Endoscopy training through the COVID-19 pandemic: maintaining procedural volumes and key performance standards.

Objective: Endoscopy departments have experienced considerable challenges in the provision of endoscopy services since the start of the COVID-19 pandemic. Several studies have reported a reduction of procedures performed by trainee endoscopists during the pandemic. The aim of this study was to assess the impact on colonoscopy training and quality in an academic centre throughout successive waves of the pandemic. Methods: This was a single-centre, retrospective, observational study comparing colonoscopies performed at a tertiary endoscopy centre in Ireland at different stages of the pandemic with those performed during a similar time frame prepandemic. Data were collected using electronic patient records. Primary outcomes were procedure volumes, adenoma detection rate and mean adenoma per procedure. Results: In the prepandemic period, 798 colonoscopies were performed. During the same period in 2020, 172 colonoscopies were performed. In 2021, during the third wave of the pandemic, 538 colonoscopies were performed. Percentages of colonoscopies performed by trainees were 46.0% (n=367) in 2019, 25.6% (n=44) in 2020 and 45.2% (n=243) in 2021. Adenoma detection rate was 21.3% in 2019, 38.6% in 2020 and 23.9% in 2021. Mean adenoma per procedure was 0.45 in 2019, 0.86 in 2020 and 0.49 in 2021. Caecal intubation rate was 90.74% in 2019, 90.9% in 2020 and 95.88% in 2021. Conclusion: The COVID-19 pandemic initially had a negative impact on overall colonoscopy volumes and training. Despite a reduction in procedural volume, key performance standards were maintained by trainees. Maintenance of hands-on training is essential to allow trainees achieve and retain competency in endoscopy.

Metastatic medullary thyroid carcinoma presenting as ectopic Cushing's syndrome.

SUMMARY: A 41-year-old male presented to the Emergency Department with a 6-month history of back and hip pain. Skeletal survey revealed bilateral pubic rami fractures and MRI of the spine demonstrated multiple thoracic and lumbar fractures. Secondary work up for osteoporosis was undertaken. There was no evidence of hyperparathyroidism and the patient was vitamin D replete. Testosterone (T) was low at 1.7 nmol/L (8.6-29.0) and gonadotrophins were undetectable. The patient failed a 1 mg dexamethasone suppression test (DST) with a morning cortisol of 570 nmol/L (<50) and subsequently a low dose DST with a cortisol post 48 h of dexamethasone of 773 nmol/L (<50) and an elevated ACTH 98 ng/L. A corticotropin-releasing factor (CRF) test suggested ectopic ACTH secretion. The patient was commenced on teriparatide for osteoporosis and metyrapone to control the hypercortisolaemia. A positron emission tomography (PET) scan to look for the source of ACTH secretion demonstrated right neck adenopathy. Biopsy and subsequent lymph node dissection were performed and histology revealed a metastatic neuroendocrine tumour. Immunostaining was positive for calcitonin and thyroid transcription factor 1 (TTF1). Serum calcitonin was also significantly elevated at 45 264 ng/L (<10). The patient proceeded to a total thyroidectomy and left neck dissection. Histology confirmed a 7 mm medullary thyroid carcinoma (MTC). Post-operatively, the patient commenced vandetanib therapy and achieved a clinical and biochemical response. After approximately 18 months of vandetanib therapy, the patient developed recurrent disease in his neck. He is currently on LOXO-292 and is doing well 36 months post-diagnosis. LEARNING POINTS: Unexplained osteoporosis requires thorough investigation and the workup for secondary causes is not complete without excluding glucocorticoid excess. MTC should be considered when searching for sources of ectopic ACTH secretion. Resistance to tyrosine kinase inhibitors is well described with MTC and clinicians should have a low threshold for screening for recurrent disease.