Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice

BACKGROUND & AIMS

It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence.

METHODS

We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs.

RESULTS

By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate).

CONCLUSIONS

In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Didactic training vs. computer-based self-learning in the prediction of diminutive colon polyp histology by trainees: a randomized controlled study

Background and study aim Experts can accurately predict diminutive polyp histology, but the ideal method to train nonexperts is not known. The aim of the study was to compare accuracy in diminutive polyp histology characterization using narrow-band imaging (NBI) between participants undergoing classroom didactic training vs. computer-based self-learning. Participants and methods Trainees at two institutions were randomized to classroom didactic training or computer-based self-learning. In didactic training, experienced endoscopists reviewed a presentation on NBI patterns for adenomatous and hyperplastic polyps and 40 NBI videos, along with interactive discussion. The self-learning group reviewed the same presentation of 40 teaching videos independently, without interactive discussion. A total of 40 testing videos of diminutive polyps under NBI were then evaluated by both groups. Performance characteristics were calculated by comparing predicted and actual histology. Fisher's exact test was used and P < 0.05 was considered significant. Results A total of 17 trainees participated (8 didactic training and 9 self-learning). A larger proportion of polyps were diagnosed with high confidence in the classroom group (66.5 % vs. 50.8 %; P < 0.01), although sensitivity (86.9 % vs. 95.0 %) and accuracy (85.7 % vs. 93.9 %) of high-confidence predictions were higher in the self-learning group. However, there was no difference in overall accuracy of histology characterization (83.4 % vs. 87.2 %; P = 0.19). Similar results were noted when comparing sensitivity and specificity between the groups. Conclusion The self-learning group showed results on a par with or, for high-confidence predictions, even slightly superior to classroom didactic training for predicting diminutive polyp histology. This approach can help in widespread training and clinical implementation of real-time polyp histology characterization.

Effectiveness of focal vs. balloon radiofrequency ablation devices in the treatment of Barrett's esophagus

BACKGROUND AND AIMS

The safety and efficacy of radiofrequency ablation (RFA) in treatment of Barrett's esophagus (BE)-associated dysplasia has been well established. The effectiveness of focal and balloon RFA devices has not been compared. Therefore, the aim of our study was to assess the effectiveness of focal and balloon RFA devices in the treatment of BE by calculating absolute and percentage change in BE length with RFA therapy by comparing pre- and post-treatment BE length.

PATIENTS AND METHODS

This is a retrospective cross-sectional study of patients who underwent at least one treatment with either focal and/or balloon RFA devices who were identified from two tertiary centers. Patients' demographics, hiatal hernia, pre- and post-treatment BE length, prior use of endoscopic therapies and number of sessions were recorded.

RESULTS

Sixty-one patients who had undergone 161 RFA treatment sessions met inclusion criteria. There was no significant difference in percentage change in BE length with greater number of RFA sessions. RFA with a focal device resulted in greater percentage reduction in BE length compared to the balloon system (73% vs. 39%, p < 0.01). After adjusting for initial BE length, pre-treatment BE length, hernia status, prior endoscopic mucosal resection (EMR), prior RFA, and prior EMR/RFA sessions, RFA with a focal device at each session remained an independent predictor for a significant reduction in BE extent as compared to the balloon system.

CONCLUSION

The focal RFA device alone was more effective in treatment of BE compared to the balloon system, with a greater reduction in extent of BE. The focal RFA device for endoscopic eradication therapy of BE should be considered the preferred technique.

Impact of a computer-based teaching module on characterization of diminutive colon polyps by using narrow-band imaging by non-experts in academic and community practice: a video-based study

BACKGROUND

Experts can accurately characterize the histology of diminutive polyps with narrow-band imaging (NBI). There are limited data on the performance of non-experts.

OBJECTIVE

To assess the impact of a computer-based teaching module on the accuracy of predicting polyp histology with NBI by non-experts (in academics and community practice) by using video clips.

DESIGN

Prospective, observational study.

SETTING

Academic and community practice.

PARTICIPANTS

A total of 15 gastroenterologists participated-5 experts in NBI, 5 non-experts in academic practice, and 5 non-experts in community practice.

INTERVENTION

Participants reviewed a 20-minute, computer-based teaching module outlining the different NBI features for hyperplastic and adenomatous polyps.

MAIN OUTCOME MEASUREMENTS

Performance characteristics in characterizing the histology of diminutive polyps with NBI by using short video clips before (pretest) and after (posttest) reviewing the teaching module.

RESULTS

Non-experts in academic practice showed a significant improvement in the sensitivity (54% vs 79%; P < .001), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 69%; P < .001) in the posttest. Non-experts in community practice had significantly higher sensitivity (58% vs 75%; P = .004), specificity (76% vs 90%; P = .04), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 72%; P < .001) in the posttest. Performance of experts in NBI was significantly better than non-experts in both academic and community practice.

LIMITATIONS

Selection bias in selecting good quality videos. Performance not assessed during live colonoscopy.

CONCLUSION

Academic and community gastroenterologists without prior experience in NBI can achieve significant improvements in characterizing diminutive polyp histology after a brief computer-based training. The durability of these results and applicability in everyday practice are uncertain.

Inhibition of mesothelin as a novel strategy for targeting cancer cells

Mesothelin, a differentiation antigen present in a series of malignancies such as mesothelioma, ovarian, lung and pancreatic cancer, has been studied as a marker for diagnosis and a target for immunotherapy. We, however, were interested in evaluating the effects of direct targeting of Mesothelin on the viability of cancer cells as the first step towards developing a novel therapeutic strategy. We report here that gene specific silencing for Mesothelin by distinct methods (siRNA and microRNA) decreased viability of cancer cells from different origins such as mesothelioma (H2373), ovarian cancer (Skov3 and Ovcar-5) and pancreatic cancer (Miapaca2 and Panc-1). Additionally, the invasiveness of cancer cells was also significantly decreased upon such treatment. We then investigated pro-oncogenic signaling characteristics of cells upon mesothelin-silencing which revealed a significant decrease in phospho-ERK1 and PI3K/AKT activity. The molecular mechanism of reduced invasiveness was connected to the reduced expression of β-Catenin, an important marker of EMT (epithelial-mesenchymal transition). Ero1, a protein involved in clearing unfolded proteins and a member of the ER-Stress (endoplasmic reticulum-stress) pathway was also markedly reduced. Furthermore, Mesothelin silencing caused a significant increase in fraction of cancer cells in S-phase. In next step, treatment of ovarian cancer cells (OVca429) with a lentivirus expressing anti-mesothelin microRNA resulted in significant loss of viability, invasiveness, and morphological alterations. Therefore, we propose the inhibition of Mesothelin as a potential novel strategy for targeting human malignancies.

A comparative study of endoscopic ultrasound guided fine needle aspiration with and without a stylet

BACKGROUND

Despite lack of evidence, use of a stylet during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is assumed to improve the quality and diagnostic yield of specimens.

AIM

The purpose of this study was to compare EUS-FNA specimens obtained with stylet (S+) and without stylet (S-) for: (i) cellularity, contamination, adequacy, and amount of blood and (ii) diagnostic yield of malignancy.

METHODS

Patients who underwent EUS-FNA of solid lesions by two experienced endosonographers at a tertiary referral center using a 22-gauge FNA needle with suction were included. Stylet was used for all EUS-FNA procedures performed between January 2006 and September 2007 and no stylet was used between October 2007 and April 2009 allowing comparison between the two techniques. Cytology slides were retrieved, de-identified and evaluated by two experienced cytopathologists blinded to FNA technique. Slides were evaluated for cellularity, degree of contamination, adequacy, amount of blood and cytologic diagnosis. Fisher's exact and unpaired t-test were used for comparative analysis.

RESULTS

A total of 162 patients with 228 lesions were included. FNA of 106 and 122 lesions each was performed in the S+ and S- groups, respectively. FNA sites included pancreas [41 (18%)], lymph node [125 (55%)], liver [20 (9%)], adrenal [21 (9%)] and others [21 (9%)]. No significant differences in the cellularity (P=0.37), contamination (P=0.18), significant blood (P=0.42) and adequacy of specimen (P=0.45) were found between S+ and S- specimens. There was no statistically significant difference in the diagnostic yield of malignant lesions (P=0.48).

CONCLUSIONS

The use of stylet during FNA does not appear to confer any advantage with regards to the adequacy of specimen or diagnostic yield of malignancy.