The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised ...practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training.
ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions.
Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1—very important to 5—very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees.
Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.
Summary
Recently, there has been considerable interest in using 4‐methylumbelliferone (4‐MU) to inhibit hyaluronan (HA) synthesis in mouse models of cancer, autoimmunity and a variety of other ...inflammatory disorders where HA has been implicated in disease pathogenesis. In order to facilitate future studies in this area, we have examined the dosing, treatment route, treatment duration and metabolism of 4‐MU in both C57BL/6 and BALB/c mice. Mice fed chow containing 5% 4‐MU, a dose calculated to deliver 250 mg/mouse/day, initially lose substantial weight but typically resume normal weight gain after 1 week. It also takes up to a week to see a reduction in serum HA in these animals, indicating that at least a 1‐week loading period on the drug is required for most protocols. At steady state, more than 90% of the drug is present in plasma as the glucuronidated metabolite 4‐methylumbelliferyl glucuronide (4‐MUG), with the sulphated metabolite, 4‐methylumbelliferyl sulphate (4‐MUS) comprising most of the remainder. Chow containing 5% but not 0·65% 4‐MU was effective at preventing disease in the experimental autoimmune encephalomyelitis (EAE) mouse model of multiple sclerosis, as well as in the DORmO mouse model of autoimmune diabetes. While oral 4‐MU was effective at preventing EAE, daily intraperitoneal injections of 4‐MU were not. Factors potentially affecting 4‐MU uptake and plasma concentrations in mice include its taste, short half‐life and low bioavailability. These studies provide a practical resource for implementing oral 4‐MU treatment protocols in mice.
We have shown that the genetically diabetic mouse (C57BLKS/J‐m+/+Leprdb) has a wound healing and neovascularization deficit associated with an inability to recruit endothelial precursor cells (EPCs) ...to the wound. This may account for a fundamental mechanism in impaired diabetic wound healing. We hypothesized that the adenoviral mediated overexpression of platelet‐derived growth factor‐B (PDGF‐B) would enhance wound healing, improve neovascularization, and recruit EPCs to the epithelial wound in three diabetic mouse models. Eight‐mm full‐thickness flank wounds were made in db/db, nonobese NOD/Ltj, streptozotocin, and C57BLKS/J mice. Wounds were treated with either 1 × 108 PFU Ad‐PDGF‐B or Ad LacZ or phosphate buffered saline solution. Wounds harvested at seven days were analyzed for epithelial gap, blood vessel density, granulation tissue area, and EPCs per high powered field. All three diabetic models have a significant wound healing and neovascularization defect compared to C57BLKS/J controls. Adenoviral‐PDGF‐B treatment significantly enhanced epithelial gap closure in db/db, streptozotocin, and nonobese NOD/Ltj mice as compared to diabetic phosphate buffered saline solution or Ad LacZ controls. A similar increase in the formation of granulation tissue and vessel density was also observed. All three models had reduced levels of GATA‐2 positive EPCs in the wound bed that was corrected by the adenoviral mediated gene transfer of PDGF. EPC recruitment was positively correlated with neovascularization and wound healing. Three different diabetic models have a wound healing impairment and a decreased ability to recruit EPCs. The vulnerary effect of adenoviral mediated gene therapy with PDGF‐B significantly enhanced wound healing and neovascularization in diabetic wounds. The PDGF‐B mediated augmentation of EPC recruitment to the wound bed may be a fundamental mechanism of these results.
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.
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 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.
Bacteriophage are abundant at sites of bacterial infection, but their effects on mammalian hosts are unclear. We have identified pathogenic roles for filamentous Pf bacteriophage produced by
(
) in ...suppression of immunity against bacterial infection. Pf promote
wound infection in mice and are associated with chronic human
wound infections. Murine and human leukocytes endocytose Pf, and internalization of this single-stranded DNA virus results in phage RNA production. This triggers Toll-like receptor 3 (TLR3)- and TIR domain-containing adapter-inducing interferon-β (TRIF)-dependent type I interferon production, inhibition of tumor necrosis factor (TNF), and the suppression of phagocytosis. Conversely, immunization of mice against Pf prevents
wound infection. Thus, Pf triggers maladaptive innate viral pattern-recognition responses, which impair bacterial clearance. Vaccination against phage virions represents a potential strategy to prevent bacterial infection.
Because trypsin-like serine proteases have a major role in the truncation of CCL23 in NPs and inhibitors of neutrophil elastase (SSR69071) and matrix metalloproteinases (MMPs; marimastat), which are ...known to cleave CCL23,8,9 did not block the truncation (Fig 1, C), we focused on the mast cell trypsin-like serine protease tryptase. Importantly, the CCR1 antagonist CCX8960 completely blocked NP-treated CCL23-dependent but not CCL2 (a CCR2 ligand)-dependent migration of THP-1 cells, indicating that truncation of CCL23 by NP extracts results in increased CCR1-dependent migration of THP-1 cells (see Fig E3, B). Because previously known active truncated forms of CCL23 are formed by N-terminal truncations, we initially assessed N-terminal protein sequences.
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