Background and Aims There are limited data on learning curves and competence in ERCP. By using a standardized data collection tool, we aimed to prospectively define learning curves and measure ...competence among advanced endoscopy trainees (AETs) by using cumulative sum (CUSUM) analysis. Methods AETs were evaluated by attending endoscopists starting with the 26th hands-on ERCP examination and then every ERCP examination during the 12-month training period. A standardized ERCP competency assessment tool (using a 4-point scoring system) was used to grade the examination. CUSUM analysis was applied to produce learning curves for individual technical and cognitive components of ERCP performance (success defined as a score of 1, acceptable and unacceptable failures p1 of 10% and 20%, respectively). Sensitivity analyses varying p1 and by using a less-stringent definition of success were performed. Results Five AETs were included with a total of 1049 graded ERCPs (mean ± SD, 209.8 ± 91.6/AET). The majority of cases were performed for a biliary indication (80%). The overall and native papilla allowed cannulation times were 3.1 ± 3.6 and 5.7 ± 4, respectively. Overall learning curves demonstrated substantial variability for individual technical and cognitive endpoints. Although nearly all AETs achieved competence in overall cannulation, none achieved competence for cannulation in cases with a native papilla. Sensitivity analyses increased the proportion of AETs who achieved competence. Conclusion This study demonstrates that there is substantial variability in ERCP learning curves among AETs. A specific case volume does not ensure competence, especially for native papilla cannulation.
Abstract Background The successful prevention and treatment of coronary heart disease (CHD) and stroke has resulted in a substantial increase in longevity, with subsequent growth in the population of ...older people at risk for dementia. Objectives The authors evaluated the relationship of coronary and other peripheral atherosclerosis to risk of death, dementia, and CHD in the very elderly. Because the extent of vascular disease differs substantially between men and women, sex- and race-specific analyses were included, with a specific focus on women with low coronary artery calcium (CAC) Agatston scores. Methods We evaluated the relationship between measures of subclinical cardiovascular disease (CAC, carotid intimal medial thickness, stenosis, and ankle brachial index) and risk of dementia, CHD, and total mortality in 532 participants of the Cardiovascular Health Study-Cognition Study from 1998/1999 (mean age, 80 years) to 2012/2013 (mean age, 93 years). Results Thirty-six percent of participants had CAC scores >400. Women and African-Americans had lower CAC scores. Few men had low CAC scores. CAC score and number of coronary calcifications were directly related to age-adjusted total mortality and CHD. The age-specific incidence of dementia was higher than for CHD. Only about 25% of deaths were caused by CHD and 16% by dementia. Approximately 64% of those who died had a prior diagnosis of dementia. White women with low CAC scores had a significantly decreased incidence of dementia. Conclusions In subjects 80+ years of age, there is a greater incidence of dementia than of CHD. CAC, as a marker of atherosclerosis, is a determinant of mortality, and risk of CHD and myocardial infarction. White women with low CAC scores had a significantly decreased risk of dementia. A very important unanswered question, especially in the very elderly, is whether prevention of atherosclerosis and its complications is associated with less Alzheimer disease pathology and dementia. (Cardiovascular Health Study CHS; NCT00005133 )
Background American Society for Gastrointestinal Endsocopy (ASGE) guidelines for assessing minimal competence in EUS are based on expert opinion and retrospective studies. Objective To prospectively ...define learning curves in EUS among advanced endoscopy trainees (AETs). Design Prospective trial. Setting Three tertiary-care referral centers. Patients AETs with no prior EUS experience. Intervention AETs were evaluated by attending endosonographers at intervals of 10 EUS examinations (beginning at the 25th examination) during a 12-month training period. A standardized data collection form was used to grade examination of EUS anatomic stations and, when applicable, lesion of interest, accurate uTNM staging, wall layer origin of subepithelial lesions, and technical success with FNA. Main Outcome Measurements Cumulative sum analysis was applied to assess competency and produce a learning curve for each trainee for overall performance and for each anatomic station. Acceptable and unacceptable failure rates of 10% and 20%, respectively, were used. Results Five AETs were included, with a total of 1412 EUS examinations (AET1-225, T2-175, T3-402, T4-315, T5-295). Two AETs crossed the threshold for acceptable performance at cases number 255 and 295, two AETs showed a trend toward acceptable performance after 225 and 196 cases but needed ongoing training, and 1 AET demonstrated the need for ongoing training after 402 cases. Similar variable results were noted for individual stations. Limitations Results from this study may not be generalizable to other centers' AETs. Conclusion We observed substantial variability in achieving competency and a consistent need for more supervision in all AETs than current recommendations (150 cases). Future studies should focus on standardization of trainee performance, definition of competency, and widespread applicability of AET evaluation.
Background There are limited data on the safety of anesthesia-assisted endoscopy by using propofol-mediated sedation in obese individuals undergoing advanced endoscopic procedures (AEPs). Objective ...To study the association between obesity (as measured by body mass index BMI) and the frequency of sedation-related complications (SRCs) in patients undergoing AEPs. Design Prospective cohort study. Setting Tertiary referral center. Patients A total of 1016 consecutive patients undergoing AEPs (BMI <30, 730 72%; 30-35, 159 16%; >35, 127 12%). Intervention Monitored anesthesia sedation with propofol alone or in combination with benzodiazepines and/or opioids. Main Outcome Measurements SRCs, airway maneuvers (AMs), hypoxemia, hypotension requiring vasopressors, and early procedure termination were compared across 3 groups. Results There were 203 AMs in 13.9% of patients, hypoxemia in 7.3%, need for vasopressors in 0.8%, and premature termination in 0.6% of patients. Increasing BMI was associated with an increased frequency of AMs (BMI <30, 10.5%; 30-35, 18.9%; >35–26.8%; P < .001) and hypoxemia (BMI <30, 5.3%; 30-35, 9.4%; >35, 13.4%; P = .001); there was no difference in the frequency of need for vasopressors ( P = .254) and premature termination of procedures ( P = .401). On multivariable analysis, BMI (odds ratio OR 2.0; 95% CI, 1.3-3.1), age (OR 1.1; 95% CI, 1.0-1.1), and American Society of Anesthesiologists class 3 or higher (OR 2.4; 95% CI, 1.1-5.0) were independent predictors of SRCs. In obese individuals (n = 286), there was no difference in the frequency of SRCs in patients receiving propofol alone or in combination ( P = .48). Limitations Single tertiary center study. Conclusions Although obesity was associated with an increased frequency of SRCs, propofol sedation can be used safely in obese patients undergoing AEPs when administered by trained professionals.
Background Use of a stylet during EUS-guided FNA (EUS-FNA) is believed to improve the quality and diagnostic yield of specimens. Objective To compare samples obtained by EUS-FNA with (S+) and without ...(S−) a stylet for diagnostic yield of malignancy and cytological characteristics. Design Randomized, controlled trial. Setting Tertiary referral center. Patients Consecutive patients referred for EUS-FNA of solid lesions. Intervention EUS-FNA; the number of passes was determined by lesion site (6 pancreas/others and 4 lymph nodes). Main Outcome Measurements Diagnostic yield of malignancy and degree of cellularity, specimen adequacy, contamination, and amount of blood. Results One hundred patients were prospectively enrolled in this randomized, controlled trial and the sites of EUS-FNA were the pancreas, 58; lymph node, 25; and other, 17. The overall diagnosis was malignancy in 56, benign in 30, suspicious/atypical in 7, and inadequate specimen in 7 lesions. There were 550 passes made (275 with a stylet and 275 without a stylet). Interim analysis demonstrated no difference in the diagnostic yield of malignancy (94 passes with a stylet 34.2% vs 110 without a stylet 40%, P = .2) and in the proportion of inadequate specimens (57 with a stylet 20.7% vs 64 without a stylet 23.3%, P = .2). There was no difference with regard to cellularity ( P = .83), contamination ( P = .31), number of cells ( P = .25), and amount of blood ( P = .6). Similar results were noted in a subgroup analysis based on lesion site. Applying the rules of futility, the study was terminated. Limitations Subjectivity in cytopathologists' assessment, endosonographer not blinded. Conclusions There was no difference in the diagnostic yield of malignancy or proportion of inadequate specimens between passes with and without a stylet. These results suggest that the use of a stylet does not confer any advantage during EUS-FNA. (Clinical trial registration number: NCT01316614 .)
Background There are conflicting data on the risk of post-ERCP pancreatitis (PEP) related to self-expandable metallic stents (SEMSs). Objective To compare rates of PEP in patients who undergo biliary ...drainage with SEMSs or polyethylene stents (PSs). Design Retrospective, cohort study. Setting Tertiary-care medical center. Patients This study involved patients undergoing ERCP for malignant biliary obstruction between January 2005 and October 2008. Intervention First-time placement of a SEMS or PS for biliary decompression. Main Outcome Measurements Early post-ERCP complications, particularly PEP. Results We identified 544 eligible patients, 248 SEMSs (102 covered), and 296 PSs. The etiology of malignant biliary obstruction was similar between groups, with 55% from pancreatic cancer. The frequency of PEP was significantly higher in the SEMS group (7.3%) versus the PS group (1.3%) (OR 5.7 95% CI, 1.9-17.1). On univariate analysis, patient age of <40 years, a history of PEP, and at least 1 pancreatic duct injection were also significant predictors of PEP, whereas female sex and having pancreatic cancer were not. When significant variables were added to a multiple-predictor regression model, the odds of PEP from SEMS placement increased to 6.8 (95% CI, 2.2, 21.4). However, the frequency of PEP was similar between covered (6.9%) and uncovered (7.5%) SEMSs (OR 0.9 CI, 0.3-2.4). Purported SEMS-specific risk factors, including the use of cSEMSs, overlapping SEMSs, or having a biliary sphincterotomy were not found to be significant contributors to the higher risk. Limitations Retrospective design. Conclusion After we controlled for confounding variables, the frequency of PEP was significantly higher with placement of a SEMS compared with a PS. Rates of PEP were comparable with use of covered and uncovered SEMSs.
Background American Gastroenterological Association guidelines recommend performing EUS to characterize subepithelial lesions (SELs) discovered on upper endoscopy (EGD), followed by surveillance if ...no high-risk features are identified. However, limited data are available on the impact of and compliance with surveillance recommendations. Objective To determine the natural history of SELs < 30 mm in size evaluated by EUS and to determine the degree of patient compliance with surveillance recommendations. Design Prospective registry. Setting Two tertiary centers. Patients We studied 187 consecutive adult patients referred for EUS evaluation of foregut SELs. Main Outcome Measurements Proportion of patients in whom SELs change in size or echo-features and compliance with follow-up recommendations. Results Surveillance was recommended in 65 patients with hypoechoic SELs (44.6% women, age 59.5 ± 13.2 years); of these, 29 (44.6%) underwent surveillance EUS as recommended and were followed for a median of 30 months (range, 12-105). During follow-up, 16 SELs (25%) increased in size, with a mean increase of 3.4 ± 3.9 mm (range, 1-15). No changes in echo-texture of the SELs were observed. One patient was referred to surgery during follow-up (because of SEL growth > 30 mm). Limitations Short follow-up duration; compliance was a secondary aim. Conclusions During a median follow-up of 30 months, growth in size was observed in 25% of small foregut SELs. However, change in size was minimal, and only 1 patient was referred for surgery based on surveillance EUS findings. Compliance with surveillance recommendations is poor, with fewer than 50% of patients undergoing surveillance EUS as recommended.
Nutrition/Exercise
The Standard American Diet (SAD), typically poor in nutritional value, is a known contributor to cardiometabolic syndromes and cardiovascular disease. Suboptimal nutrition composed ...of processed and red meat, refined carbohydrates, high salt and added sugars contributes to cardiovascular death and premature mortality. Dietary patterns that focus on plant-based foods are associated with reductions and slowing progression of cardiovascular disease . Specifically, the Mediterranean Diet (MD) has a strong association with lower rates of heart disease, cancer, and obesity while increasing longevity. In recent years, a plant based diet (PBD) has also emerged as a nutritional alternative to the MD with health benefits.
The growing knowledge of the importance of well-balanced diet to cardiovascular health has become more well-known as it is a component of the AHA's Life Essential 8, which illustrates the factors that are important to cardiovascular health. Dietary changes are traditionally focused in the outpatient setting, though little has been done in the acute care setting when patients are most vulnerable and amenable to change, especially after a life altering event.
We will recruit adults >18 years of age who are admitted to Temple University Hospital with a standard cardiac diet order with one of the following diagnoses: acute coronary syndrome, heart failure, atrial fibrillation/flutter or hypertensive crisis. Patients will be given a baseline questionnaire to assess dietary behaviors prior to hospital admission.
Patients will then be randomized to either a cardiac, PBD or MD. The PBD and MD were created for this study in collaboration with registered dietitians to assure all nutritional requirements were met during the admission.
One month following hospital discharge, patients will be contacted with a follow up questionnaire to assess if dietary behaviors have changed compared to baseline.
The study is in the enrollment phase. We plan to have preliminary data to present at the conference.
A prior inpatient study illustrated that inpatient diet could impact dietary behaviors. We hypothesize that an intervention with either a PBD or MD in patients hospitalized for cardiovascular disease will have a positive impact on dietary behaviors one month post discharge.
Background Because of greater recognition and improved imaging capabilities, intraductal papillary mucinous neoplasms (IPMNs) are being diagnosed with increasing frequency. IPMNs of the main ...pancreatic duct cause symptoms and lead to pancreatitis. Side-branch (SB) IPMNs are thought to cause symptoms less frequently, and their association with pancreatitis is not well defined. Objective Our purpose was to ascertain whether an association exists between SB-IPMN and pancreatitis. Design Single-center, retrospective study. Setting Academic medical center. Patients A total of 305 patients underwent EUS examinations between October 2002 and October 2006 for pancreatic cystic lesions. Main Outcome Measurement The main outcome measure was the frequency of acute or chronic pancreatitis that was not procedurally related. Results Thirty-two patients had SB-IPMNs, and 11 (34%) had pancreatitis. Three patients reported a single episode, and 8 patients reported having recurrent episodes of pancreatitis. Overall, 17 (53%) patients had symptoms possibly attributable to SB-IPMN. Female sex (73% vs 38%) and multiple pancreatic lesions (54% vs 24%) were more commonly seen in those with pancreatitis, but were not statistically significant factors. Larger cyst size or cyst fluid marker levels did not appear associated with pancreatitis occurrence. EUS-FNA demonstrated communication with the pancreatic duct in 94% and thick, mucinous fluid in 84%. Limitations Single-center, retrospective study. Conclusions Pancreatitis was frequently associated with the presence of SB-IPMNs in our referral practice. SB-IPMNs should be considered in the differential diagnosis of patients with recurrent pancreatitis with cystic lesions seen on imaging studies. EUS-FNA was the most useful modality in helping to differentiate SB-IPMNs from other lesions.
Coronary artery calcium (CAC) has been previously associated with atherosclerotic plaque disease and coronary events. Thus, identifying predictors of CAC progression may provide new insights for ...early risk-factor intervention and subsequent reduction of the rates of more severe atherosclerotic disease. The aim of this study was to identify risk factors for CAC progression and evaluate whether risk-factor change was related to CAC progression in a cohort of patients with type 1 diabetes mellitus (DM). Participants in the Pittsburgh EDC Study, a prospective investigation of childhood-onset type 1 DM, who underwent 2 electron beam tomographic screenings 4 years apart were selected for study (n = 222). CAC was calculated using the Agatston method of scoring, and progression was defined as an increase >2.5 in the square root–transformed CAC score. Adjusting for DM duration and initial CAC score, body mass index (BMI; odds ratio OR 1.13, 95% confidence interval CI 1.01 to 1.26), non–high-density lipoprotein cholesterol (OR 1.01, 95% CI 1.003 to 1.03), and albumin excretion rate (OR 1.30, 95% CI 1.03 to 1.63) were associated with CAC progression. When considering change in risk factors, an increase in BMI (OR 1.38, 95% CI 1.10 to 1.72) was also associated with CAC progression after adjustment. In conclusion, in this cohort with type 1 DM, in addition to baseline BMI, non–high-density lipoprotein cholesterol, albumin excretion rate, and all known coronary artery disease risk factors, weight gain further added to the prediction of CAC progression. Thus, weight control, in addition to lipid and renal management, may help retard atherosclerosis progression in persons with type 1 DM.
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