Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.

RESULTS

From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11).

CONCLUSIONS

The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

Extended delay in endoscopic mucosal resection is not associated with adverse outcomes: Findings from the COVID-19 pandemic

Background and study aims The aim of this study was to investigate the impact of delayed endoscopic mucosal resection (EMR) of colorectal polyps on health outcomes.

Patients and methods A bidirectional cohort study was completed. A baseline group consisting of all EMRs performed within a 15-month period before a province-wide, government-mandated cessation of EMR procedures due to the global pandemic was compared to EMRs impacted by the shutdown, defined as the COVID-19-delayed group. The primary outcome was the incidence of malignant polyps. Secondary outcomes included technical success, polyp recurrence at follow-up colonoscopy, advanced polyp histology, probability of meeting endoscopic criteria for adequate resection for malignant polyps, metastatic colorectal cancer, and complications.

Results A total of 268 EMR procedures were included in the study cohort, of which 208 formed the baseline group and 60 were in the COVID-19-delayed group. The median (IQR) patient age was 72 (13.0) and 113 (41.2 %) were females. The median (IQR) wait time was 92 days (87.8) in the baseline group and 191 days (127.8) in the COVID-19-delayed group (P < 0.001). Overall, there were no significant differences in the incidence of malignant polyps, technical success, polyp recurrence on follow-up colonoscopy, advanced polyp histology, adequate endoscopic resection for malignant polyps, metastatic colorectal cancer, or complications between the two groups (P > 0.05 for all outcomes).

Conclusions A longer wait time for EMR of colorectal polyps, increasing from a median of 92 to 191 days, was not associated with worse outcomes.

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics

IMPORTANCE

Trainees routinely participate in colonoscopy procedures, yet whether their involvement is positively or negatively associated with procedural quality is unknown because prior studies involved small number of trainees and/or supervisors, lacked generalizability, and/or failed to adjust for potential confounders.

OBJECTIVE

To assess the association between trainee participation and colonoscopy quality metrics.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter population-based cohort study was conducted at 21 academic and community hospitals between April 1, 2017, and October 31, 2018, among consecutive adult patients undergoing colonoscopy. Procedures performed by endoscopists who did not supervise trainees were excluded. Statistical analysis was performed from April 3, 2017, to October 31, 2018.

EXPOSURE

Participation by a trainee, defined as a resident or fellow enrolled in a gastroenterology or general surgery training program.

MAIN OUTCOMES AND MEASURES

The primary outcome was the adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate.

RESULTS

A total of 35 499 colonoscopies (18 989 women [53.5%]; mean [SD] patient age, 60.0 [14.1] years) were performed by 71 physicians (mean [SD] time in practice, 14.0 [9.3] years); 5941 colonoscopies (16.7%) involved trainees. There were no significant differences in the ADR (26.4% vs 27.3%; P = .19), CIR (96.7% vs 97.2%; P = .07), and perforation rate (0.05% vs 0.06%; P = .82) when trainees participated vs when they did not participate, whereas the the ssPDR (4.4% vs 5.2%; P = .009) and PDR (39.2% vs 42.0%; P < .001) were significantly lower when trainees participated vs when they did not. After adjustment for potential confounders, the ADR (risk ratio [RR], 0.97; 95% CI, 0.91-1.03; P = .30), PDR (RR, 0.98; 95% CI, 0.93-1.04; P = .47), and CIR (RR, 0.93; 95% CI, 0.78-1.10; P = .38) were not associated with trainee participation, although the ssPDR remained significantly lower (RR, 0.79; 95% CI, 0.64-0.98; P = .03).

CONCLUSIONS AND RELEVANCE

This study suggests that trainee involvement during colonoscopy was associated with reduced ssPDR but not other colonoscopy outcome measures. Extra care should be exercised when examining the right colon when trainees are involved.

VIBe Scale: Validation of the Intraoperative Bleeding Severity Scale by Spine Surgeons

BACKGROUND

The Validated Intraoperative Bleeding Scale (VIBe Scale) was initially validated with surgeons who operate on cardiothoracic, abdominal, and pelvic cavities and fulfilled criteria for a clinician-reported scale. However, there is a need for a tool to aid in intraoperative blood management during spine surgeries. The purpose of the present study was to establish the reliability and consistency of the VIBe Scale as a tool for spine surgeons to assess intraoperative bleeding.

METHODS

Orthopedic (n = 16) and neurological (n = 9) spine surgeons scored videos depicting surgical bleeding and assessed the VIBe Scale's relevance and clarity. Inter- and intraobserver agreement (Kendall's W) were calculated for all surgeons and pooled with responses from the original study to establish agreement across specialties.

RESULTS

All of the spine surgeons indicated that the scale was clinically relevant for evaluating hemostasis and could be implemented in a clinical study. Twenty-two spine surgeons (88%) reported that the scale represents the range of bleeding site sizes and severities expected in their practice. Twenty-four spine surgeons (96%) indicated that the scale would be useful in communicating bleeding severity with other members of the surgical team. Interobserver agreement was acceptable (0.79) for orthopedic specialists, appreciable (0.88) for neurological specialists, and appreciable (0.88) for the combined specialists. Intraobserver agreement was excellent for orthopedic (0.91) and neurological (0.91) spine surgeons and excellent (0.96) for the combined specialists.

CONCLUSIONS

The results highlight the reliability of the VIBe Scale and potential utility for quantifying intraoperative blood loss in spine surgery.

LEVEL OF EVIDENCE: 3

CLINICAL RELEVANCE

The VIBe Scale may be useful for evaluating the efficacy of untested intraoperative hemostatic agents and for comparing the relative efficacy of 2 or more analogous agents. It may also prove useful for intraoperative staff by quantifying ongoing intraoperative blood loss and correlating losses with the potential transfusion and intraoperative hemostatic agent requirements.

Nocardia infections in hematopoietic cell transplant recipients: a multicenter international retrospective study of the Infectious Diseases Working Party (IDWP) of the European Society for Blood and Marrow Transplantation (EBMT)

BACKGROUND

Nocardiosis is rare after hematopoietic cell transplantation (HCT). Little is known regarding its presentation, management, and outcome in this population.

METHODS

In this retrospective international study, we reviewed nocardiosis episodes in HCT recipients (01.01.2000-31.12.2018; 135 transplant centers; 33 countries) and described their clinical, microbiological, radiological, and outcome characteristics.

RESULTS

We identified 81 nocardiosis episodes in 74 allo- and 7 auto-HCT recipients. Nocardiosis occurred at a median of 8 (IQR 4-18) months post-HCT. The most frequently involved organs were lungs (70/81; 86%) and brain (30/81; 37%); 29 (36%) patients were afebrile; 46/81 (57%) had disseminated infections. The most common lung imaging findings were consolidations (33/68; 49%) or nodules (32/68; 47%); and brain imaging findings were multiple brain abscesses (19/30; 63%). 10/30 (33%) patients with brain involvement lacked neurological symptoms. 14/48 (29%) patients were bacteremic. N. farcinica was the most common among molecularly identified species (27%, 12/44). Highest susceptibility rates were reported to linezolid 45/45 (100%), amikacin 56/57 (98%), trimethoprim-sulfamethoxazole 57/63 (90%), and imipenem 49/57 (86%).One-year and last follow-up (IQR: 4-42.5 months) all-cause mortality were 40% (32/81) and 52% (42/81), respectively. In the multivariable analysis, underlying disease not in complete remission (HR 2.81, 95%CI 1.32-5.95), and prior bacterial infection (HR 3.42, 95%CI 1.62-7.22) were associated with higher one-year all-cause mortality.

CONCLUSIONS

Nocardiosis is a late post-HCT infection usually manifesting as a pulmonary disease with frequent dissemination, brain infection and bacteremia. Brain imaging should be performed in HCT recipients with nocardiosis regardless of neurological symptoms. Overall mortality is high.

[EVIVO program adapted for the labor sector : a help for managing chronic condition and professional life]

EVIVO is a well-established chronic disease self-management program, having been successfully implemented during the last decade in Switzerland. The program has shown positive results in facilitation of self-management competences for patients living with chronic diseases and their relatives. EVIVO was designed to run for 6 weeks with weekly sessions of 2 and a half hour each. We tested the effectiveness of a shortened version of EVIVO, running it over five half days in order to make it more focused for patients who are challenged by managing their chronic illness within the context of their professional life. Participants in the five-session version showed comparable self-efficacy levels compared with those who had attended the standard six-week six-session courses. Overall, the five-session version was well accepted, considered very useful, met the participants' needs and changed their perception of their own expectations towards self-management of their illness.

Successful treatment of Rhizopus arrhizus rhino-orbital-cerebral mucormycosis with isavuconazole salvage therapy following extensive debridement

A 61-year old lady with poorly-controlled type 2 diabetes mellitus was diagnosed with rhino-orbital-cerebral mucormycosis following presentation with sinusitis, ophthalmoplegia, proptosis and facial numbness. She was treated successfully with aggressive surgical intervention including orbital exenteration, accompanied by anti-fungal therapy with liposomal amphotericin B and posaconazole, followed by isavuconazole as salvage therapy. We discuss the challenges around optimising antifungal therapy of this lethal infection in the context of hepatic and renal toxicity.

A113 ANNUAL COLONOSCOPY VOLUME IS NOT PREDICTIVE OF COLONOSCOPY QUALITY - FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

Performing a minimum number of colonoscopies annually has been proposed by some jurisdictions as a requirement for maintaining privileges. However, this practice is supported by limited evidence.

Aims

The objective of this study was to determine if annual colonoscopy volume was associated with colonoscopy quality metrics.

Methods

A population-based study was performed using the Southwest Ontario Colonoscopy cohort, which consists of all adult patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 academic and community hospitals within the health region. Data were collected through a mandatory quality assurance form completed after each procedure and pathology reports were manually reviewed. Physician annualized colonoscopy volumes were compared by correlation analysis to each quality-related outcome, by means of the area under the receiver operating characteristics curve (AUROC), and logistic regression. The prognostic value of colonoscopy volume was also adjusted for case-mix and potential confounders in separate regression analyses for each outcome. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and cecal intubation.

Results

A total of 47,195 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others). There were no clear relationships between annual colonoscopy volumes and study outcomes. Colonoscopy volume was not associated with ADR (OR 1.03, 95% CI 0.96–1.10, p=0.48) and corresponded to an AUROC not significantly different from the null (AUROC 0.52, 95% CI 0.43–0.61, p=0.65). Multi-variable regression adjusting for case-mix also demonstrated no predictive value of annual colonoscopy volume for the primary outcome (OR 1.03, 95% CI 0.94–1.12, p=0.55). Similarly, analyses of secondary outcomes failed to find an association between colonoscopy volume and PDR, SSPDR, or cecal intubation (Table 1).

Conclusions

Annual colonoscopy volumes do not predict ADR, PDR, SSPDR, or cecal intubation rate.

Results of unconditional and conditional approaches for examining the predictive value of annual colonoscopy volume for quality related outcomes.

Funding Agencies

None

A117 PROPOFOL SEDATION DOES NOT IMPROVE MEASURES OF COLONOSCOPY QUALITY – FINDINGS FROM THE SOUTHWEST ONTARIO COLONOSCOPY COHORT

Background

The use of propofol during colonoscopy has gained increased popularity due to deeper anesthesia compared to conscious sedation. Prior studies examining the use of propofol sedation during colonoscopy have primarily focused on anesthesia outcomes. Whether propofol sedation is associated with improvements in colonoscopy outcomes is uncertain.

Aims

The primary outcome was adenoma detection rate (ADR). Secondary outcomes were the detection of any adenoma (conventional adenoma, sessile serrated polyp, and traditional serrated adenoma), sessile serrated polyp detection rate, polyp detection rate, cecal intubation rate, and perforation rate.

Methods

The Southwest Ontario Colonoscopy cohort consists of all patients who underwent colonoscopy between April 2017 and Oct 2018 at 21 hospitals serving a large geographic area in Southwest Ontario. Procedures performed in patients less than 18 years of age or by endoscopist who perform &lt;50 colonoscopies/year were excluded. Data were collected through a mandatory quality assurance form that was completed by the endoscopist after each procedure. Pathology reports were manually reviewed.

Results

A total of 46,634 colonoscopies were performed by 75 physicians (37.5% by gastroenterologists, 60% by general surgeons, 2.5% others) of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation (e.g. combination of a benzodiazepine and a narcotic). Patients who received propofol were likely to have a screening indication (49.2% vs 45.5%, p&lt;0.0001), not have a trainee endoscopist present and be performed at a non-academic centre (32.2% vs 44.6%, p&lt;0.0001). Compared to conscious sedation, use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p&lt;0.0001) and detection of any adenoma (27.7% vs. 29.8%, p&lt;0.0001); no difference was observed in the detection ofsessile serrated polyps (5.0% vs. 4.7%, p=0.26), polyp detection rate (41.2% vs 41.2%, p=0.978), cecal intubation rate (97.1% vs. 96.8%, p=0.15) or perforation rate (0.04% vs. 0.06%,p=0.45). On multi-variable analysis, the use of propofol was not significantly associated with any improvement in ADR (RR=0.90, 95% CI 0.74–1.10, p=0.30), detection of any adenoma (RR=0.93, 95% CI 0.75–1.14, p=0.47), sessile serrated polyp detection rate (RR=1.20, 95%CI 0.90–1.60, p=0.22), polyp detection rate (RR=1.00, 95% CI 0.90–1.11, p=0.99), or cecal intubation rate (RR=1.00, 95%CI 0.80–1.26, p=0.99).

Conclusions

The use of propofol sedation does not improve colonoscopy quality metrics.

Funding Agencies

None

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

BACKGROUND

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI).

AIM

To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort.

METHODS

Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases.

FINDINGS

Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population.

CONCLUSION

Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

Unexpected Mycoplasma hominis infection in two renal transplant recipients traced back to the same donor by whole-genome sequencing

Mycoplasma hominis is a common colonizer of the lower genitourinary tract. Although its clinical relevance for causing urogenital infections in immunocompetent individuals is controversial, this bacterium has been involved in severe invasive infections in allograft recipients. In this report, we describe two cases of M. hominis infection in two young renal transplant recipients within the first month post-transplant. Although at first no epidemiological link between the two cases had been suspected, whole-genome sequencing (WGS) analysis showed that both isolates were identical, highly suggestive of an origin with the common organ donor.

Investigating the Effect of Vibrotactile Feedback in Transfemoral Amputee With and Without Movable Ankle Joint

The loss of somatosensory feedback after transfemoral amputation imposes a serious challenge in achieving postural stability. In the recent past, weight shifting exercises with fixed ankle joint have been reported useful in boosting the limit of stability (LOS) only in the sound limb; the LOS on the prosthetic limb did not improve. A fixed ankle joint restricts movement in the anterior-posterior direction at the ankle level. Thus, it may suppress the ability to move forward LOS despite awareness of center of pressure (COP) due to vibrotactile feedback. Therefore, it could have limited the improvement in the LOS of a prosthetic limb in previous studies. This article investigates this hypothesis by evaluating the effect of vibrotactile feedback in the LOS of transfemoral amputees with fixed as well as movable ankle joints. This evaluation is done during weight shifting exercises. Firstly, we developed an in-house COP guided vibrotactile sensory feedback system. Next, we recruited five transfemoral amputees to perform a weight-shifting exercise with a) fixed ankle joint (single-axis cushion heel (SACH) foot) and b) movable ankle joint (single-axis foot). Finally, we analyzed the recorded center of pressure trajectory signals for the limit of stability. The findings of repeated measures ANOVA showed a marginally significant interaction ( [Formula: see text], [Formula: see text], [Formula: see text]) between ankle joint and feedback conditions during backward shifting in weight shifting exercise. Further analysis showed that during the backward shifting fixed ankle joint did not improve in the presence of vibrotactile feedback, while a marginally significant ( [Formula: see text]) improved LOS was observed in the movable ankle joint with feedback. The findings conclude that the vibrotactile feedback is more effective in transfemoral amputees with movable ankle joint compared with fixed ankle joint.

Emerging echinocandin-resistant Candida albicans and glabrata in Switzerland

Echinocandins represent the first-line therapy of candidemia. Echinocandin resistance among Candida spp. is mainly due to acquired FKS mutations. In this study, we report the emergence of FKS-mutant Candida albicans/glabrata in Switzerland and provide the microbiological and clinical characteristics of 9 candidemic episodes. All patients were previously exposed to echinocandins (median 26 days; range 15–77). Five patients received initial echinocandin therapy with persistent candidemia in 4 of them. Overall mortality was 33%.

Cone-beam CT for imaging of the head/brain: Development and assessment of scanner prototype and reconstruction algorithms

PURPOSE

Our aim was to develop a high-quality, mobile cone-beam computed tomography (CBCT) scanner for point-of-care detection and monitoring of low-contrast, soft-tissue abnormalities in the head/brain, such as acute intracranial hemorrhage (ICH). This work presents an integrated framework of hardware and algorithmic advances for improving soft-tissue contrast resolution and evaluation of its technical performance with human subjects.

METHODS

Four configurations of a CBCT scanner prototype were designed and implemented to investigate key aspects of hardware (including system geometry, antiscatter grid, bowtie filter) and technique protocols. An integrated software pipeline (c.f., a serial cascade of algorithms) was developed for artifact correction (image lag, glare, beam hardening and x-ray scatter), motion compensation, and three-dimensional image (3D) reconstruction [penalized weighted least squares (PWLS), with a hardware-specific statistical noise model]. The PWLS method was extended in this work to accommodate multiple, independently moving regions with different resolution (to address both motion compensation and image truncation). Imaging performance was evaluated quantitatively and qualitatively with 41 human subjects in the neurosciences critical care unit (NCCU) at our institution.

RESULTS

The progression of four scanner configurations exhibited systematic improvement in the quality of raw data by variations in system geometry (source-detector distance), antiscatter grid, and bowtie filter. Quantitative assessment of CBCT images in 41 subjects demonstrated: ~70% reduction in image nonuniformity with artifact correction methods (lag, glare, beam hardening, and scatter); ~40% reduction in motion-induced streak artifacts via the multi-motion compensation method; and ~15% improvement in soft-tissue contrast-to-noise ratio (CNR) for PWLS compared to filtered backprojection (FBP) at matched resolution. Each of these components was important to improve contrast resolution for point-of-care cranial imaging.

CONCLUSIONS

This work presents the first application of a high-quality, point-of-care CBCT system for imaging of the head/ brain in a neurological critical care setting. Hardware configuration iterations and an integrated software pipeline for artifacts correction and PWLS reconstruction mitigated artifacts and noise to achieve image quality that could be valuable for point-of-care detection and monitoring of a variety of intracranial abnormalities, including ICH and hydrocephalus.

A109 CELIAC DISEASE IS A RARE CAUSE OF BENIGN DUODENAL STRICTURE

Background

Benign duodenal stricture is an uncommon problem encountered by gastroenterologists. The most common cause is peptic ulcer disease (PUD). With the diagnosis and eradication of H. Pylori, early diagnosis of PUD and the use of PPIs to treat upper gastrointestinal inflammation, the incidence of benign duodenal stricture has dramatically decreased. Patients with duodenal stricture may present with early satiety, nausea, vomiting and weight loss. We present the case of a man with a refractory web-like stricture in the second part of the duodenum (D2) caused by Celiac disease.

Aims

To describe a rare endoscopic finding in a patient with Celiac disease

Methods

Case report with literature review

Results

We present a case of a 64 year old male was referred for consideration of duodenal stenting of a refractory stricture in the second part of the duodenum D2. The patient had a 1 year history of abdominal pain, early satiety and weight loss (10 lbs). He also reported intermittent episodes of diarrhea. Investigations included a CT scan of the abdomen which showed a stricture at the level of proximal D2 described as a “duodenal band”. Previous attempts at balloon dilation had not resulted in prolonged symptomatic or endoscopic improvement. Testing for H. Pylori was negative and he did not use NSAIDs.

Upper endoscopy was performed to assess the stricture prior to consideration of stenting. This showed a tight web-like stricture in proximal D2. The stricture was balloon dilated up to 16.5 mm, enabling the endoscope to pass beyond it. The mucosa in D2 was atrophic with flattening of the folds and scalloping. There was no inflammation seen. Biopsies from D2 revealed moderate villous blunting and intraepithelial lymphocytosis. Celiac serology testing was abnormal, with an anti-tTG Ab level of 32 RU/ml which confirmed the diagnosis of Celiac disease. The balloon dilation and gluten-free diet resulted in resolution of his symptoms. Follow up endoscopy revealed normalization of his duodenal folds and biopsies. In addition, anti-tTG Ab level was normalized. Although stricture improved with prolonged patency, he still has mild recurrence of his stricture requiring balloon dilation on an annual basis.

Conclusions

This case describes a very uncommon complication of Celiac disease. The likely pathophysiology involves inflammation and potentially ulceration from Celiac disease, resulting in a benign stricture. There have been a few case reports describing duodenal strictures as a complication of Celiac disease. Treatment involves a gluten-free diet and endoscopic therapy. More severe cases of obstruction would likely require surgical intervention. In our case, the gluten-free diet and balloon dilation were successful and duodenal stenting was not necessary. Given the possibility of Celiac disease as a cause of duodenal stricture, it would be reasonable to biopsy D2 and check anti-tTG Ab in cases of duodenal stricture.

Funding Agencies

None

Floseal only versus in combination in spine surgery: a comparative, retrospective hospital database evaluation of clinical and healthcare resource outcomes

OBJECTIVE

Flowable agents such as Floseal® (F) are often reserved as adjuncts to non-flowable agents (i.e. gelatin (G) sponges and thrombin (T)) when bleeding is not sufficiently controlled. Based on their perceived positive impact, it is postulated that flowable agents alone may result in better clinical and resource utilization outcomes. Clinical and health-care utilization outcomes were compared in this retrospective analysis of spine surgery cases with charges for Floseal only (FO) and F + G/T.

METHODS

The United States Premier Hospital Database was searched for adult spine surgeries performed between October 2010 and September 2015 with FO or F and G/T charges. To obtain an unbiased treatment estimate, 1:1 propensity-score matching was used to identify FO and F + G/T cohorts. The cohorts were compared for rates of intraoperative, perioperative, postoperative and transfusion; blood loss-related, serious and other complications; hospital length-of-stay (LOS), surgical time, and volume of hemostat charged.

RESULTS

Among 40,335 spine surgeries, 15,105 FO and F + G/T matched pairs were compared. Significantly (p < 0.0001) lower percentages of FO than F + G/T cases received intraoperative (1.4% vs. 2.5%), perioperative (1.6% vs. 2.8%), postoperative (1.6% vs 3.0%), and any transfusion (2.3% vs. 4.3%). FO cases had significantly less blood loss complications than F + G/T cases (0.5% vs. 0.8%, p = 0.0022) and significantly (p < 0.0001) shorter hospital LOS (-0.45 days), surgical time (-39.0 min), and used less hemostat (-12.5 mL).

CONCLUSIONS

Results from this observational hospital database analyses indicate that FO use in spine surgery is associated with lower blood transfusion use and blood loss complications compared to its use with adjunct non-flowable hemostatic agents. The shorter hospital stay, reduced surgical time, and less hemostat volume health-care utilization outcomes that favored FO versus combination use may translate to health system cost savings. Further validation of these findings using controlled clinical trials and cost-consequence studies is warranted.

CLINICAL RELEVANCE

The use of flowable hemostatic agents alone may result in better clinical and possibly economic outcomes in spine surgery.

Barriers and enablers to meticillin-resistant Staphylococcus aureus admission screening in hospitals: a mixed-methods study

BACKGROUND

To reduce the risk of transmission of meticillin-resistant Staphylococcus aureus (MRSA), international guidelines recommend admission screening to identify hospital patients at risk of colonization. However, routine monitoring indicates that optimum screening compliance levels are not always achieved. In order to enhance compliance, we must better understand those factors which influence staff screening behaviours.

AIM

To identify factors which influence staff compliance with hospital MRSA screening policies.

METHODS

A sequential two-stage mixed-methods design applied constructs from normalization process theory and the theoretical domains framework to guide data collection and analysis. Initial qualitative findings informed subsequent development of a national cross-sectional survey of nursing staff (N = 450). Multiple regression modelling identified which barriers and enablers best predict staff compliance.

FINDINGS

Three factors were significant in predicting optimum (>90%) compliance with MRSA screening: having MRSA screening routinized within the admission process; category of clinical area; feedback of MRSA screening compliance within the clinical area. Integration of data-sets indicated that organizational systems which 'make doing the right thing easy' influence compliance, as does local ward culture. Embedded values and beliefs regarding the relative (de)prioritization of MRSA screening are important.

CONCLUSION

To our knowledge, this is the first study to provide original evidence of barriers and enablers to MRSA screening, applying both sociological and psychological theory. As antimicrobial resistance is a global health concern, these findings have international relevance for screening programmes. Future policy recommendations or behaviour change interventions, based on the insights presented here, could have significant impact upon improving screening compliance.

A Multicenter Radiographic Evaluation of the Rates of Preoperative and Postoperative Malalignment in Degenerative Spinal Fusions

STUDY DESIGN

Multicenter, retrospective, institutional-review-board -approved study at 18 institutions in the United States with 24 treating investigators.

OBJECTIVE

This study was designed to retrospectively assess the prevalence of spinopelvic malalignment in patients who underwent one- or two-level lumbar fusions for degenerative (nondeformity) indications and to assess the incidence of malalignment after fusion surgery as well as the rate of alignment preservation and/or correction in this population.

SUMMARY OF BACKGROUND DATA

Spinopelvic malalignment after lumbar fusion has been associated with lower postoperative health-related quality of life and elevated risk of adjacent segment failure. The prevalence of spinopelvic malalignment in short-segment degenerative lumbar fusion procedures from a large sample of patients is heretofore unreported and may lead to an under-appreciation of these factors in surgical planning and ultimate preservation or correction of alignment.

METHODS

Lateral preoperative and postoperative lumbar radiographs were retrospectively acquired from 578 one- or two-level lumbar fusion patients and newly measured for lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt. Patients were categorized at preop and postop time points as aligned if PI-LL < 10° or malaligned if PI-LL≥10°. Patients were grouped into categories based on their alignment progression from pre- to postoperative, with preserved (aligned to aligned), restored (malaligned to aligned), not corrected (malaligned to malaligned), and worsened (aligned to malaligned) designations.

RESULTS

Preoperatively, 173 (30%) patients exhibited malalignment. Postoperatively, 161 (28%) of patients were malaligned. Alignment was preserved in 63%, restored in 9%, not corrected in 21%, and worsened in 7% of patients.

CONCLUSION

This is the first multicenter study to evaluate the preoperative prevalence and postoperative incidence of spinopelvic malalignment in a large series of short-segment degenerative lumbar fusions, finding over 25% of patients out of alignment at both time points, suggesting that alignment preservation/restoration considerations should be incorporated into the decision-making of even degenerative lumbar spinal fusions.

LEVEL OF EVIDENCE

3.

Accuracy of Sensititre YeastOne echinocandins epidemiological cut-off values for identification of FKS mutant Candida albicans and Candida glabrata: a ten year national survey of the Fungal Infection Network of Switzerland (FUNGINOS)

OBJECTIVES

Echinocandins represent the first-line treatment of candidaemia. Acquired echinocandin resistance is mainly observed among Candida albicans and Candida glabrata and is associated with FKS hotspot mutations. The commercial Sensititre YeastOne™ (SYO) kit is widely used for antifungal susceptibility testing, but interpretive clinical breakpoints are not well defined. We determined echinocandins epidemiological cut-off values (ECV) for C. albicans/glabrata tested by SYO and assessed their ability to identify FKS mutants in a national survey of candidaemia.

METHODS

Bloodstream isolates of C. albicans and C. glabrata were collected in 25 Swiss hospitals from 2004 to 2013 and tested by SYO. FKS hotspot sequencing was performed for isolates with an MIC≥ECV for any echinocandin.

RESULTS

In all, 1277 C. albicans and 347 C. glabrata were included. ECV 97.5% of caspofungin, anidulafungin and micafungin were 0.12, 0.06 and 0.03 μg/mL for C. albicans, and 0.25, 0.12 and 0.03 μg/mL for C. glabrata, respectively. FKS hotspot sequencing was performed for 70 isolates. No mutation was found in the 52 'limit wild-type' isolates (MIC=ECV for at least one echinocandin). Among the 18 'non-wild-type' isolates (MIC>ECV for at least one echinocandin), FKS mutations were recovered in the only two isolates with MIC>ECV for all three echinocandins, but not in those exhibiting a 'non-wild-type' phenotype for only one or two echinocandins.

CONCLUSION

This 10-year nationwide survey showed that the rate of echinocandin resistance among C. albicans and C. glabrata remains low in Switzerland despite increased echinocandin use. SYO-ECV could discriminate FKS mutants from wild-type isolates tested by SYO in this population.

Epidemiology, risk factors and outcomes of invasive aspergillosis in solid organ transplant recipients in the Swiss Transplant Cohort Study

BACKGROUND

There is lack of recent multicenter epidemiological data on invasive aspergillosis (IA) among solid organ transplant recipient (SOTr) in the mold-acting antifungal era. We describe the epidemiology and outcomes of IA in a contemporary cohort of SOTr using the Swiss Transplant Cohort Study.

METHODS

All consecutive SOTr with proven or probable IA between 01.05.2008 and 31.12.2014 were included. A case-control study to identify IA predictors was performed: 1-case was matched with 3-controls based on SOT type, transplant center, and time post-SOT.

RESULTS

Among 2868 SOTr, 70 (2.4%) patients were diagnosed with proven (N: 30/70, 42.9%) or probable (N: 40/70, 57.1%) IA. The incidence of IA was 8.3%, 7.1%, 2.6%, 1.3%, and 1.2% in lung, heart, combined, kidney, and liver transplant recipients, respectively, Galactomannan immunoassay was positive in 1/3 of patients tested. Only 33/63 (52.4%) of patients presented with typical pulmonary radiographic findings. Predictors of IA included: renal insufficiency, re-operation, and bacterial and viral infections. 12-week mortality was higher in liver (85.7%, 6/7) compared to other (15.9%, 10/63; P < .001) SOTr.

CONCLUSIONS

Invasive aspergillosis remains a rare complication post-SOT, with atypical radiographic presentations and low positivity rates of biomarkers posing significant diagnostic challenges. Although overall mortality has decreased in SOTr, it remains high in liver SOTr.

A prospective comparison of live and video-based assessments of colonoscopy performance

BACKGROUND AND AIMS

Colonoscopy performance is typically assessed by a supervisor in the clinical setting. There are limitations of this approach, however, because it allows for rater bias and increases supervisor workload demand during the procedure. Video-based assessment of recorded procedures has been proposed as a complementary means by which to assess colonoscopy performance. This study sought to investigate the reliability, validity, and feasibility of video-based assessments of competence in performing colonoscopy compared with live assessment.

METHODS

Novice (<50 previous colonoscopies), intermediate (50-500), and experienced (>1000) endoscopists from 5 hospitals participated. Two views of each colonoscopy were videotaped: an endoscopic (intraluminal) view and a recording of the endoscopist's hand movements. Recorded procedures were independently assessed by 2 blinded experts using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT), a validated procedure-specific assessment tool comprising a global rating scale (GRS) and checklist (CL). Live ratings were conducted by a non-blinded expert endoscopist. Outcomes included agreement between live and blinded video-based ratings of clinical colonoscopies, intra-rater reliability, inter-rater reliability and discriminative validity of video-based assessments, and perceived ease of assessment.

RESULTS

Forty endoscopists participated (20 novices, 10 intermediates, and 10 experienced). There was good agreement between the live and video-based ratings (total, intra-class correlation [ICC] = 0.847; GRS, ICC = 0.868; CL, ICC = 0.749). Intra-rater reliability was excellent (total, ICC = 0.99; GRS, ICC = 0.99; CL, ICC = 0.98). Inter-rater reliability between the 2 blinded video-based raters was high (total, ICC = 0.91; GRS, ICC = 0.918; CL, ICC = 0.862). GiECAT total, GRS, and CL scores differed significantly among novice, intermediate, and experienced endoscopists (P < .001). Video-based assessments were perceived as "fairly easy," although live assessments were rated as significantly easier (P < .001).

CONCLUSIONS

Video-based assessments of colonoscopy procedures using the GiECAT have strong evidence of reliability and validity. In addition, assessments using videos were feasible, although live assessments were easier.

HLA-DQA1-HLA-DRB1 polymorphism is a major predictor of azathioprine-induced pancreatitis in patients with inflammatory bowel disease

BACKGROUND

Azathioprine (AZA)-induced pancreatitis is an unpredictable and dose-independent adverse event affecting 2%-7% of patients with inflammatory bowel disease (IBD) patients treated with AZA. There are no tools in clinical practice to identify at-risk individuals; however, a genome wide association study (GWAS) identified a strong association between the Class II HLA gene region polymorphism (rs2647087) and thiopurine-induced pancreatitis.

AIM

To independently confirm the findings of the GWAS in an IBD cohort, to evaluate its utility in clinical practice and to offer a novel AZA treatment algorithm for IBD based on pharmacogenomic principles.

METHODS

A retrospective cohort study evaluated 373 AZA-exposed IBD patients from a tertiary care academic centre in London, Canada. Due to the limited number of patients taking mercaptopurine (MP), such patients were not included this cohort. All subjects underwent screening for the single nucleotide polymorphism (SNP) rs2647087 mapped to the HLA-DQA1*02:01-HLA-DRB1*07:01 haplotype and were sub-divided based on the presence (n = 13) or absence (n = 360) of an AZA-induced pancreatitis diagnosis. The risk of AZA-induced pancreatitis was assessed based on rs2647087 genotype.

RESULTS

The risk of pancreatitis during AZA-therapy was highly predictable and genotype dependent: 0.53% for wild type (A/A), 4.25% (OR = 4.19, 95% CI 1.02-36.45, P = 0.044) for heterozygous (A/C), and 14.63% (OR = 15.83, 95% CI 3.80-145.26, P = 0.0001) for homozygous variant (C/C) patients.

CONCLUSIONS

The class II HLA region (at rs2647087) is an important marker of AZA-induced pancreatitis risk. We propose a simple and clinically implementable algorithm based on rs2647087 and TPMT genotypes for AZA selection and dosing for patients with IBD.

Impact of experience on self-assessment accuracy of clinical colonoscopy competence

BACKGROUND AND AIMS

Self-assessment is important for life-long learning and a recommended assessment method for endoscopy skills. Prior literature has not investigated self-assessment accuracy of colonoscopic competence in the clinical setting. This study aimed to determine the self-assessment accuracy of novice, intermediate, and experienced endoscopists.

METHODS

Novice (performed <50 previous colonoscopies), intermediate (50-500), and experienced (>1000) endoscopists from 5 hospitals each performed a clinical colonoscopy. Video recordings of procedures were independently assessed by 2 blinded expert endoscopists by using the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT). Externally assessed and self-assessed GiECAT scores were defined as the mean of the 2 video-based ratings and as participants' own assigned ratings, respectively. Self-assessment accuracy between the externally assessed and self-assessed scores was evaluated by using absolute difference scores, intraclass correlation coefficients, and the Bland-Altman analysis.

RESULTS

Twenty novice, 10 intermediate, and 10 experienced endoscopists participated. There was moderate agreement of externally assessed and self-assessed GiECAT scores, with an intraclass correlation coefficient of 0.65 (95% confidence interval, 0.44-0.80). The absolute difference scores among the 3 groups were significantly different (P = .002), with experienced endoscopists demonstrating a more accurate self-assessment ability compared with novices (P = .002). Bland-Altman plots suggest that novice and experienced endoscopists tend to overrate and underrate their clinical competence, respectively; no specific trends were associated with intermediates.

CONCLUSION

Participants demonstrated moderate self-assessment accuracy of clinical competence. Endoscopist experience was positively associated with self-assessment accuracy; novices demonstrated lower self-assessment accuracy compared with experienced endoscopists. Moreover, novices tended to overestimate their performances. Novice endoscopists may benefit from targeted interventions to improve self-assessment accuracy.

Preventive Strategies Against Cytomegalovirus and Incidence of α-Herpesvirus Infections in Solid Organ Transplant Recipients: A Nationwide Cohort Study

We assessed the impact of antiviral preventive strategies on the incidence of herpes simplex virus (HSV) and varicella-zoster virus (VZV) infections in a nationwide cohort of transplant recipients. Risk factors for the development of HSV or VZV infection were assessed by Cox proportional hazards regression. We included 2781 patients (56% kidney, 20% liver, 10% lung, 7.3% heart, 6.7% others). Overall, 1264 (45%) patients received antiviral prophylaxis (ganciclovir or valganciclovir, n = 1145; acyclovir or valacyclovir, n = 138). Incidence of HSV and VZV infections was 28.9 and 12.1 cases, respectively, per 1000 person-years. Incidence of HSV and VZV infections at 1 year after transplant was 4.6% (95% confidence interval [CI] 3.5-5.8) in patients receiving antiviral prophylaxis versus 12.3% (95% CI 10.7-14) in patients without prophylaxis; this was observed particularly for HSV infections (3% [95% CI 2.2-4] versus 9.8% [95% CI 8.4-11.4], respectively). A lower rate of HSV and VZV infections was also seen in donor or recipient cytomegalovirus-positive patients receiving ganciclovir or valganciclovir prophylaxis compared with a preemptive approach. Female sex (hazard ratio [HR] 1.663, p = 0.001), HSV seropositivity (HR 5.198, p < 0.001), previous episodes of rejection (HR 1.95, p = 0.004), and use of a preemptive approach (HR 2.841, p = 0.017) were significantly associated with a higher risk of HSV infection. Although HSV and VZV infections were common after transplantation, antiviral prophylaxis significantly reduced symptomatic HSV infections.

The effect of small solar powered 'Bͻkͻͻ' net fans on mosquito net use: results from a randomized controlled cross-over trial in southern Ghana

BACKGROUND

Long-lasting insecticidal nets (LLINs) are ineffective malaria transmission prevention tools if they are unused. Discomfort due to heat is the most commonly reported reason for not using nets, but this problem is largely unaddressed. With increasing rural electrification and the dropping price of solar power, fans could improve comfort inside nets and be affordable to populations in malaria endemic areas. Here, results are presented from a pilot randomized controlled cross-over study testing the effect of fans on LLIN use.

METHODS

Eighty-three households from two rural communities in Greater Accra, Ghana, randomized into three groups, participated in a 10-month cross-over trial. After a screening survey to identify eligible households, all households received new LLINs. Bͻkͻͻ net fan systems (one fan per member) were given to households in Group 1 and water filters were given to households in Group 2. At mid-point, Group 1 and 2 crossed over interventions. Households in Group 1 and 2 participated in fortnightly surveys on households' practices related to nets, fans and water filters, while households in Group 3 were surveyed only at screening, mid-point and study end. Entomological and weather data were collected throughout the study. Analysis took both 'per protocol' (PP) and 'intention to treat' (ITT) approaches. The mid- and end-point survey data from Group 1 and 2 were analysed using Firth logistic regressions. Fortnightly survey data from all groups were analysed using logistic regressions with random effects.

RESULTS

Provision of fans to households appeared to increase net use in this study. Although the increase in net use explained by fans was not significant in the primary analyses (ITT odds ratio 3.24, p > 0.01; PP odds ratio = 1.17, p > 0.01), it was significant in secondary PP analysis (odds ratio = 1.95, p < 0.01). Net use was high at screening and even higher after provision of new LLINs and with follow up. Fan use was 90-100% depending on the fortnightly visit.

CONCLUSIONS

This pilot study could not provide definitive evidence that fans increase net use. A larger study with additional statistical power is needed to assess this association across communities with diverse environmental and socio-demographic characteristics.

Long-term remission of clear cell carcinoma of the cervix after chemoradiation with 109 cycles of paclitaxel: a case report and literature review

BACKGROUND

Clear cell carcinoma of cervix (CCCC) is a rare cervical neoplasm that is usually associated with diethylstilbestrol (DES) exposure in utero as a primary risk factor. Advanced stage disease typically has poor outcomes and no evidence-based approach exists to guide clinicians in treating this rare disease.

CASE

The authors report a case of locally advanced CCCC in a 37-year-old Caucasian female. She underwent chemoradiation therapy that included 109 courses of paclitaxel chemotherapy until no disease could be detected on imaging studies. She is now disease-free 13 years after discontinuing chemotherapy.

CONCLUSION

A prolonged course of single agent paclitaxel after completing standard radiation therapy was successful in achieving remission in a patient with this rare disease.

Clinical outcomes and the role of adjuvant therapy sequencing in Type II uterine cancer following definitive surgical treatment

PURPOSE OF INVESTIGATION

Because of rarity, consensus on adjuvant therapies for Type II endometrial cancers (BC) remains undefined. Reporting their institutional outcomes, the present authors assessed the impact of adjuvant therapies on recurrence and overall survival in women with 2009 FIGO Stage I-III Type II BC.

MATERIAL AND METHODS

The authors identified 108 women, treated with definitive surgery between 2000-2013, with pathologically-confirmed Type II EC (non-endometrioid [NEM, n=801 and high grade endometrioid [G3EEC, n=28]) Cox proportional hazard models were used to assess the effect of prognostic variables on disease-free (DFS) and overall survival (OS). Kaplan-Meier method was used to assess survival.

RESULTS

Of the 108 women, 83 (77%) were African American (AA). Fifty-nine (55%), 12 (11%), and 37 (34%) were Stage I, II, and III, respectively. Ninety-seven patients received adjuvant therapy: 52 (radiation only), four (chemotherapy only), and 40 (combined). During follow-up (median 41 months), 44 patients (41%) recurred. Five-year DFS was 53% overall (48% [NEM], 80% [G3EEC]). Five-year OS was 75% overall (68% [NEM], 95% [G3EEC]). On multivariate analysis, lower stage and adjuvant radiation improved DFS. Higher stage, NEM, and increasing age were poor prognostic indicators of OS.

CONCLUSION

Representing a large single institutional cohort for Type II BC, the present study's observed sur- vival rates are consistent with previous studies, despite the relatively high frequency of carcinosarcoma and Stage III/nodal disease. The protective effect on recurrence was not lost when radiation was delayed for chemotherapy. The present results support a multimodal adjuvant approach for treating all stages of invasive NEM EC.

A Mobile Food Record For Integrated Dietary Assessment

This paper presents an integrated dietary assessment system based on food image analysis that uses mobile devices or smartphones. We describe two components of our integrated system: a mobile application and an image-based food nutrient database that is connected to the mobile application. An easy-to-use mobile application user interface is described that was designed based on user preferences as well as the requirements of the image analysis methods. The user interface is validated by user feedback collected from several studies. Food nutrient and image databases are also described which facilitates image-based dietary assessment and enable dietitians and other healthcare professionals to monitor patients dietary intake in real-time. The system has been tested and validated in several user studies involving more than 500 users who took more than 60,000 food images under controlled and community-dwelling conditions.

Intracranial Applications of MR Imaging-Guided Focused Ultrasound

Initially used in the treatment of prostate cancer and uterine fibroids, the role of focused ultrasound has expanded as transcranial acoustic wave distortion and other limitations have been overcome. Its utility relies on focal energy deposition via acoustic wave propagation. The duty cycle and intensity of focused ultrasound influence the rate of energy deposition and result in unique physiologic and biomechanical effects. Thermal ablation via high-intensity continuous exposure generates coagulative necrosis of tissues. High-intensity, pulsed application reduces temporally averaged energy deposition, resulting in mechanical effects, including reversible, localized BBB disruption, which enhances neurotherapeutic agent delivery. While the precise mechanisms remain unclear, low-intensity, pulsed exposures can influence neuronal activity with preservation of cytoarchitecture. Its noninvasive nature, high-resolution, radiation-free features allow focused ultrasound to compare favorably with other modalities. We discuss the physical characteristics of focused ultrasound devices, the biophysical mechanisms at the tissue level, and current and emerging applications.

Gastrointestinal Endoscopy Competency Assessment Tool: reliability and validity evidence

BACKGROUND

Rigorously developed and validated direct observational assessment tools are required to support competency-based colonoscopy training to facilitate skill acquisition, optimize learning, and ensure readiness for unsupervised practice.

OBJECTIVE

To examine reliability and validity evidence of the Gastrointestinal Endoscopy Competency Assessment Tool (GiECAT) for colonoscopy for use within the clinical setting.

DESIGN

Prospective, observational, multicenter validation study. Sixty-one endoscopists performing 116 colonoscopies were assessed using the GiECAT, which consists of a 7-item global rating scale (GRS) and 19-item checklist (CL). A second rater assessed procedures to determine interrater reliability by using intraclass correlation coefficients (ICCs). Endoscopists' first and second procedure scores were compared to determine test-retest reliability by using ICCs. Discriminative validity was examined by comparing novice, intermediate, and experienced endoscopists' scores. Concurrent validity was measured by correlating scores with colonoscopy experience, cecal and terminal ileal intubation rates, and physician global assessment.

SETTING

A total of 116 colonoscopies performed by 33 novice (<50 previous procedures), 18 intermediate (50-500 previous procedures), and 10 experienced (>1000 previous procedures) endoscopists from 6 Canadian hospitals.

MAIN OUTCOME MEASUREMENTS

Interrater and test-retest reliability, discriminative, and concurrent validity.

RESULTS

Interrater reliability was high (total: ICC=0.85; GRS: ICC=0.85; CL: ICC=0.81). Test-retest reliability was excellent (total: ICC=0.91; GRS: ICC=0.93; CL: ICC=0.80). Significant differences in GiECAT scores among novice, intermediate, and experienced endoscopists were noted (P<.001). There was a significant positive correlation (P<.001) between scores and number of previous colonoscopies (total: ρ=0.78, GRS: ρ=0.80, CL: Spearman's ρ=0.71); cecal intubation rate (total: ρ=0.81, GRS: Spearman's ρ=0.82, CL: Spearman's ρ=0.75); ileal intubation rate (total: Spearman's ρ=0.82, GRS: Spearman's ρ=0.82, CL: Spearman's ρ=0.77); and physician global assessment (total: Spearman's ρ=0.90, GRS: Spearman's ρ=0.94, CL: Spearman's ρ=0.77).

LIMITATIONS

Nonblinded assessments.

CONCLUSION

This study provides evidence supporting the reliability and validity of the GiECAT for use in assessing the performance of live colonoscopies in the clinical setting.