Faculty Bibliography

BACKGROUND: New York City was the epicenter of the COVID pandemic in the US during early 2020. NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients. During the onset of the pandemic, clinic leadership identified, oriented, and rapidly deployed a COVID Army, consisting of non-hospitalist physicians, to meet the needs of this patient influx. Orientation and training included an hour-long session with an emphasis on the inpatient electronic medical record system and a plan for at the elbow assistance from senior hospitalists. Here, we share feedback from our providers on our capacity building process and use information gathered to offer specific lessons learned in planning for workforce mobilization.
METHOD(S): A 32-item survey was distributed from March-June of 2020 in order to assess the experiences of these ancillary physicians, all of which were NYU Langone providers. Items included a mix of Likert and open-ended questions on demographics and attitudes toward experiences on the COVID team.
RESULT(S): All 272 volunteers received a survey. 67% (n=183) responded. 84 (46%) were from the Department of Medicine, the remainder were primarily from surgical, pediatrics or obstetrics/gynecology. Respondents worked in combination ambulatory/inpatient practices (n=94; 52%) or outpatient only (n=85; 47%) (Mean years in practice: 7.18). 76% felt that the number of patients they were in charge of felt Just Right (average: 7). 10% rated the experience as challenging (n=17). On their perception of support and training, 94% and 63% rated the support and training they received as somewhat or very effective, respectively. 89% (n=99) and 96% (n=107) of supplemental attendings felt valued and valuable to their team, respectively. 87% of respondents identified as being willing to volunteer again. In review of open-ended feedback, we identified a series of themes surrounding areas for improvement. These include the need to 1) invest time into orientations, including training on EHR use, (2) clarify roles and workflow within each team up front, (3) balance team workload if possible, (4) keep teams updated on evolving policies and recommendations, (5) make team members feel valued and supported, and (6) ensure they have the right tools available.
CONCLUSION(S): Given what we have learned from our survey, the continued waxing and waning of community infection, and the unknown length and extent of the COVID pandemic, we recommend providing transparent leadership, frequent communication, and an educational series to ensure everyone is learning together. In addition, clarity is essential, and it is important to be specific in defining the exact roles of ancillary physicians. It is our hope that the lessons learned from our needs assessment can be applied to other hospitals currently in the throes of a surge of COVID inpatients. LEARNING OBJECTIVE #1: Identify best practices for preparing an ancillary workforce for patient surge. LEARNING OBJECTIVE #2: Understand tools for quality patient care

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.

INTRODUCTION: Multi-society recommendations state, "Given the importance of polyp size for informing surveillance intervals, documentation of a polyp > 10 mm within a report should be accompanied by an endoscopic photo of the polyp with comparison to an open snare or open biopsy forceps".¹ We evaluate the feasibility of the Napoleon, an endoscopically-deployed small ruler to more accurately measure and document the size of colon polyps.
METHOD(S): The Micro-Tech Endoscopic Gauge (Non-FDA approved) named Napoleon, a catheter with a 15 mm ruler calibrated in 1 mm intervals with demarcations every 5 MM, was advanced through the biopsy channel of a colonoscope and positioned adjacent to a polyp to accurately measure polyp size (Image 1). Polyps sizes were first assessed visually and then measured using the Napoleon. Patients included were 50 to 85 years of age and undergoing screening or surveillance colonoscopy. Napoleon placement, extension/retraction, and photograph acquisition were evaluated on a 1-s10 scale (1 = Easy, 10 = Difficult).
RESULT(S): 23 patients were evaluated by 6 physicians. A total of 36 polyps were found. Each score represents the average of several polyps if more than one polyp was identified per patient (Table 1). The most polyps found in any patient was 3. Each polyp size was placed into 1 of 3 categories (Table 2): 1-5 mm (Diminutive), 6-9 mm (Small) and $ 10 mm (Large). 30 of the 36 total polyps (83%) were diminutive. 3 polyps were downgraded into the next smaller size category after measurement with the Napoleon - specifically, 1 polyp (33%) dropped from small to diminutive size and 2 polyps (67%) dropped from large to small size.
CONCLUSION(S): Prior studies on polyp size have shown that visual assessment is inaccurate.² This study demonstrates the ease and feasibility of the Napoleon as an endoscopic measuring device. The majority of polyps found were diminutive (1-5 mm) and explains why there is such a minute difference noted in the weighted mean polyp size (0.28 mm). Of the 3 polyps that were visually assessed to be $ 10 mm, 2 of those polyps (67%) were measured to be < 10 mm, changing recommended surveillance from 3 years to 7-10 years.¹ Further studies utilizing an endoscopic measuring tool such as the Napoleon are needed to evaluate the effect of accurate polyp measurement on our clinical management, training, and colonoscopy surveillance intervals

INTRODUCTION: Lipomas are benign submosal lesions, which can be found throughout the gastrointestinal tract. In most patients, these are incidentals findings and patients are asymptomatic. However, there are instances when lipomas can cause symptoms of obstruction if very large. This case highlights a rare complication of a colonic lipoma. CASE DESCRIPTION/METHODS: The case is of a 31-year-old man, who initially presented for intermittent rectal bleeding. On initial evaluation he had a benign abdominal exam, but a rectal exam was performed suggested hemorrhoids. There was no significant past medical history and no family history of colon cancer. A colonoscopy was performed demonstrating sigmoid diverticulosis, an ascending colon lipoma, and internal hemorrhoids, the likely cause of bleeding. Ten days later the patient calls with intermittent abdominal pain for the last several days. On further questioning, the patient does report occasional episodes of a similar sharp pain for the last few years, but in the last few days the pain has intensified. An outpatient CT scan was performed showing a 6.8 cm lipoma in the transverse colon causing colo-colonic intussusception (image 1). The patient was taken for urgent robotic right hemicolectomy with a side to side ileocolic anastomosis. Final pathology confirmed a large lipoma. The patient fully recovered and symptoms have resolved.
Discussion(s): DISCUSSION: Intussusception is when the bowel telescopes on itself. The most common location is the small bowel, but intussusception can occur in the colon 1. A lipoma is a benign submucosal tumor, which can be found in the colon. In the majority of cases lipomas are incidental finding and cause no symptoms. Based on autopsy reports, the incidence rate of colonic lipomas is 0.2-0.8%. However, clinical symptoms might include abdominal pain, bleeding, and perforation. Clinicians should be aware of this unique presentation, which requires surgical intervention

INTRODUCTION: Telehealth involves the use of electronic information and telecommunications to promote healthcare. Physician experience is critical in assessing the impact of telehealth on clinical outcomes and utilization. Gastroenterologists' use and attitudes towards telehealth are largely unknown. We aimed to identify gastroenterologists' professional attitudes towards their use of telehealth and its effect on patient care during the COVID-19 pandemic.
METHOD(S): We performed a cross sectional survey of outpatient gastroenterologists and hepatologists at a single tertiary academic medical center in June 2020. Clinicians were invited to participate in an electronic survey. Survey questions involved either single or multiple categorical responses.
RESULT(S): A total of 46 respondents (51 +/- 14 years old) participated, 70% of which were male. 44 (96%) respondents had no telehealth experience prior to the pandemic. Clinicians conducted 19 +/- 13 visits weekly with a mean length of 24 +/- 9 minutes. 88% of providers reported telehealth allowed for increased flexibility, both in patient scheduling and their personal lives. Telehealth was always or usually effective in addressing patients' clinical needs 91% of the time. 29 (63%) respondents estimated that 10% or fewer patients required in-person follow-up. Clinicians estimated 93% of patients desired the continued option of telehealth, and 42 (91%) providers wanted to continue telehealth in some capacity, conditional on reimbursement. Those interested would use telehealth for follow-up visits (28%), on a patient-by-patient basis (23%), or for new visits (20%). While 21 (46%) respondents felt that telehealth and in-person visits required equal effort, 16 (35%) felt telehealth required more effort. Reasons cited for telehealth requiring more effort included coordination of care (30%), technical difficulty for the patient (20%), and more charting (17%).
CONCLUSION(S): While most clinicians had no telehealth experience before the pandemic, a majority were interested in using telehealth in the future, citing increased flexibility for both provider and patient. Physicians felt that telehealth was effective in addressing patients' needs. However, many felt that telehealth required more effort, particularly in regard to coordination of care and technical difficulties. Newer telehealth platforms should address connectivity issues. Future studies should focus on patients' attitudes towards telehealth, and the effect of telehealth on healthcare outcomes, utilization and costs

BACKGROUND:Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy (SC) still occur. Increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device comprises a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing ADR. METHODS:In this randomized, controlled, international, multicenter study (11 centers), subjects (age ≥50) referred to colonoscopy for screening, surveillance, or due to changes in bowel habits, were randomized to undergo either balloon-assisted colonoscopy using an insufflated balloon during withdrawal or standard high-definition colonoscopy. Primary endpoint was ADR. RESULTS:One thousand subjects were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (SC: n=396; balloon-assisted colonoscopy: n=407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the SC group (28% increase, p=0.0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (p=0.0033), flat adenomas (p<0.0001), and sessile serrated adenoma/polyp (SSA/Ps) (p=0.0026). CONCLUSIONS:Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat and SSA/Ps when compared with SC. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates, and consequently reducing of interval cancers incidence; clinicaltrials.gov (NCT01917513).

Colorectal cancer remains the second-leading cause of cancer death in the United States-but efforts over the past two decades have resulted in tremendous progress in understanding the biology of how this disease develops, increasing screening rates, and decreasing incidence and mortality in those age 50 years and older. The drivers of this movement have been outstanding leadership, innovation, and collaboration. As we move forward to tackle issues such as the increasing incidence of this disease in younger adults, the need to address disparities in care and outcomes, and our shared goal to reach 80% screening rates, it's important to understand and appreciate the story of our past success in order to advance our future efforts.

Background: Inadequate bowel preparation is estimated to occur in as many as 25% of colonoscopies, and can lead to adverse outcomes including prolonged examination times, missed lesions of up to 42-48% and an increased rate of complications. Adequacy of bowel preparation is recognized as an important metric when assessing quality of colonoscopy. National guidelines state that when bowel preparation for colonoscopy is considered inadequate, repeat examination should occur within one year. Our aim was to evaluate the timing of recommendation for repeat colonoscopy when inadequate bowel prep was reported using GIQuIC, the GI Quality Improvement Consortium, a large, national clinical gastroenterology data registry. Methods: We performed an analysis of all screening and surveillance colonoscopies among adults age 18-89 reported in GIQuIC during the period from 2010-2017. A standardized data collection tool captured information about bowel preparation quality. GIQuIC prospectively collects patient and procedural information on colonoscopies from over 450 sites across the US. We examined data on colonoscopy where bowel preparation was deemed to be inadequate and then evaluated recommendations for interval follow up. Results: A total of 3,773,519 colonoscopies were analyzed for this study, recorded in the registry between 2010-2017. Inadequate bowel preparation was reported in 201,804 (5.3%). Of these, 127,854 were found on examinations where the indication was screening and 74,220 where the indication was surveillance. The recommendation for follow up interval to be less than one year was made in 25.1% when all examinations were assessed. The rate was 25.6% when only looking at screening exams and 24.2% for surveillance exams. (Table 1) When assessed per physician, data was available for 3582 physicians, and mean performance to recommend follow up in less than one year when poor preparation was noted was 34.2%; median performance was 27.3%. When follow up other than within 1 year was recommended, the recommendation was for none (4.9%), 2 years (5.2%), 3 years (26.7%), 5 years (37.9%), 10 years (11.2%), and other (14.2%) (Table 2) Conclusions: The recommendation for repeat screening or surveillance colonoscopy in less than one year when the index colonoscopy has an inadequate bowel prep is a quality measure in gastroenterology. This study, using data from GIQuIC, demonstrates poor compliance with these guideline recommendations. Given the consequences of poor bowel prep in colonoscopy, including possible missed lesions, repeat examination is recommended soon after the initial procedure, and certainly within one year. Adherence to these guidelines as demonstrated here is low, and this suggests the need to understand factors behind this low adherence, as well as increased education and increased adherence to colorectal cancer screening and surveillance guidelines