A survey of physician training and credentialing in endoscopic submucosal dissection in the United States.

BACKGROUND: Endoscopic submucosal dissection (ESD) is technically challenging, has a longer learning curve and a greater complication rate than most new endoscopic procedures. Formal training and credentialing guidelines for ESD are currently lacking in the United States (US). AIM: To survey ESD experts across the US to determine their learning process and obtain their opinion on how training and credentialing for ESD should develop. DESIGN: Anonymous electronic survey. SUBJECTS: ASGE members who are practicing US endoscopists. METHODS: The survey was developed by iterative revisions of questions administered to three investigators who have been performing ESD for > 5 years. The final survey was distributed electronically to US endoscopists who had previously attended ESD expert conferences. RESULTS: Thirty-five (58.3%) of 60 practicing ESD experts responded to the survey. A majority (91%) were in university-based, community, or tertiary care hospitals. All practitioners practiced on porcine explants and observed live ESD procedures as part of the training. Out of the participants, 75.8% received formal supervised hands-on training on porcine explants and/or humans before performing ESD independently. Fifty percent indicated that their facility had written guidelines specifically for ESD credentialing. Four out of 5 felt that credentialing requirements should include attending weekend ESD courses, observing live procedures, practicing on explants, and advanced endoscopic training in interventional endoscopy such as an additional year of fellowship. LIMITATIONS: Survey completion rate of 58.3%. CONCLUSION: ESD training should include practicing on explants, observation of live procedures, training in interventional endoscopy, and attending educational courses. Credentialing guidelines for ESD based on expert opinion need to be developed in the US.

A rare pulmonary manifestation of Crohn's disease: Acute fibrinous and organizing pneumonia presenting as multifocal nodules.

Acute Fibrinous and Organizing Pneumonia (AFOP) is a rare pulmonary disease, and it has not been recorded in literature as a pulmonary manifestation of Crohn's disease. A 22-year-old individual with an extensive history of Crohn's disease presented to the hospital initially for hematochezia and diarrhea. Computed tomography of her abdomen and pelvis showed multiple pulmonary nodules bilaterally. The patient did not report cough, sputum production, or dyspnea. Autoimmune and infectious workup were overall unremarkable. A CT-guided percutaneous biopsy of a peripheral lung nodule was performed showing features consistent with AFOP. The patient was ultimately treated with a long taper of prednisone and Ustekinumab for Crohn's disease. Follow-up CT-chest showed interval reduction and improvement in lung nodules, which correlated with better control of the patient's Crohn's disease. Pulmonary manifestations of IBD are varied, including pleural disease, bronchiectasis, and organizing pneumonia. Bronchiolitis obliterans organizing pneumonia has been described more frequently in patients with ulcerative colitis compared to Crohn's. Pulmonary nodules are a rare manifestation of IBD and often tend to be granulomatous or necrobiotic. AFOP is a rare entity with no previously reported association with IBD. Secondary AFOP can be caused by autoimmune diseases, drug reactions, infections, or radiation. Treatment of AFOP is usually immunosuppression by glucocorticoids.

Prognostic significance of mild aortic regurgitation in predicting mortality after transcatheter aortic valve replacement.

OBJECTIVE: Moderate to severe aortic regurgitation after transcatheter aortic valve replacement is associated with worse outcomes. The impact of mild aortic regurgitation has been less clear, possibly because of the broad categories that have been used in clinical trials, but holds increasing importance in the study of next-generation devices in low- and intermediate-risk cohorts. A more granular scheme, which is common in clinical practice and proposed for future trials, may add prognostic value. METHODS: We evaluated all patients undergoing transfemoral transcatheter aortic valve replacement at the Cleveland Clinic from 2006 to 2012. The degree of aortic regurgitation after transcatheter aortic valve replacement was reported from the echocardiography database based on a clinical, transthoracic echocardiogram performed within 30 days of the procedure. Aortic regurgitation was finely discriminated on the basis of a multiwindow, multiparametric, integrative approach using our usual clinical scale: none, trivial to 1+, 1+, 1 to 2+, 2+, 2 to 3+, 3+, 3 to 4+, or 4+. RESULTS: There were 237 patients included in the analysis. By controlling for age, gender, Society of Thoracic Surgeons score, baseline ejection fraction, and aortic regurgitation before transcatheter aortic valve replacement, there was a significant increase in mortality for each half grade of aortic regurgitation compared with the complete absence of aortic regurgitation after transcatheter aortic valve replacement. The unit hazard ratio for each 1+ increase in aortic regurgitation after transcatheter aortic valve replacement was 2.26 (95% confidence interval, 1.48-3.43; P < .001) considering aortic regurgitation as a continuous variable. Other clinical variables did not significantly affect mortality. CONCLUSIONS: Even mild aortic regurgitation after transcatheter aortic valve replacement is associated with worse long-term mortality. There may be prognostic value in reporting milder categories of aortic regurgitation with more granular gradations.