Benchmarks for the interpretation of esophageal high-resolution manometry.

BACKGROUND: Competent interpretation of esophageal high-resolution manometry (HRM) is integral to a quality study. Currently, methods to assess physician competency for the interpretation of esophageal HRM do not exist. The aim of this study was to use formal techniques to (i) develop an HRM interpretation exam, and (ii) establish minimum competence benchmarks for HRM interpretation skills at the trainee, physician interpreter, and master level. METHODS: A total of 29 physicians from 8 academic centers participated in the study: 9 content experts separated into 2 study groups-expert test-takers (n=7) and judges (n=2), and 20 HRM inexperienced trainees ("trainee test-taker"; n=20). We designed the HRM interpretation exam based on expert consensus. Expert and trainee test-takers (n=27) completed the exam. According to the modified Angoff method, the judges reviewed the test-taker performance and established minimum competency cut scores for HRM interpretation skills. KEY RESULTS: The HRM interpretation exam consists of 22 HRM cases with 8 HRM interpretation skills per case: identification of pressure inversion point, hiatal hernia >3 cm, integrated relaxation pressure, distal contractile integral, distal latency, peristaltic integrity, pressurization pattern, and diagnosis. Based on the modified Angoff method, minimum cut scores for HRM interpretation skills at the trainee, physician interpreter, and master level ranged from 65-80%, 85-90% (with the exception of peristaltic integrity), and 90-95%, respectively. CONCLUSIONS & INFERENCES: Using a formal standard setting technique, we established minimum cut scores for eight HRM interpretation skills across interpreter levels. This examination and associated cut scores can be applied in clinical practice to judge competency.

Competency based medical education in gastrointestinal motility.

Traditional apprenticeship-based medical education methods focusing on subjective evaluations and case-volume requirements do not reliably produce clinicians that provide high-quality care in unsupervised practice. Consequently, training approaches are shifting towards competency based medical education, which incorporates robust assessment methods and credible standards of physician proficiency. However, current gastroenterology and hepatology training in the US continues to utilize procedural volume and global impressions without standardized criteria as markers of competence. In particular, efforts to optimize competency based training in gastrointestinal (GI) motility are not underway, even though GI motility disorders account for nearly half of outpatient gastroenterology visits. These deficiencies compromise the quality of patient care. Thus, there is a great need and opportunity to shift our focus in GI motility training towards a competency based approach. First, we need to clarify the variable rates of learning for individual diagnostic tests. We must develop integrated systems that standardize training and monitor physician competency for GI motility diagnostics. Finally, as a profession and society, we must create certification processes to credential competent physicians. These advances are critical to optimizing the quality of GI motility diagnostics in practice.

Status of Competency-Based Medical Education in Endoscopy Training: A Nationwide Survey of US ACGME-Accredited Gastroenterology Training Programs.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training. METHODS: ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions. RESULTS: Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1­very important to 5­very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees. CONCLUSIONS: Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.

Endoscopic ultrasound as an adjunctive evaluation in patients with esophageal motor disorders subtyped by high-resolution manometry.

BACKGROUND: Esophageal motor disorders are a heterogeneous group of conditions identified by esophageal manometry that lead to esophageal dysfunction. The aim of this study was to assess the clinical utility of endoscopic ultrasound (EUS) in the further evaluation of patients with esophageal motor disorders categorized using the updated Chicago Classification. METHODS: We performed a retrospective, single center study of 62 patients with esophageal motor disorders categorized according to the Chicago Classification. All patients underwent standard radial endosonography to assess for extra-esophageal findings or alternative explanations for esophageal outflow obstruction. Secondary outcomes included esophageal wall thickness among the different patient subsets within the Chicago Classification. KEY RESULTS: EUS identified 9/62 (15%) clinically relevant findings that altered patient management and explained the etiology of esophageal outflow obstruction. We further identified substantial variability in esophageal wall thickness in a proportion of patients including some with a significantly thickened non-muscular layer. CONCLUSIONS & INFERENCES: EUS findings are clinically relevant in a significant number of patients with motor disorders and can alter clinical management. Variability in esophageal wall thickness of the muscularis propria and non-muscular layers identified by EUS may also explain the observed variability in response to standard therapies for achalasia.

Sorafenib inhibits MAPK-mediated proliferation in a Barrett's esophageal adenocarcinoma cell line.

SUMMARY: Esophageal adenocarcinoma continues to rise in incidence. Despite recognition of Barrett's metaplasia as the histological precursor, prognosis remains poor. The mitogen-activated protein kinases (MAPK) pathway is activated in Barrett's-associated dysplasia and adenocarcinoma and this activation is, in part, due to acid and bile acid reflux. We investigated the effects of sorafenib, an orally active Raf-inhibitor, on acid and bile acid-stimulated growth and signaling in SEG-1 cells, derived from a Barrett's esophageal cancer. SEG-1 cells were pretreated with sorafenib or vehicle and subsequently stimulated with acid or bile acid. MAPK signals, including phospho-ERK and phospho-p38, as well as cyclin D1 expression were assessed by Western blotting. Cell proliferation was measured by WST-1 colorimetric assay. Acid (pH 3.0-4.0) and bile acid (taurocholate 50-100 micromol/L) activated ERK and p38. Acid and bile acid exposure also increased levels of cyclin D1, a G1 to S cell cycle regulator. Furthermore, acid and taurocholate exposure increased cell proliferation. Sorafenib abrogated MAPK activation and cyclin D1 up-regulation and significantly inhibited cell growth. In summary, sorafenib inhibits acid or bile acid-stimulated Barrett's esophageal cancer cell proliferation by a mechanism involving the MAPK pathway. Our results suggest that sorafenib might be useful in the management of Barrett's-associated dysplasia and adenocarcinoma. These findings provide a foundation for in vivo studies to assess the efficacy of sorafenib in Barrett's-related neoplasia.

[The three-dimensional spiral scanner and volume rendering technique: importance in craniofacial traumatology and reconstructive surgery]. / Le scanner spiralé 3 D avec traitement de l'image en rendu de volume.

There are two reconstruction methods for 3D imaging with a helical scanner: a surface rendering process providing a 3D-SSD (Surface Shaded Display) image that looks like a plaster cast skull and 3D-VRD (Volume Rendering Technique) which is more precise and gives 3D images similar to radiographs. We review briefly the techniques used to acquire these images and present 3D volume-rendering scanners, pointing out its usefulness in craniomaxillofacial traumatology and reconstructive surgery.

The crossed femoral nerve stretch test to improve diagnostic sensitivity for the high lumbar radiculopathy: 2 case reports.

The femoral nerve stretch test (FNST) is commonly used to assess high lumbar radiculopathy. It may be falsely positive secondary to tight or injured muscles of the anterior thigh, and to osseous or joint pathology in and about the hip. We report on the crossed FNST, which may improve the specificity of the FNST. Two cases that occurred within 2 months are presented. The physical examinations suggested high lumbar radiculopathy, which was confirmed by both the FNST and crossed FNST. The crossed FNST may thus be a valuable screening test that further supports a diagnosis of upper lumbar radiculopathy. Further study is necessary to identify its prevalence in the assessment of the high lumbar radiculopathy.

Long-term enhancement of botulinum toxin injections by upper-eyelid surgery in 14 patients with facial dyskinesias.

OBJECTIVES: To determine the effects of upper-eyelid surgery (limited myectomy, blepharoplasty, and levator aponeurotic advancement) on patients who demonstrated a suboptimal response or residual heaviness of the upper eyelids after botulinum toxin eyelid injections for facial dyskinesia. DESIGN: Retrospective study. SUBJECTS: Charts of 358 patients with a diagnosis of benign essential blepharospasm, Meige syndrome (with eyelid involvement), and hemifacial spasm were reviewed. METHODS: Data were retrospectively analyzed and included subjective and objective responses about botulinum toxin injections (number and duration of effect of injections before and after eyelid surgery). RESULTS: Of 358 patients with facial dyskinesias, 14 (3.91%) underwent upper-eyelid limited myectomy with or without upper-lid blepharoplasty (n = 5), upper-lid blepharoplasty alone (n = 6), or levator advancement with or without blepharoplasty (n = 3). Mean subjective improvement was 68.75% after limited myectomy combined with blepharoplasty and 58.33% after levator and/or blepharoplasty surgery. Average duration of effect of injections increased from 122.1 days in the patients prior to undergoing eyelid surgery to 210.5 days after surgery. CONCLUSIONS: Upper-eyelid surgery, including limited myectomy, enhanced the effect of the botulinum toxin in this small group of patients. Patients with a suboptimal response to injections in terms or moderate to marked dermatochalasis with subjective heaviness of the eyelids, upper-eyelid blepharoplasty, and/or limited myectomy should be considered.

Evaluation of E and EAC rosette-forming cells in patients with thermal injuries.

Thermal injuries lead to changes in both the cell-mediated and humoral responses of the patient. This study was undertaken to assess these responses in the post-burn period and also to see if bacterial infection altered these responses. It has been concluded that alterations in the cell-mediated and humoral immune responses following thermal injuries are altered by infection and consequently are also important in the healing process.

Correlation of quantitative burn wound biopsy culture and surface swab culture to burn wound sepsis.

The present study includes seventeen patients with second and third degree fresh burns involving 15-50 per cent total body surface area (TBSA). Surface swabs and quantitative burn wound biopsy cultures were obtained during postburn weeks 1, 2 and 3 and correlation was studied. To obtain bacterial counts the technique described by Loebel et al. (1974) was used. The patients were divided in two groups depending upon burn body surface area involved. The first group includes five patients with burns between 15-29 per cent body surface area and the second group includes the rest of the twelve patients with burns between 30-50 per cent body surface area. No patient from group I showed any sign or symptom of sepsis whereas seven patients from group II developed sepsis and three died. These three patients showed positive blood culture at the time of death. Of the 48 cultures obtained in all the patients over 3 weeks, 7 cultures showed differences between swab and biopsy cultures. Genticyn was the most effective drug against Gram-negative organisms.

Infection in burn patients.

In a recently opened burn unit which used a semi-isolation technique to treat burn patients, burn bacteriology has shown the usual pattern of bacterial cultures i.e. Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, Klebsiella and proteus; with the first two predominating. Comparison with a similar study done in 1974 revealed that Streptococcus faecalis was absent in these cultures, E. coli and S. aureus infection had decreased, the number of sterile wounds had increases, there was slight increase in P. aeruginosa infection. A survey of burn wound, throat and stool cultures of patients and attendants over a 2-week period revealed pathogenic S. aureus in 3 out of 26 throat cultures. Phage typing of these strains did not reveal the same strain in any wound cultures. Similar phage type was grown from wounds in two different cabins on two different dates. thus indicating cross infection. Persistence of similar phage type was also seen in wounds of one patient. Similar aeruginocine typing of P. aeruginosa was seen in wound cultures of two different patients; one of these, type 15, was also grown in stool of the third patient thus indicating transmission of infection from the stool of one patient to the wound of other patient and from the wound of one patient to the wound of other patient.

Serodiagnosis of the role of opportunistic bacteria in cases of burn wound sepsis.

In the present study, the antibody titres in the serum of 21 patients with burns were analysed against various Gram-negative organisms, infecting the wounds of these patients. Antibody titre was determined on the first, fourth and tenth day of admission. The rise in antibody titre was correlated with the age of the patient, degree and area of burns and clinical status of the burn wounds.