We appreciate the interest of Dr. LØvy and colleagues [1] in our report [2]. We agree that endoscopic ultrasound−guided fine− needle aspiration (EUS−FNA) should be performed to direct clinical management, meaning FNA results will affect surgical decision making. Our purpose in publish− ing this multicenter experience was two− fold: (i) to increase awareness in the EUS community of this very rare entity, the solid pseudopapillary tumor (SPT), and (ii) to evaluate, we emphasize, the diag− nostic accuracy of EUS−FNA in making a definitive diagnosis, as compared to sur− gical pathology. The key word here is "di− agnostic." No patient in the series was re− ferred with a pre−EUS suspicion of an SPT, and SPT was included in the differential diagnosis on the EUS report in only 50 % of cases in our series. Thus it was consid− ered, but not necessarily suspected. This tumor is frequently misdiagnosed as a neuroendocrine tumor preoperatively. In the study by Bardeles et al., 50 % of the cases were diagnosed as neuroendocrine tumors based upon the EUS appearance [3]. In our series, five patients were diag− nosed with neuroendocrine tumors by EUS−FNA cytology and immunostaining (as immunostains specific for SPT were not performed). Hence, our purpose here− in of increasing awareness and recom− mending immunostain profiles when this lesion is considered, which will in− crease the diagnostic accuracy. Regarding the influencing of surgical de− cision making, one could argue that a dif− ferential diagnosis of neuroendocrine tu− mor vs SPT is moot, as recommendations are to resect both. However, in the era of minimally invasive surgical approaches, a definitive preoperative diagnosis can in− fluence decision making. Indeed, in our series, laparoscopic distal pancreatect− omy was performed in 29 % based upon the definitive preoperative diagnosis. Our recent series reporting EUS−FNA re− sults of nonfunctioning neuroendocrine tumors had a similar conclusion: defini− tive preoperative diagnosis led to a la− paroscopic approach in 34 % of cases [4]. As physicians, don't we owe it to our pa− tients to recommend the least morbid treatment? And the other often forgotten factor is that patients, at least in our neck of the woods, want to know their diagno− sis before undergoing a surgery that can carry a significant morbidity. This brings us to the safety of the proce− dure. There were no complications relat− ed to the EUS−FNA procedure in our ser− ies, thus it is a safe procedure. LØvy et al.[1] infer that our procedures were not "safe" given our short follow−up period. They insinuate that EUS−FNA will lead to peritoneal seeding, equating the FNA pro− cedure (with a 22− or 25−g needle) to "ab− dominal trauma" [5]. In the much more prevalent scenario of pancreatic cancer, tumor seeding has always been a con− cern. EUS−FNA has been found to be a much "safer" approach compared with percutaneous biopsy, with a far smaller incidence of tumor seeding [6]. In the case of EUS−FNA of pancreatic head tu− mors (25 % of our SPT series), the needle p...

The difficulty of students in writing narratives is a problem that has been found in the field. Students lack mastery in giving an idea and developing it into a narrative essay. The purpose of this research is to create a learning tool for writing narratives based on tree chart media that is valid, practical, and effective. The type of research used is development research with the ADDIE model. The teacher and the fifth grade students of SD Islam Al-Azhar Simabur are the subjects of this study. Looking at the research data with the validity test, which was obtained from the validation sheet of the learning device. Then to see the practicality data from the observation sheet on the implementation of the lesson plans, along with the teacher and student response questionnaires. Activities and assessments of student learning outcomes are obtained from the effectiveness of learning tools. The results of the validation of learning tools that have been carried out are stated in the very valid category. The learning tools developed are also stated to be very practical, this is supported by the RPP implementation sheet with an average of 90 and the teacher's response 89 then students 91. After that, it can be seen that the results of student activities and student learning outcomes are very satisfying so that it can be stated very effective when applied in learning. In summary, the learning tools developed using the tree chart media in fifth grade elementary school were declared valid, practical and effective.