Use of fully covered self-expanding metal biliary stents for managing endoscopic biliary sphincterotomy related bleeding

Background and study aims  Endoscopic biliary sphincterotomy (EBS) related-bleeding is a common adverse event related to endoscopic retrograde cholangiopancreatography (ERCP). Traditionally, endoscopic modalities such as epinephrine injection, cauterization, and balloon tamponade have been used for management. Recently, use of a fully covered self-expandable metal stent (FCSEMS) to manage EBS-related bleeding has gained popularity. However, data regarding its use are limited to small case series. Therefore, we aimed to evaluate the safety and efficacy of FCSEMS placement for the treatment of EBS-related bleeding. Patients and methods  All patients referred to our center from October 2014 to November 2019 who had an FCSEMS placed for EBS-related bleeding were included. FCSEMS was placed either for primary control of bleeding or after failure of other traditional endoscopic hemostasis techniques at the discretion of the endoscopist. Data was collected regarding patient demographics, procedural characteristics, clinical and technical success rates of FCSEMS, as well as adverse events. Results  A total of 97 patients underwent placement of FCSEMS for EBS-related bleeding, of which 76.3 % had immediate bleeding and 23.7 % had delayed bleeding. Mean age was 67.2 years and 47.4 % were males. Seven patients who had immediate EBS-related bleeding at index ERCP underwent other endoscopic therapies prior to placement of FCSEMS for rebleeding. The technical success rate for FCSEMS placement was 100 % and the rebleeding rate was 6.2 %. Four patients with FCSEMS placement developed pancreatitis and four had stent migration. Conclusions  Our findings suggest that FCSEMS is a highly effective treatment modality for managing EBS-related bleeding and has an acceptable safety profile.

Impact of a simulation-based ergonomics training curriculum on work-related musculoskeletal injury risk in colonoscopy

BACKGROUND AND AIMS

Endoscopists are at risk of developing musculoskeletal injuries (MSIs), and few receive training on ergonomics. The aim of this study was to determine the impact of a simulation-based ergonomics training curriculum (ETC) on work-related MSI risk during clinical colonoscopy.

METHODS

Novice endoscopists underwent a simulation-based ETC and were compared with an historical control group who received simulation-based training without ergonomics training. The ETC included a didactic lecture and video on ergonomics in colonoscopy, feedback from supervisors on ergonomics, and an ergonomics checklist to augment feedback and promote self-reflection. Participants were assessed using the rapid entire body assessment (REBA) and rapid upper limb assessment (RULA). The primary outcome was participants' REBA scores during 2 clinical colonoscopies 4 to 6 weeks after training.

RESULTS

In clinical colonoscopy, the ETC group had superior REBA scores (clinical procedure 1: median score, 6 vs 11; P < .001; clinical procedure 2: median score, 6 vs 10; P < .001). In a simulated colonoscopy, the ETC group did not have significantly different REBA or RULA scores between baseline, immediately after training, and 4 to 6 weeks after (REBA: median scores of 5, 5, and 5, respectively; P > .05; RULA: median scores of 6, 6, and 6, respectively; P > .05). The control group had worsening REBA and RULA scores during the study timeline (REBA: median scores of 5 at baseline, 9 immediately after training, and 9 at 4-6 weeks after training; P < .001; RULA: median scores of 6, 7, and 7, respectively; P = .04) during simulated procedures.

CONCLUSIONS

A simulation-based ETC is associated with reduced risk of MSI during endoscopy. Although the REBA score was improved, the intervention group was still within the medium-risk range.

Incidence of cirrhosis in young birth cohorts in Canada from 1997 to 2016: a retrospective population-based study

BACKGROUND

Recent data show that the prevalence of chronic liver disease and cirrhosis is increasing in adolescents and young adults in the USA. We aimed to describe the epidemiology of cirrhosis using an age-period-cohort approach to define birth-cohort effects on the incidence of cirrhosis in Ontario, Canada.

METHODS

We did a retrospective population-based cohort study in Ontario, Canada, using linked administrative health data from the databases of ICES, formerly the Institute for Clinical Evaluative Sciences. Patients aged at least 18 years with cirrhosis were identified by use of a validated case definition (defined as at least one inpatient or outpatient visit with a diagnosis of cirrhosis or oesophageal varices without bleeding). We calculated annual standardised incidence and prevalence in the general population. We used an age-period-cohort approach to assess the independent association between birth cohort and incidence of cirrhosis in men and women.

FINDINGS

Between Jan 1, 1997, and Dec 31, 2016, 165 979 individuals with cirrhosis were identified. The age-standardised incidence increased over the study (from 70·6 per 100 000 person-years in 1997 to 89·6 per 100 000 person-years in 2016) as did the prevalence (from 0·42% in 1997 to 0·84% in 2016). Using age-period-cohort modelling and the median birth year as the reference, the incidence of cirrhosis was higher in participants born in 1980 (incidence rate ratio 1·55, 95% CI 1·50-1·59, p<0·0001); and in participants born in 1990 (2·16, 95% CI 2·06-2·27, p<0·0001) compared with a person of the same age born in 1951. The increase in incidence of cirrhosis was greater in women than in men (eg, women born in 1990: 2·60, 95% CI 2·41-2·79; men born in 1990: 1·98, 1·85-2·12).

INTERPRETATION

The incidence of cirrhosis has increased over the past two decades, and more so in younger birth cohorts and in women. Future studies to define the cause and natural history of cirrhosis in these groups are essential to develop strategies that could reverse these trends for future generations.

FUNDING

Southeastern Ontario Academic Medical Association New Clinician Scientist Award; American Association for the Study of Liver Disease (AASLD) Foundation Clinical, Translational and Outcomes Research Award in Liver Disease (JAF).

Relationships of maternal and paternal birthweights to features of the metabolic syndrome in adult offspring: an inter-generational study in South India

AIMS/HYPOTHESIS

The association between lower birthweight and metabolic syndrome may result from fetal undernutrition (fetal programming hypothesis) and/or genes causing both low birthweight and insulin resistance (fetal insulin hypothesis). We studied associations between the birthweight of parents and metabolic syndrome in the offspring.

METHODS

We identified men and women (aged 35-68 years), who had been born in Holdsworth Memorial Hospital, Mysore, India. We also identified the offspring (20-46 years) of these men and women. In total, 283 offspring of 193 mothers and 223 offspring of 144 fathers were studied. Investigations included anthropometry, oral glucose tolerance, plasma insulin and lipid concentrations and blood pressure. The metabolic syndrome was defined using WHO criteria.

RESULTS

Among the offspring, lower birthweight was associated with an increased risk of glucose intolerance (impaired glucose tolerance, impaired fasting glucose or type 2 diabetes) and higher cholesterol and triacylglycerol concentrations (p < 0.05 for all adjusted for sex and age). Most outcomes in the offspring, including most individual components of the metabolic syndrome, were unrelated to parental birthweight. However, both maternal and paternal birthweight were inversely related to offspring metabolic syndrome (odds ratio [OR] 0.36 [95% CI: 0.13-1.01] per kg, p = 0.053 for mother-offspring pairs; OR 0.26 [0.07-0.93], p = 0.04 for father-offspring pairs, adjusted for offspring age, sex, BMI and socioeconomic status). Maternal birthweight was inversely related to offspring systolic blood pressure (beta = -2.5 mmHg [-5.00 to 0.03] per kg maternal birthweight; p = 0.052).

CONCLUSIONS/INTERPRETATION

Factors in both parents may influence the risk of metabolic syndrome in their offspring. There are several possible explanations, but the findings are consistent with the fetal insulin (genetic) hypothesis.

Truncal adiposity is present at birth and in early childhood in South Indian children

OBJECTIVES

Muscle-thin but adipose ('thin-fat') body composition of south Asian adults contributes to their high risk of type 2 diabetes. Studies in Pune, India showed that this phenotype is present at birth. We aimed to determine if south Indian babies have a 'thin-fat' phenotype and if this persists in childhood.

DESIGN

Prospective cohort study.

SETTING

Holdsworth Memorial Hospital, Mysore, India.

SUBJECTS

Children (n = 663) whose mothers were recruited from the antenatal clinics.

METHODS

Weight, length, head, mid-upper-arm, abdominal circumferences; triceps and subscapular skinfolds were measured at birth, one and four years, and compared with white Caucasian babies born in Southampton, UK (birth), and UK and Dutch growth standards (one and four years).

RESULTS

Mysore babies were lighter (2983 g vs 3472 g; -1.10 SD, CI -1.16, -1.02) and smaller in all body measurements than UK neonates (P < 0.001). The deficit was greatest for mid-upper-arm (-1.07 SD), head (-0.89 SD) and abdominal circumferences (-0.73 SD), and least for length (-0.25 SD) and subscapular skinfold thickness (-0.19 SD). Predictors of skinfold thickness were maternal body mass index (P < 0.001) and socio-economic status (P = 0.05). At four years, subscapular skinfold thickness was larger than UK (+0.18 SD, CI +0.11, +0.25; P < 0.001) and Dutch standards (+0.61 SD, CI +0.51, +0.71; P < 0.001), despite all other body measurements remaining smaller. Predictors of 4-year skinfold thickness were neonatal skinfold thickness (P = 0.001) and maternal insulin concentrations (P = 0.05).

CONCLUSIONS

Mysore newborns have a 'thin-fat' phenotype. This may reflect the action of genes and/or the 'maternal environment'. The phenotype persists in childhood, and may be the forerunner of a diabetogenic adult phenotype.