Covid-19: exploring the "new normal" in gastroenterology training.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented.

Colorectal trainees in the UK struggle to meet JAG certification standards in colonoscopy by the end of their training.

AIM: Colonoscopy certification in the UK is taken in two parts - provisional and full - mandating lifetime procedure counts of 200 or 300, respectively. The aim of this study was to determine the number of procedures performed by colorectal trainees by the end of training compared with their gastroenterology peers and to determine the factors associated with achieving the 300-procedure target for full certification. METHOD: Dates of entry onto the specialist register were obtained from the General Medical Council. This list was cross-referenced with procedure counts from the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) Endoscopy Training System database to determine the number of colonoscopies and polypectomies performed during training. Factors associated with achieving 300 procedures were analysed by logistic regression. RESULTS: Procedures numbers were obtained for 234 gastroenterology and 148 colorectal surgery trainees. Over the last 5 years, the number of colonoscopies performed during training has declined for colorectal surgery trainees but increased for gastroenterology trainees. Gastroenterology trainees are more likely to achieve provisional and full certification. For trainees completing training in 2017, 19% of colorectal surgery trainees compared with 88% of gastroenterology trainees were able to reach the threshold of 300 procedures for full certification. CONCLUSION: Colorectal surgery trainees lag behind their gastroenterology counterparts in accruing endoscopy experience. This affects the ability of colorectal surgery trainees to achieve certification prior to completion of training. An urgent debate is required to decide what endoscopy training is required of a colorectal surgeon and how a robust training system can be put in place to ensure this is achieved.

Colonoscopy conversion after flexible sigmoidoscopy screening: results from the UK Bowel Scope Screening Programme.

AIM: In the UK Bowel Scope Screening Programme (BSSP), patients progress to colonoscopy based on high-risk features on flexible sigmoidoscopy (FS). We aim to assess the practice of colonoscopy conversion and predictors of detection of additional adenomas on colonoscopy. METHOD: The Bowel Cancer Screening database was interrogated and collated with endoscopic and histological findings from patients undergoing colonoscopy following FS between August 2013 and August 2016. Multivariate analysis was performed to identify predictors of new adenomas. RESULTS: FS was performed on 11 711 patients, with an adenoma detection rate (ADR) of 8.5% and conversion to colonoscopy in 421 (3.6%). The additional ADR at colonoscopy was 35.2%, with one additional malignant diagnosis (0.26%). The adenoma miss rate was 3.6%. On multivariate analysis, a polyp ≥ 10 mm was the only high-risk indication associated with additional ADR at colonoscopy (OR 3.68, 95% CI 1.51-3.65, P < 0.001), in addition to male gender (OR 2.36, 95% CI 1.46-3.83, P < 0.001). Predictors of detection of a new adenoma ≥ 10 mm included: villous adenoma (P = 0.002), polyp ≥ 10 mm (P = 0.007) and male gender (P = 0.039). The presence of any conversion criterion was associated with the detection of any proximal adenoma (P < 0.001) and adenoma ≥ 10 mm (P = 0.031). CONCLUSION: Male gender, polyps ≥ 10 mm and villous-preponderant histology at FS were predictors of adenomas < 10 mm and ≥ 10 mm at colonoscopy. Further data are required to assess the role for gender-based stratification of conversion criteria.

Management of acute upper gastrointestinal bleeding: an update for the general physician.

Acute upper gastrointestinal bleed (AUGIB) is one of the most common medical emergencies in the UK, with roughly one presentation every 6 min. Despite advances in therapeutics and endoscopy provision, mortality following AUGIB over the last two decades has remained high, with over 9,000 deaths annually in the UK; consequently, several national bodies have published UK-relevant guidelines. Despite this, the 2015 UK National Confidential Enquiry into Patient Outcome and Death in AUGIB highlighted variations in practice, raised concerns regarding suboptimal patient care and released a series of recommendations. This review paper incorporates the latest available evidence and UK-relevant guidelines to summarise the optimal pre-endoscopic, endoscopic, and post-endoscopic approach to and management of non-variceal and variceal AUGIB that will be of practical value to both general physicians and gastroenterologists.

Is there still a role for computerized strain gauge plethysmography in the assessment of patients with suspected deep vein thrombosis?

INTRODUCTION: Although deep vein thromboses (DVTs) are common, only a minority of patients referred with suspected DVT will have the condition. Various strategies exist to allow rapid and safe discharge of low-risk patients, thus precluding the need for imaging. AIMS AND OBJECTIVES: We aimed to investigate the accuracy of clinical risk assessment, D-Dimer analysis, computerized strain gauge plethysmography (CSGP) or a combination of the above in the assessment of outpatients with suspected DVT. METHODS: We performed a prospective cohort study on outpatients referred with suspected DVT to our medical assessment unit. Patients systematically underwent clinical risk assessment, D-Dimer analysis, CSGP and imaging with ultrasonography and/or venography. RESULTS: One hundred and eighty patients with suspected DVT were included in the analysis. Using a threshold of 0.6 mg/l, D-Dimer had a sensitivity and negative predictive value (NPV) of 100% for detecting DVT. Incorporating D-Dimer analysis with clinical risk assessment increased the specificity of the test. The sensitivity and NPV of CSGP were poor at 52.8 and 86.7%, respectively. Incorporating CSGP with D-Dimer did not influence decision making. Although the sensitivity of CSGP was higher for above knee (73.7%) than below knee DVT (29.4%), neither was sufficient for use as a screening tool. CONCLUSION: Our study did not support the role of CSGP either as a stand-alone screening tool or in conjunction with clinical risk scoring. As the evidence base for CSGP is conflicting, its accuracy should first be assessed before being incorporated into hospital algorithms as a DVT exclusion tool. However, our results support the current practice for D-Dimer use either alone or in conjunction with clinical assessment tool in the assessment of lower limb DVT.

Ruptured aneurysm of the common iliac artery as a cause of unilateral hip pain.

Rupture of an aneurysm of the common iliac artery is a rare cause of pain in the hip. We describe an elderly hypertensive patient with an aneurysmal rupture of the left common iliac artery who presented with unilateral hip pain masquerading as septic arthritis.