EUS.

Introduction: Symptomatic gastroesophageal reflux disease (GERD) is very common in North America, with a 2014 study estimating prevalence at 18.1% to 27.8 %. Ambulatory pH monitoring is the preferred gold standard diagnostic modality, with the catheter-based esophageal monitoring being the most widely used test to correlate reflux with symptomology. Capsule-pH reflux testing has been introduced as a wireless system intended to replicate the traditional catheter-based monitoring without the drawbacks of patient discomfort. However, the nature of the wireless system does lend itself to misplacement if direct guidance is not utilized. We present a case of capsule deployment in the oropharynx and subsequent aspiration. Case Description/Methods: A 72-year-old woman presented to outpatient surgery for routine capsule-pH reflux testing placement. Upper endoscopy revealed normal appearing Z-line at 34 cm from the incisors. The capsule was positioned at 28 cm, suction was applied, and subsequently the plunger was depressed and then rotated to release the capsule. Upon reinsertion of the endoscope, the capsule was seen near the pyriform sinus (Figure 1, left). The patient was repositioned with a plan for snare retrieval; however, the patient began to desaturate to 85 % and capsule was unable to be visualized. Patient was intubated and bronchoscopy revealed the capsule to be in the left main bronchus. Pediatric gastroscope was inserted through the endotracheal tube (ET) and pediatric snare was used to secure the capsule (Figure 1, right). Unfortunately, the capsule could not pass through the ET tube. The decision was made to remove the ET tube along with the capsule. The patient was then reintubated and extubated without further complication. The patient did develop asymptomatic mild atelectasis with prompt resolution without intervention. Discussion: This case highlights one of the potential complications when deploying a wireless esophageal pH testing capsule. Conventional blind placement of the capsule does not guarantee suctioning of the esophageal wall into the capsule and attaching the capsule to the esophageal wall with the metal pin. This may result in capsule dislodgement. This may skew readings or, as seen in this patient, may lead to pulmonary compromise. The direct guidance technique is equally efficacious, avoids second endoscopy and likely decreases misplacement of deployment.Figure 1.: Left: Wireless esophageal pH testing capsule visualized near the piriformis sinus. Right: Wireless esophageal pH testing capsule visualized in left main bronchus with retrieval utilizing a pediatric snare.

Estimating demand for licenses for recreational activities is complicated because of a lack of meaningful variation across time, space, buyer types, and license attributes, including price. Prior work uses discrete choice experiments (DCEs) to over-come this challenge, but the resulting demand models are unlikely to replicate observed de-mands in the absence of ad hoc calibration procedures. We use a generalized method of moments-based approach that combines DCE data with observed market share data to estimate a choice model that yields demand functions that much more closely replicate ob-served data.

BACKGROUND:Percutaneous liver biopsy (P-bx) is the gold standard for diagnosing advanced fibrosis. Despite the proven technical feasibility of EUS-guided liver bx (EUS-bx) as a novel alternative way of liver biopsy, the clinical applicability remains to be determined. AIMS:The primary aim of this study is to evaluate if EUS-bx, compared to P-bx, can effectively and safely obtain adequate specimen and accurately predict hepatic fibrosis. METHODS:This is a single center, retrospective chart review among patients with liver diseases at a tertiary endoscopy center from February 2011 to March 2020. We assessed the EUS-bx versus P-bx outcomes by success rate, performance, and safety profile. The primary outcome was the association between EUS-bx clinical variables and the presence of histologic liver fibrosis stage ≥ 3. The secondary outcomes were the associations between EUS-bx and variables indicative of fibrosis. RESULTS:Fifty-nine patients underwent EUS-bx; and 59, P-bx. All EUS-bx procedures were successfully completed. All 56/56 (100%) of EUS-bx vs. 50/52 (96.2%) P-bx were considered adequate samples. Tissue lengths were significantly longer in the EUS-bx cohort (p < 0.0001) with a trend towards a greater number of portal tracts. 46/56 (82.1%) cases of EUS-bx vs. 32/52 (61.5%) of P-bx had > 10 portal tracts; 21/56 (37.5%) cases of EUS-bx vs. 14/52 (26.9%) of P-bx had > 15 portal tracts. There were 6 (10.2%) EUS-bx vs. 1 (1.7%) P-bx related complication leading to a phone call (p = 0.061). CONCLUSIONS:EUS-bx can safely performed and accurately predict liver fibrosis stage as the standard P-bx without being influenced by procedure-related factors.