Faculty Bibliography

BACKGROUND:Competency in endoscopy has traditionally been based on number of procedures performed. With movement towards milestone-based accreditation, new standards of establishing competency are required. The Thompson Endoscopic Skills Trainer (TEST) is a training device previously shown to differentiate between novice and expert endoscopists. This study aims to correlate TEST scores to other markers of performance in endoscopy. METHODS:Trainees of a gastroenterology fellowship program were guided through the TEST. Their scores and sub-scores were correlated to their endoscopic metrics of performance, including adenoma detection rate, cecal intubation rate, cecal intubation time, withdrawal time, fentanyl usage, midazolam usage, pain score, overall procedure time, and performance on the ASGE Assessment of Competency in Endoscopy Tool (ACE Tool). RESULTS:The Overall Score positively correlated with the ACE Tool Total Score (r = 0.707, p = 0.010) and sub-scores (Cognitive Skills Score: r = 0.624, p = 0.030; Motor Skills Score: r = 0.756, p = 0.004), and negatively correlated with cecal intubation time (r = - 0.591, p = 0.043). The Gross Motor Score positively correlated with cecal intubation rate (r = 0.593, p = 0.042), ACE Tool Total Score (r = 0.594, p = 0.042) and Motor Skills Score (r = 0.623, p = 0.031), and negatively correlated with cecal intubation time (r = - 0.695, p = 0.012). The Fine Motor Score positively correlated with the ACE Tool Polypectomy Score (r = 0.601, p = 0.039), and negatively correlated with procedure time (r = - 0.640, p = 0.025), cecal intubation time (r = - 0.645, p = 0.024), and withdrawal time (r = - 0.629, p = 0.028). CONCLUSION/CONCLUSIONS:This study demonstrates that performance on the TEST correlate to endoscopic measures. Given these results, the TEST may be used in conjunction with existing assessment tools for demonstrating competency in endoscopy.

INTRODUCTION: Endoscopic bariatric therapies (EBTs) have become available for the treatment of obesity, but their role in the treatment of diabetes is not well defined. EBTs can loosely be grouped into gastric or small bowel EBTs, with some data suggesting that small bowel EBTs have greater effect on diabetes. Our aim is to assess the impact of EBTs on diabetes and compare the effect of small bowel EBTs to gastric EBTs on diabetes outcomes, gut hormones, and weight loss parameters.
METHOD(S): MEDLINE, Embase, and Cochrane were searched through 2018. Randomized clinical trials and observational studies of EBTs that reported diabetic outcomes with >5 adult patients with obesity and at least 3 months of follow up were included. Primary outcomes included the pooled mean difference (MD) in baseline and final values in weight loss (% total weight loss, % excess weight loss, BMI change from baseline) and glycemic control (fasting glucose, HbA1c) parameters. Secondary analyses included changes in gut hormones by Hedges' g: ghrelin, glucagon-like peptide 1 (GLP-1), peptide YY (PYY), and glucose-dependent insulinotropic peptide (GIP). Gastric EBTs included intragastric balloons, gastric restrictive procedures such as endoscopic sleeve gastroplasty (ESG), primary obesity surgery endoluminal procedure (POSE), transoral endoscopic vertical gastroplasty (TOGA), aspiration therapy. Small bowel EBTs included duodenal-jejunal bypass liner (DJBL), duodenal mucosal resurfacing (DMR), incisionless intestinal anastomosis system (IAS).
RESULT(S): From 1053 citations, 79 studies with 7,692 subjects were included. EBT use for 3-12 months was associated with significant improvements in diabetes outcomes and weight loss indices compared to baseline or control groups (Table 1). Weight loss outcomes with small bowel EBTs were similar to gastric EBTs. Small bowel EBTs led to a statistically significant greater improvement than gastric EBTs in diabetic parameters. Improvements in diabetes were associated with weight loss for gastric EBTs and an increase in postprandial GLP-1 and PYY for small bowel EBTs (Table 2).
CONCLUSION(S): Discussion: Diabetes and weight loss parameters improved significantly after 3-12 months of EBT. Small bowel EBTs were more effective than gastric EBTs, likely due to different mechanisms of action. EBT should be considered as an option to treat obesity in patients with diabetes in conjunction with diet and lifestyle interventions

Needs and Objectives: Superior clinical reasoning is a hallmark of the expert clinician. However, to a passive listener at a traditional case conference, the process by which this expert arrives at a diagnosis may not be obvious. Discussion often focuses on medical knowledge, rather than on the Methods the expert uses to reach a Conclusion. Experts vary in their ability to describe how they approach a case, and it is debatable whether narratives produced in this manner are in fact reliable representations of their mental processes. Teaching clinical reasoning can thus be challenging even for experienced faculty. In response, we designed a podcast series using actual cases to explore the conscious and unconscious habits and strategies used by physicians. Our intention was to immerse listeners in the language of clinical problem solving in an accessible and interactive way. Setting and Participants: Hoofbeats is one of several series that comprise the CoreIM podcast. It is targeted at trainees and medical professionals across all specialties within internal medicine. Description: Hoofbeats listeners play the role of the clinician, as a difficult case is presented in stepwise fashion with pauses to allow revision of an impression or differential. Listeners hear a discussant work through the case, accompanied by commentary from the show's hosts, who interpret and elaborate on the discussant's reasoning behaviors. Clinical pearls, useful schema, and biases are highlighted. To reinforce the challenge, a visual representation of the case is sent out via social media. In some episodes users can solve an interactive version of the case on the online database HumanDx; the resulting collective differential is then explored within the episode. Evaluation: From March to December 2018 we released six Hoofbeats episodes, with over 64,000 total downloads by listeners across 170 countries. In our descriptive analysis of feedback, we found that listeners valued the explicit analysis of the problem-solving behavior of experienced clinicians. Interactive elements successfully engaged our listeners, who actively attempted cases and reflected on their reasoning. Through role modeling from the hosts, listeners reported greater confidence articulating and teaching clinical reasoning concepts. Interestingly, commentary on particularly challenging points in a difficult case led our listeners to appreciate the honesty and humility of our hosts and experts, who frequently recognized their own shortcomings. Discussion/Reflection/Lessons Learned: Decades of research into clinical problem-solving have produced a terminology now familiar to many trainees and medical professionals, such as the practice of "problem representation" or the concept of the "availability heuristic." Many of these abstract concepts originated in behavioral science and artificial intelligence programming, and do not lend themselves naturally to book or lecture-based learning. However, our experience with Hoofbeats suggests there is significant interest among learners in the practical application of these constructs

Broad-spectrum antibiotics are frequently prescribed to children. Early childhood represents a dynamic period for the intestinal microbial ecosystem, which is readily shaped by environmental cues; antibiotic-induced disruption of this sensitive community may have long-lasting host consequences. Here we demonstrate that a single pulsed macrolide antibiotic treatment (PAT) course early in life is sufficient to lead to durable alterations to the murine intestinal microbiota, ileal gene expression, specific intestinal T-cell populations, and secretory IgA expression. A PAT-perturbed microbial community is necessary for host effects and sufficient to transfer delayed secretory IgA expression. Additionally, early-life antibiotic exposure has lasting and transferable effects on microbial community network topology. Our results indicate that a single early-life macrolide course can alter the microbiota and modulate host immune phenotypes that persist long after exposure has ceased.High or multiple doses of macrolide antibiotics, when given early in life, can perturb the metabolic and immunological development of lab mice. Here, Ruiz et al. show that even a single macrolide course, given early in life, leads to long-lasting changes in the gut microbiota and immune system of mice.

ObjectivesTherapies less invasive than surgery and more effective than lifestyle and pharmacotherapy are needed to contend with the obesity epidemic. Intragastric balloons (IGBs) are a minimally invasive endoscopic weight loss method recently approved for use in the US. The purpose of the study is to assess the effect of IGBs on metabolic outcomes associated with obesity.MethodsMEDLINE, Embase, and Cochrane Database were searched through July 2016. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. Primary outcomes included the change from baseline in metabolic parameters. Secondary outcomes included resolution and/or improvement in metabolic co-morbidities and association with baseline parameters.Results10 randomized controlled trials (RCT) and 30 observational studies including 5,668 subjects were analyzed. There was moderate-quality evidence for improvement in most metabolic parameters in subjects assigned to IGB therapy as compared to conventional non-surgical therapy in RCTs: mean difference (MD) in fasting glucose change: -12.7 mg/dl (95% confidence interval (CI) -21.5, -4); MD in triglycerides: -19 mg/dl (95% CI -42, 3.5); MD in waist circumference: -4.1 cm (95% CI -6.9, -1.4); MD in diastolic blood pressure: -2.9 mm Hg (95% CI -4.1, -1.8). The odds ratio for diabetes resolution after IGB therapy was 1.4 (95% CI 1.3, 1.6). The rate of serious adverse events was 1.3%.ConclusionsIGBs are more effective than diet in improving obesity-related metabolic risk factors with a low rate of adverse effects, however the strength of the evidence is limited given the small number of participants and lack of long-term follow-up.Am J Gastroenterol advance online publication, 24 January 2017; doi:10.1038/ajg.2016.530.

BACKGROUND AND STUDY AIMS/OBJECTIVE:There is currently no objective and validated methodology available to assess the progress of endoscopy trainees or to determine when technical competence has been achieved. The aims of the current study were to develop an endoscopic part-task simulator and to assess scoring system validity. METHODS:Fundamental endoscopic skills were determined via kinematic analysis, literature review, and expert interviews. Simulator prototypes and scoring systems were developed to reflect these skills. Validity evidence for content, internal structure, and response process was evaluated. RESULTS:The final training box consisted of five modules (knob control, torque, retroflexion, polypectomy, and navigation and loop reduction). A total of 5 minutes were permitted per module with extra points for early completion. Content validity index (CVI)-realism was 0.88, CVI-relevance was 1.00, and CVI-representativeness was 0.88, giving a composite CVI of 0.92. Overall, 82 % of participants considered the simulator to be capable of differentiating between ability levels, and 93 % thought the simulator should be used to assess ability prior to performing procedures in patients. Inter-item assessment revealed correlations from 0.67 to 0.93, suggesting that tasks were sufficiently correlated to assess the same underlying construct, with each task remaining independent. Each module represented 16.0 % - 26.1 % of the total score, suggesting that no module contributed disproportionately to the composite score. Average box scores were 272.6 and 284.4 (P = 0.94) when performed sequentially, and average score for all participants with proctor 1 was 297.6 and 308.1 with proctor 2 (P = 0.94), suggesting reproducibility and minimal error associated with test administration. CONCLUSION/CONCLUSIONS:A part-task training box and scoring system were developed to assess fundamental endoscopic skills, and validity evidence regarding content, internal structure, and response process was demonstrated.