Training pathway for small bowel capsule endoscopy in the UK.

The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Influence of target-distractor neural similarity on working memory performance in older and younger adults.

According to the inhibitory deficit hypothesis, older adults often fail to selectively inhibit distractors and attend to relevant information in working memory, leading to poorer memory of target items but better recall of irrelevant distractors compared to younger adults. Here, we explored how neural similarity of activity patterns between relevant and irrelevant stimulus categories impacts memory performance. We found evidence that older adults may benefit from failing to inhibit distractors that are similar to targets, perhaps because sustained neural activation of distractors partially supports maintenance of targets when they share neural resources, allowing for better subsequent recognition of studied target items. We also found increased category-specific multivoxel pattern activity in medial temporal regions in younger compared to older adults as category similarity increased. We propose that this reduced category-specific activation in medial temporal regions in older adults may reflect more blended representations of all the information available in working memory.

The cascade of care for opioid use disorder among youth in British Columbia, 2018.

BACKGROUND: Medication for opioid use disorder (MOUD) is associated with substantial reductions in the risk of mortality, and American and Canadian guidelines recommend it as part of the full range of available treatments for youth with opioid use disorder (OUD). We estimated the OUD cascade of care for all adolescents (ages 12-18) and young adults (19-24) with OUD in British Columbia, Canada (BC) in 2018. METHODS: Using a provincial-level linkage of six health administrative databases, we classified youth with OUD as adolescents (ages 12-18) or young adults (19-24) to compare with older adults (≥25) and described key factors known to influence engagement in health care. The eight-stage cascade of care included diagnosed with OUD, ever engaged in MOUD, recently in MOUD, currently in MOUD, and retained in MOUD for ≥1 month, ≥3 months, ≥12 months, ≥24 months. RESULTS: We identified 4048 youth diagnosed with OUD as of September 30, 2018 (6.3% of all people with OUD). Most were young adults, aged 19-24 (n = 3602; 89.0% of all youth), a majority of whom were males (n = 1984; 55.1%). In contrast, adolescents diagnosed with OUD (n = 446; 11.0% of all youth) were mostly females (n = 287; 64.4%). Compared to adolescents, there were more young adults diagnosed with OUD ever engaged in MOUD (71.4% v. 36.5%), currently on MOUD (29.3% v. 16.8%), and retained in care for ≥1 year (8.6% v. 2.0%). CONCLUSIONS: A high proportion of youth aged 12-24 diagnosed with OUD in a health care setting in British Columbia received MOUD yet continued engagement is infrequent, particularly for adolescents. Long-term treatment plans for youth need to consider including MOUD when appropriate as part of tailored, youth-friendly services.

The role of mathematical modelling in aiding public health policy decision-making: A case study of the BC opioid overdose emergency.

The province of British Columbia is currently experiencing the highest rate of apparent opioid-related deaths within Canada. This dramatic increase in overdose deaths has been primarily driven by the increase of fentanyl and fentanyl-analogues within the unregulated, highly unpredictable and toxic street drug supply. A public health emergency was declared in B.C. in April 2016. After the emergency was declared, overdose-related death rates continued to rise, reaching unprecedented levels. In the context of enhanced collaboration between government organizations and researchers, a series of mathematical studies improved the ability of government and service providers to understand the impact of scaled-up strategies, including harm reduction and treatment services. In this commentary we describe how government agencies collaborated with researchers and other experts to use modelling results, and describe lessons learned for enhancing these collaborations. Mathematical modelling provides a viable and timely approach to the generation of intelligence, combining disparate data to assess the on-going impact of a comprehensive package of interventions during a public health emergency, and enhancing accountability for investments.

Evaluating complex transformation.

PURPOSE: The purpose of this paper is to present a detailed case study of the evaluation strategies of a complex, multi-faceted response to a public health emergency: drug-related overdose deaths. It sets out the challenges of evaluating such a complex response and how they were overcome. It provides a pragmatic example of the rationale and issues faced to address the what, the why and particularly the how of the evaluation. DESIGN/METHODOLOGY/APPROACH: The case study overviews British Columbia's Provincial Response to the Overdose Public Health Emergency, and the aims and scope of its evaluation. It then outlines the conceptual approach taken to the evaluation, setting out key methodological challenges in evaluating large-scale, multi-level, multisectoral change. FINDINGS: The evaluation is developmental and summative, utilization focused and system informed. Defining the scope of the evaluation required a strong level of engagement with government leads, grantees and other evaluation stakeholders. Mixed method evaluation will be used to capture the complex pattern of relationships that have informed the overdose response. Working alongside people with drug use experience to both plan and inform the evaluation is critical to its success. ORIGINALITY/VALUE: This case study builds on a growing literature on evaluating large-scale and complex service transformation, providing a practical example of this.

International core curriculum for capsule endoscopy training courses.

Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of trainees' skills in order to certify readers' competency.

Practical aspects of delivering a small bowel endoscopy service in the UK.

Capsule endoscopy remains at the forefront of small bowel investigation, offering the only non-invasive means of directly imaging the mucosa of the small bowel. Recommended for the investigation of obscure gastrointestinal bleeding, Crohn's disease, coeliac disease, small bowel tumours and hereditary polyposis syndromes, the uptake of small bowel capsule endoscopy has been widespread in the UK. However, despite a wealth of published literature supporting the utility of capsule endoscopy in clinical practice, there are limited data regarding the actual practical aspects of service delivery, training and quality assurance. In this article, we attempt to address this by considering specific factors that contribute to provision of a high-quality capsule service. The role of formal training, accreditation and quality assurance measures is also discussed.

Capsule endoscopy--not just for the small bowel: a review.

Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.

Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work.

BACKGROUND: For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why. METHODS: The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data. RESULTS: For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement. CONCLUSIONS: It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.

Training in Capsule Endoscopy: Are We Lagging behind?

Capsule endoscopy (CE) is a new modality to investigate the small bowel. Since it was invented in 1999, CE has been adopted in the algorithm of small bowel investigations worldwide. Reporting a CE video requires identification of landmarks and interpretation of pathology to formulate a management plan. There is established training infrastructure in place for most endoscopic procedures in Europe; however despite its wide use, there is a lack of structured training for CE. This paper focuses on the current available evidence and makes recommendations to standardise training in CE.

Provision of service and training for small bowel endoscopy in the UK.

OBJECTIVE: To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery. DESIGN: Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training. RESULTS: 45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses. CONCLUSIONS: Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.