The synergistic role of virtual coaching with simulation-based mastery learning for upper endoscopy

Introduction

Our simulation-based mastery learning (SBML) curriculum, delivered in person, has been shown to successfully train novices in structured esophagogastroduodenoscopy (EGD). SBML with virtual coaching (VC) has the potential to improve the effectiveness and efficiency of endoscopy training and expand access to trainees from around the world. We share our observations conducting an EGD training course using SBML with VC.

Methods

We conducted a 1-week virtual SBML course for novice trainees across seven academic centers in the USA and Asia. The cognitive component was delivered using an online learning platform. For technical skills, a virtual coach supervised hands-on training and local coaches provided assistance when needed. At the end of training, an independent rater assessed simulation-based performance using a validated assessment tool. We assessed the clinical performance of 30 EGDs using the ASGE Assessment of Competency in Endoscopy tool. We compared the trainees' scores to our cohort trained using in-person SBML training using non-inferiority t-tests.

Results

We enrolled 21 novice trainees (mean age: 30.8 ± 3.6 years; female: 52%). For tip deflection, the trainees reached the minimum passing standard after 31 ± 29 runs and mastery after 52 ± 37 runs. For structured EGD, the average score for the overall exam was 4.6 ± 0.6, similar to the in-person cohort (4.7 ± 0.5, p = 0.49). The knowledge-based assessment was also comparable (virtual coaching: 81.9 ± 0.1; direct coaching: 78.3 ± 0.1; p = 0.385). Over time, our novice trainees reached clinical competence at a similar rate to our historical in-person control.

Conclusions

VC appears feasible and effective for training novice gastroenterology trainees. VC allowed us to scale our SBML course, expand access to experts, and administer SBML simultaneously across different sites at the highest standards.

Use of a flexible tip bougie (FlexTip) in the management of the first-attempt failure intubation with the C-MAC D-Blade videolaryngoscope in the intensive care unit: A prospective, case series

We describe a series of 11 cases in which we used the new flexible tip (FlexTip) bougie as a rescue device following first-attempt failure at intubation with the C-MAC D-Blade video laryngoscope in our UCI. We collected data from all intubations performed using the C-MAC D-Blade video laryngoscope over a 16-month period. Ninety six patients were included in the study: 79 (86.8%) were intubated at the first attempt; 11 (12.1%) required 2 attempts; and 1 patient required 3 attempts. The Frova Intubating Introducer was used in 1 of the 12 patients requiring more than 1 intubation attempt, and the FlexTip was used in the remaining 11. This study shows that the new FlexTip bougie is a good rescue device when the first attempt at video laryngoscope intubation fails.

Competing-risks model in screening for pre-eclampsia in twin pregnancy according to maternal factors and biomarkers at 11-13 weeks' gestation

OBJECTIVE

To develop a model for screening for pre-eclampsia (PE) in twin pregnancies based on maternal demographic characteristics and medical history and biomarkers at 11-13 weeks' gestation.

METHODS

This was a screening study in twin pregnancies at 11-13 weeks' gestation. Bayes theorem was used to combine the a-priori risk from maternal factors with various combinations of uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), serum pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) multiples of the median (MoM) values. The performance of screening for PE requiring delivery at < 32, < 37 and < 42 weeks' gestation was estimated in 1100 twin pregnancies and 35 948 singleton pregnancies with complete data on UtA-PI, MAP, PlGF and PAPP-A.

RESULTS

In twin pregnancies that developed PE, the values of MAP and UtA-PI were increased and the values of PlGF and PAPP-A were decreased. The distributions of log₁₀ MoM values of biomarkers with gestational age at delivery were similar to those that were previously reported in singleton pregnancies and it was therefore assumed that the same model could be used for both singleton and twin pregnancies. The performance of screening for PE by maternal factors was improved by the addition of MAP, UtA-PI and PlGF; there was no further improvement with the addition of PAPP-A. In a mixed population of singleton and twin pregnancies, combined screening by maternal factors, MAP, UtA-PI and PlGF and risk cut-off of 1 in 75 for PE at < 37 weeks, the detection rate of PE at < 32, < 37 and < 42 weeks in singleton pregnancies was 91%, 77% and 57%, respectively, at a screen-positive rate (SPR) of 13%; the respective rates for twin pregnancies were 100%, 99% and 97%, at a SPR of 75%.

CONCLUSION

First-trimester combined screening for PE in singleton pregnancies can be adapted for screening in twins, leading to detection of nearly all affected cases but at a high SPR. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Competing-risks model in screening for pre-eclampsia in twin pregnancy by maternal characteristics and medical history

OBJECTIVE

A survival-time regression model for gestational age at delivery with pre-eclampsia (PE) in singleton pregnancy, using maternal demographic characteristics and medical history, was reported previously. The objective of this study was to extend this model to dichorionic (DC) and monochorionic (MC) twin pregnancy.

METHODS

The study population included 1789 DC and 430 MC twin pregnancies and 93 297 singleton pregnancies. A survival-time model for gestational age at delivery with PE was developed from variables of maternal characteristics and medical history. The risk of PE with delivery < 37 weeks and < 42 weeks in twin pregnancies was determined and compared with that in singleton pregnancies.

RESULTS

In singleton pregnancies comprising women of Caucasian racial origin, mean weight of 69 kg at 12 weeks' gestation, mean height of 164 cm, nulliparous, with spontaneous conception, no family history of PE and no history of diabetes mellitus, systemic lupus erythematosus or antiphospholipid syndrome, the mean of the Gaussian distribution of gestational age at delivery with PE was 55 weeks. In DC twins with PE, mean gestational age at delivery was shifted to the left by 8.2 (95% CI, 7.2-9.1) weeks and in MC twins it was shifted to the left by 10.0 (95% CI, 8.5-11.4) weeks. The risk of delivery with PE occurring at, or before, a specified gestational age is given by the area under the fitted distribution curve. For a reference population with the above characteristics, the estimated risk of PE < 37 weeks' gestation, assuming no other cause of delivery, was 0.6% for singletons, 9.0% for DC twins and 14.2% for MC twins; the respective values for PE < 42 weeks were 3.6%, 27.0% and 36.5%.

CONCLUSIONS

A model based on maternal characteristics and medical history has been developed for estimation of patient-specific risks for PE in DC and MC twin pregnancy. Such estimation of the a-priori risk for PE is an essential first step in the use of Bayes' theorem to combine maternal factors with biomarkers for the continuing development of more effective methods of screening for the disease. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Hidden high rate of pre-eclampsia in twin compared with singleton pregnancy

OBJECTIVES

To examine the gestational age at delivery in dichorionic (DC) and monochorionic (MC) twin pregnancies, with and without pre-eclampsia (PE), and to determine the relative risk of total and preterm PE compared with that in singleton pregnancies.

METHODS

This was a screening study for PE in twin pregnancies undergoing first-trimester combined screening for aneuploidy and subsequently delivering two phenotypically normal live or stillborn babies at ≥ 24 weeks' gestation. The distribution of gestational age at delivery in DC and MC twins was determined and compared with that in singleton pregnancies from the same population. The relative risk for total and preterm PE in twins compared with singleton pregnancies was determined. Kaplan-Meier estimates of the cumulative incidence of PE in twin and singleton pregnancies, assuming no other cause for delivery, were determined and hazard ratios for twins relative to singletons were obtained from a Cox proportional hazards regression model.

RESULTS

The incidence of PE in singletons was 2.3% (2162/93 297), in DC twin pregnancies was 8.1% (145/1789) and in MC twin pregnancies was 6.0% (26/430). Compared with singletons, the relative risk of total PE was 3.5 for DC twins and 2.6 for MC twins. Delivery < 37 weeks' gestation occurred in 5.5% of singletons, 46.5% of DC twins and 91.4% of MC twins. The incidence of preterm PE was 0.6%, 5.5% and 5.8% for singletons, DC twins and MC twins, respectively. Compared with singletons, the relative risk of preterm PE was 8.7 for DC twins and 9.1 for MC twins. In the Cox proportional hazards regression model, the hazard ratios for DC and MC twin pregnancies relative to singleton pregnancies were 14 and 23, respectively.

CONCLUSIONS

The relative risk of preterm PE in DC and MC twins is similar and substantially higher than in singleton pregnancies. In ongoing twin pregnancies, the high relative risk of PE may merit a higher intensity of monitoring than is routine for singleton pregnancies. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Place of 3D printing in facial epithesis

Facial rehabilitation from facial epithets is part of the facial surgeon's therapeutic arsenal. The primary technique requires taking imprints on the patient, which has major drawbacks such as discomfort and difficulties for precisely recording anatomical surfaces. In this paper, we present a technical improvement in the design of facial epithesis, introducing application of a 3D printing technology. By exploiting digital data in DICOM format, it is possible to produce a digital copy of an epithesis. Based on this copy a model can be printed and then used to support the final prosthesis.

IONA test for first-trimester detection of trisomies 21, 18 and 13

OBJECTIVE

To assess the potential performance of screening for fetal trisomies 21, 18 and 13 by cell-free DNA (cfDNA) analysis of maternal blood using the IONA® test.

METHODS

This was a nested case-control study of cfDNA analysis of maternal plasma using the IONA test. Samples were obtained at 11-13 weeks' gestation, before chorionic villus sampling, from 201 euploid pregnancies, 35 with trisomy 21, four with trisomy 18 and two with trisomy 13. Laboratory personnel were blinded to the fetal karyotype.

RESULTS

Probability scores for trisomies 21, 18 and 13 were given for 241/242 samples analyzed. No probability score was provided for one (0.5%) euploid pregnancy because of low fetal fraction. In all 35 cases of trisomy 21 the probability score for trisomy 21 was > 95% and the scores for trisomies 18 and 13 were ≤ 0.0001%. In all four cases of trisomy 18, the probability score for trisomy 18 was > 77% and the scores for trisomies 21 and 13 were ≤ 0.0001%. In the two cases of trisomy 13, the probability score for trisomy 13 was > 59% and the scores for trisomies 21 and 18 were ≤ 0.0001%. In the 200 euploid pregnancies with a test result, the probability score was < 0.08% for trisomy 21, < 0.001% for trisomy 18 and < 0.002% for trisomy 13. Therefore, the IONA test detected 100% of all three trisomies, with a false-positive rate of 0%.

CONCLUSION

The IONA test successfully differentiated all cases of trisomies 21, 18 and 13 from euploid pregnancies.

Fetal fraction of cell-free DNA in maternal plasma in the prediction of spontaneous preterm delivery

OBJECTIVES

To investigate whether, in pregnancies complicated by spontaneous preterm delivery, fetal fraction of cell-free DNA (cfDNA) in maternal plasma at 11-13 weeks' gestation is altered and if this measurement could be useful in the prediction of preterm delivery.

METHODS

Fetal fraction of cfDNA was measured at 10 + 0 to 13 + 6 weeks' gestation in 3169 pregnancies, 3066 (96.7%) that delivered at ≥ 37 weeks and 103 (3.3%) with spontaneous delivery at < 37 weeks, including 21 that delivered at < 34 weeks and 82 that delivered at 34-37 weeks. The measured fetal fraction was converted to multiples of the median (MoM), corrected for maternal characteristics and gestational age, and the Mann-Whitney U-test was used to determine the significance of differences in the median values in the spontaneous preterm delivery groups from that in the term delivery group.

RESULTS

In the spontaneous preterm delivery groups (< 34 weeks' gestation, 34-37 weeks, < 37 weeks), compared to the term delivery group, there was no significant difference in the median fetal fraction MoM (1.004, 0.922 and 0.946, respectively, vs 1.015).

CONCLUSION

Measurement of fetal fraction in maternal plasma at 11-13 weeks' gestation is not predictive of spontaneous preterm delivery.

Screening for trisomies 21, 18 and 13 by cell-free DNA analysis of maternal blood at 10-11 weeks' gestation and the combined test at 11-13 weeks

OBJECTIVE

To examine in a general population the performance of cell-free DNA (cfDNA) testing for trisomies 21, 18 and 13 at 10-11 weeks' gestation and compare it to that of the combined test at 11-13 weeks.

METHODS

In 2905 singleton pregnancies, prospective screening for trisomies was performed by chromosome-selective sequencing of cfDNA in maternal blood at 10-11 weeks' gestation and by the combined test at 11-13 weeks' gestation.

RESULTS

Median maternal age of the study population was 36.9 (range, 20.4-51.9) years. Results from cfDNA analysis were provided for 2851 (98.1%) cases and these were available within 14 days from sampling in 2848 (98.0%) cases. The trisomic status of the pregnancies was determined by prenatal or postnatal karyotyping or clinical examination of the neonates. Of the 2785 pregnancies with a cfDNA result and known trisomic status, cfDNA testing correctly identified all 32 cases with trisomy 21, nine of 10 with trisomy 18 and two of five with trisomy 13, with false-positive rates of 0.04%, 0.19% and 0.07%, respectively. In cases with discordant results between cfDNA testing and fetal karyotype, the median fetal fraction was lower than in those with concordant results (6% vs 11%). Using the combined test, the estimated risk for trisomy 21 was ≥ 1/100 in all trisomic cases and in 4.4% of the non-trisomic pregnancies.

CONCLUSION

The performance of first-trimester cfDNA testing for trisomies 21 and 18 in the general population is similar to that in high-risk pregnancies. Most false-positive and false-negative results from cfDNA testing could be avoided if the a priori risk from the combined test is taken into account in the interpretation of individual risk.

Cynthichlorine: a bioactive alkaloid from the tunicate Cynthia savignyi

From ether extracts of the tunicate Cynthia savignyi, collected in Morocco, a new alkaloid-cynthichlorine-has been isolated. The structure of cynthichlorine has been characterized by extensive 2D-NMR data. Cynthichlorine possesses antifungal activity against two tomato pathogenic fungi: Botrytis cinerea and Verticillium albo atrum and antibacterial activity against Agrobacterium radiobacter, Escherichia coli and Pseudomonas aeruginosa and cytotoxicity against Artemia salina larvae.

Isolation and bioactivities of epidioxysterol from the tunicate Cynthia savignyi

From a hexane extract of the tunicate Cynthia savignyi, collected in Morocco, epidioxysterol or 5,8-alpha-epidioxy-5alpha-cholest-6-en-3beta-ol has been isolated. This is the first example of epidioxysterol found in the tunicate C. savignyi. The structure of epidioxysterol has been characterised by NMR data (1H, 13C and 2D). Epidioxysterol possesses antifungal activity against three tomato pathogenic fungi: Botrytis cinerea, Fusarium oxysporum and Verticillium albo atrum and antibacterial activity against Agrobacterium tumefaciens, Escherichia coli, Staphylococcusfaecalis, Staphylococcus aureus and Pseudomonas aeruginosa and cytotoxicity against Artemia salina larvae.

Genome-wide screen for allelic imbalance in a mouse model for neuroblastoma

We have used the rat tyrosine hydroxylase promotor to overexpress MYCN in the neural crest of transgenic mice, resulting in a mouse model for neuroblastoma. Using PCR analysis of microsatellite markers, we conducted a genome-wide analysis in tumors from these animals. Regions of chromosomes 1, 3, 10, 11, 14, and 18 were affected in 20-50% of tumors. Analysis of a subset of these tumors by comparative genomic hybridization was consistent with the microsatellite data. The changes on mouse chromosomes 1, 11, 14, and 18 were syntenic with corresponding regions of loss of heterozygosity in human neuroblastoma, suggesting that genes implicated in the mouse tumors may also play a role in the pathogenesis of the human disease. One-third of the mouse tumors shared abnormalities on chromosomes 1, 3, and 10, whereas the remainder of tumors did not show this combination. These data suggest that genetic mutations on chromosomes 1, 3, and 10 cooperate in the pathogenesis of neuroblastoma and that neuroblastoma in the mouse arises from at least two distinct genetic pathways, one of which is dependent on lesions in chromosomes 1, 3, and 10, the other of which is not.

Investigation of bioactivity of extracts from Moroccan solitary tunicate Cynthia savignyi

Extracts of the tunicate Cynthia savignyi from the Moroccan Atlantic sea have been investigated in five bioassays. The first is an antibacterial test against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Agrobacterium tumefaciens; the second is an antifungal test against three tomato pathogenic fungi, Botrytis cinerea, Fusarium oxysporum and Verticillium albo-atrum; the third is a test based to the ability to reduce DNA peak size in procedures using an HPLC system for detection of antitumour agents; the fourth is a toxicity test using larva of Artemia salina; and the last is an enzymatic inhibitory test against papain and trypsin. For all the bioassays, extracts of C. savignyi were found to be bioactive. This result suggests that this tunicate is able to produce biologically active agents required for an overall defence against their predators.

Binding to DNA and cytotoxic evaluation of ascididemin, the major alkaloid from the Mediterranean ascidian Cystodytes dellechiajei

The isolation of ascididemin from the Mediterranean ascidian Cystodytes dellechiajei is described. This alkaloid consists of a planar pentacyclic chromophore which was investigated for its DNA-binding and cytotoxic properties. Spectroscopic measurements provided evidence that the drug intercalates into DNA. DNase I footprinting assays indicated that the binding of ascididemin to GC-rich sequences is favoured over binding to AT-rich and mixed sequences. Chemical probes were used to detect ligand-induced structural changes in DNA. The alkaloid induces a hyper-reactivity of the DNA towards potassium permanganate, but not towards diethylpyrocarbonate, just as is the case with ethidium bromide; it has little effect on the catalytic activities of topoisomerases I and II. Ascididemin exhibits marked cytotoxicity towards human leukaemic cells in vitro and appears to be practically equally toxic for drug-sensitive and multidrug-resistant cell lines. The results suggest that DNA, but not topoisomerases, may represent the critical cellular target at which this marine alkaloid exhibits its potent cytotoxic properties in vitro.

Eudistomin U and isoeudistomin U, new alkaloids from the Caribbean ascidian Lissoclinum fragile

Chemical investigations of the Caribbean ascidian Lissoclinum fragile (Didemnidae) have resulted in the isolation of new alkaloids which we have designated eudistomin U [1] and isoeudistomin U [2]. Their structures were determined by spectrometric and chemical means.

Novel meroterpenoids from Cystoseira mediterranea: use of the crown-gall bioassay as a primary screen for lipophilic antineoplastic agents

Using a slight modification of the crown-gall potato disc bioassay, we were able to apply this test for two previously described antineoplastic lipophilic metabolites, didemnin B and mediterraneol A [1], and to use it as a guide for chromatographic separations of meroterpenoids from Cystoseira mediterranea. An active compound, mediterraneone [3], was isolated, and its structure was found to be a novel norsesquiterpenoid by chemical and spectral methods.

Assessment of the efficacy of a nonsteroidal anti-inflammatory drug, Naprosyn, in the treatment of gingivitis

A double-blind, placebo-controlled trial was conducted to determine the effects of the nonsteroidal anti-inflammatory drug Naprosyn (naproxen) on gingival inflammation. The enrollment of 114 patients provided 102 patients valid for efficacy evaluation, each having a mean gingival index (GI) score of 1.5 or greater at test-teeth sites. Patients were given oral Naprosyn 500 mg b.i.d. or placebo for 30 days. At 28 d, full-mouth prophylaxis was performed. Gingival index, modified sulcular bleeding index (SBI), and plaque index (PII) scores were taken at baseline, at 28 d, and at 30 d. When the 28-d index measurements were compared to baseline, the drug had no significant effect on plaque index scores or gingival inflammation. Statistically, Naprosyn enhanced the resolution of gingival inflammation following removal of microbial plaque. Thus, although this drug does not suppress the inflammation-inducing properties of plaque, Naprosyn may enhance recovery following plaque removal.

Side chain-hydroxylated sterols of the red alga Asparagopsis armata: significant products or artifacts due to autoxidation?

Sterols characterized by an allylic hydroxyl group in the side chain, such as stigmasta-5,28-diene-3 beta, 24 epsilon-diol (1), cholesta-5,23-diene-3 beta,25-diol (2) and cholesta-5,25-diene-3 beta,24 epsilon-diol (3), have been identified several times in various marine algae. Their origin was considered as doubtful: they could have been bona fide constituents of the alga, or be artifacts caused by autoxidation during the isolation process. We have shown that the dihydroxy steroids 2 and 3 can indeed be produced by the autoxidation of cholesta-5,24-dien-3 beta-ol (desmosterol) (5), but that they are nevertheless present in the taxonomic significance.

[Study fo sterols from brown seaweeds of the genus Cytoseira. Identification by gas-liquid chromatography coupled with mass spectrometry (author's transl)]

All the samples of brown seaweeds (Cystoseria) that we have studied present the same deltas sterols fucosterol, 22 trans-dehydrocholesterol, brassicasterol, 24-methylene cholesterol as well as cystosterol, a new C27 sterol. This sterol has been submitted to gas-liquid chromatographic-mass spectrometric analysis.