Exploring Endoscopic Competence in Gastroenterology Training: A Simulation-Based Comparative Analysis of GAGES, DOPS, and ACE Assessment Tools.

Purpose: Accurate and convenient evaluation tools are essential to document endoscopic competence in Gastroenterology training programs. The Direct Observation of Procedural Skills (DOPS), Global Assessment of Gastrointestinal Endoscopic Skills (GAGES), and Assessment of Endoscopic Competency (ACE) are widely used validated competency assessment tools for gastrointestinal endoscopy. However, studies comparing these 3 tools are lacking, leading to lack of standardization in this assessment. Through simulation, this study seeks to determine the most reliable, comprehensive, and user-friendly tool for standardizing endoscopy competency assessment. Methods: A mixed-methods quantitative-qualitative approach was utilized with sequential deductive design. All nine trainees in a gastroenterology training program were assessed on endoscopic procedural competence using the Simbionix Gi-bronch-mentor high-fidelity simulator, with 2 faculty raters independently completing the 3 assessment forms of DOPS, GAGES, and ACE. Psychometric analysis was used to evaluate the tools' reliability. Additionally, faculty trainers participated in a focused group discussion (FGD) to investigate their experience in using the tools. Results: For upper GI endoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.8, and 0.87 for ACE, DOPS, and GAGES, respectively. Inter-rater reliability (IRR) scores were 0.79 (0.43-0.92) for ACE, 0.75 (-0.13-0.82) for DOPS, and 0.59 (-0.90-0.84) for GAGES. For colonoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.82, and 0.85 for ACE, DOPS, and GAGES, respectively. IRR scores were 0.72 (0.39-0.96) for ACE, 0.78 (-0.12-0.86) for DOPS, and 0.53 (-0.91-0.78) for GAGES. The FGD yielded three key themes: the ideal tool should be scientifically sound, comprehensive, and user-friendly. Conclusion: The DOPS tool performed favourably in both the qualitative assessment and psychometric evaluation to be considered the most balanced amongst the three assessment tools. We propose that the DOPS tool be used for endoscopic skill assessment in gastroenterology training programs. However, gastroenterology training programs need to match their learning outcomes with the available assessment tools to determine the most appropriate one in their context.

Clinical profile, diagnostic yield, and procedural outcomes of single balloon enteroscopy: A tertiary care hospital experience.

BACKGROUND: Single balloon enteroscopy (SBE) allows ease of access for small bowel visualization and has multiple diagnostic and therapeutic indications. It provides the advantage of performing various therapeutic interventions alongside the diagnostic procedure. SBE has also been considered a relatively safe procedure with no major complications. AIM: To investigate the indications, safety, and clinical yield of SBE, and determine its effect on disease outcome. METHODS: A retrospective, descriptive study was conducted at a tertiary care hospital in Karachi, Pakistan. Medical records of 56 adult patients (≥ 18 years) who underwent SBE between July 2013 and December 2021 were reviewed and data were collected using a structured proforma. A descriptive analysis of the variables was performed using Statistical Package of Social Sciences Version 19. Results are reported as the mean ± SD for quantitative variables and numbers and percentages for qualitative variables. Missing data are reported as unknown. RESULTS: A total of 56 patients who underwent 61 SBE procedures were included. The mean age was 50.93 ± 16.16 years, with 53.6% of them being males. Hypertension (39.3%) and diabetes mellitus (25.0%) were the most common pre-existing comorbidities. Obscure gastrointestinal bleed (39.3%) was the most common indication for enteroscopy, followed by chronic diarrhea (19.7%) and unexplained anemia (16.4%). The majority of procedures were performed in the endoscopy suite (90.2%) under monitored anaesthesia care (93.4%). Most procedures were diagnostic (91.8%) and completed without complications (95.1%). The depth of examination ranged from 95 cm to 500 cm with a mean of 282.05 ± 90.04 cm. The most common findings were inflammation and ulcerations (29.5%), followed by masses (19.7%) and vascular malformations (14.8%). As a result of the findings, a new diagnosis was made in 47.5% of the cases and a previous one was ruled out in 24.6% of them; 65.6% of the cases had a change in management. CONCLUSION: SBE is a suitable modality for investigating diseases in the small bowel. It is shown to be technically efficient and reasonably safe and is associated with high diagnostic and therapeutic yield.

Clinical spectrum of Celiac Disease in adults at a tertiary care hospital in Karachi, Pakistan.

Objectives: Celiac Disease (CD) is a disorder that impacts physical, social and emotional health. Requiring life-long treatment, it poses a major economic burden on the healthcare system. Our objective was to study CD in patients from initial presentation to diagnosis and to ascertain the effect of a low resource setting on improvement in disease process. Methods: This is a retrospective cross-sectional study conducted at a Aga Khan University Hospital (AKUH), a tertiary care center in Karachi, Pakistan. Medical records of patients (≥ 18 years) from 2008 to 2018 with a diagnosis of CD were reviewed. Data on demographics, presenting complaints, investigations, endoscopy results and follow up visits was collected. Results: One hundred and twenty-six patients were included (61.6% females, mean age 35.5 years). The most common intestinal and extra-intestinal symptoms were abdominal pain (56.3%) and fatigue (24.6%) respectively. After microcytic anemia (36.5%), increased ALT (27.2%) was the most common laboratory derangement. On endoscopy, visible fissuring (29.4%) and atrophic mucosa (29.4%) were reported. Biopsy findings showed increased intraepithelial lymphocytes (92.9%) and villous atrophy (77.8%). Improvement in at least one of three parameters (symptoms, laboratory values or EGD) was reported by 42.0% of subjects, whereas 48.4% subjects were lost to follow-up. Conclusion: The most commonly reported symptoms by CD patients were abdominal pain, diarrhea and anemia. Thus, patients presenting with vague abdominal symptoms and anemia should be worked up for CD. A concerning majority of subjects was lost to follow up for reasons such as inability to afford advised GFD and a poor understanding of the disease process.

Healthcare Simulation: A Key to the Future of Medical Education - A Review.

Aim: Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift of focus towards patient safety and calls for reduction in training duration have burdened educators with providing adequate quantity and quality of clinical exposure to students and residents in a short time. Furthermore, the COVID-19 pandemic has severely hindered clinical education to curb the spread of illness. Simulation may be beneficial in these circumstances and improve learner confidence. We undertook a literature search on MEDLINE using MeSH terms to obtain relevant information on simulation-based medical education and how to best apply it. Integration of simulation into curricula is an essential step of its implementation. With allocations for deliberate practice and mastery learning under supervision of qualified facilitators, this technology is becoming essential in medical education. Purpose: To review the adaptation, spectrum of use, importance, and resource challenges of simulation in medical education and how best to implement it according to learning theories and best practice guides. Conclusion: Simulation offers students and residents with adequate opportunities to practice their clinical skills in a risk-free environment. Unprecedented global catastrophes provide opportunities to explore simulation as a viable training tool. Future research should focus on sustainability of simulation-based medical education in LMICs.

Viral Hepatitis - The Road Traveled and the Journey Remaining.

Hepatitis is defined as inflammation of the liver and is commonly due to infection with The hepatotropic viruses - hepatitis A, B, C, D and E. Hepatitis carries one of the highest disease burdens globally and has caused significant morbidity and mortality among different patient populations. Clinical presentation varies from asymptomatic or acute flu-like illness to acute liver failure or chronic liver disease, characterized by jaundice, hepatomegaly and ascites among many other signs. Eventually, this can lead to fibrosis (cirrhosis) of the liver parenchyma and carries a risk of development into hepatocellular carcinoma. Hepatitis B and C are most notorious for causing liver cirrhosis; in 2019, an estimated 296 million people worldwide had chronic hepatitis B infection and 58 million are currently estimated to have chronic hepatitis C, with 1.5 million new infections of both hepatitis B and C, occurring annually. With the help of latest serological biomarkers and viral nucleic acid amplification tests, it has become rather simple to efficiently screen, diagnose and monitor patients with hepatitis, and to commence with appropriate antiviral treatment. More importantly, the development of vaccinations against some of these viruses has greatly helped to curb the infection rates. Whilst there has been exceptional progress over the years in the management of viral hepatitis, many hurdles still remain which must be addressed in order to proceed towards a hepatitis-free world. This review will shed light on the origin and discovery of the hepatitis viruses, the global epidemiology and clinical symptoms, diagnostic modalities, currently available treatment options, the importance of prevention, and the journey needed to move forward towards the eradication of its global disease burden.

Safety of Endoscopy and Its Outcome in Pregnancy.

OBJECTIVE: Gastrointestinal (GI) endoscopy is an important tool for diagnosis and treatment of GI diseases. However, when endoscopy is indicated during pregnancy, concerns about its safety for mother and fetus often arise. Our objective was to evaluate the safety and efficacy of endoscopic procedures in pregnant patients along with maternal and fetal outcomes. METHODS: This study was conducted at the Aga Khan University Hospital after Ethics review committee approval. It was a retrospective study and medical records of all pregnant patients who underwent endoscopy during pregnancy from January 2000 to January 2014 were analyzed. Data regarding the indications and type of endoscopic procedure, use of sedation and radiation were noted; data on any complications during or after pregnancy were recorded as well. RESULTS: A total of 48 pregnant women underwent endoscopic procedures. Procedures that were performed included gastroscopy, sigmoidoscopy, colonoscopy, and endoscopic retrograde cholangio-pancreaticography (ERCP) in 28, 15, 1, and 4 patients, respectively. The major indication for gastroscopy was hematemesis in 16 procedures (57.14%) and screening for esophageal varices was done in 10 (21.42%). The indications of ERCP were choledocholithiasis and cholangitis. However, bleeding per rectum was the main indication for sigmoidoscopy and colonoscopy. Some 34 (70.83%) procedures were diagnostic and the rest were therapeutic. Only one patient had a miscarriage in second trimester. CONCLUSIONS: Endoscopic procedures are safe to be performed in pregnant patients in the presence of strong indications without posing major risk to the mother or the fetus. However, further prospective multicenter research studies are strongly recommended.

MORBIDITY AND MORTALITY ASSESSMENT IN ACUTE HEPATITIS-E.

BACKGROUND: Hepatitis-E is an enterically transmitted virus causing acute hepatitis. Mostly it is a self-limiting clinical course, but can be life threatening in certain high risk groups. Pakistan is endemic for Hepatitis-E with limited published literature. The aim of this study is to evaluate the predictors of mortality in patients with acute Hepatitis-E. METHODS: We analyzed the medical records of 369 adult patients with Hepatitis-E infection admitted at Aga khan University Hospital, from January 1996 to December 2010. Details of their laboratory investigations, clinical course and complications such as FHF and mortality were noted. The outcome was compared, and determinants of mortality were evaluated in important patient subgroups. RESULTS: Out of 369 patients with Hepatitis-E, 326 (88.3%) were discharged after full recovery. Out of these 22 (6%) patients had chronic liver disease CLD in this study, of whom 10 (2.7%) expired (p-value <0.001). There were about 67 (18%) pregnant patients, with a mean gestational age of 29.19 +/- 7.68 weeks and 5 (1.4%) pregnant patients died (p-value=0.23). A total of 58 (15.7%) patients were coinfected with other hepatotropic virus, and a comparison did not find an increased risk of mortality in this group. CONCLUSION: This study showed that Hepatitis-E is significantly associated with mortality in patients suffering from pre-existing chronic liver disease. Pregnancy was not a determinant of mortality in Hepatitis-E patients in this study, and neither was coinfection with other Hepatotropic viruses.

Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: a multicentre randomized controlled trial.

BACKGROUND & AIMS: Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective ß blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. METHODS: Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. RESULTS: Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. CONCLUSIONS: Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education.

OBJECTIVE: To determine patients perception and knowledge regarding diet in cirrhosis and its relationship with the level of patients education. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: This study was conducted at Gastroenterology Outpatient Clinics at the Aga Khan University Hospital, Karachi, the Aga Khan Health Services, Malir, Karachi and Hamdard University, Karachi, from January to December 2010. METHODOLOGY: Consecutive adult patients with compensated cirrhosis were enrolled. Demographic data, level of education, type and reason of food restriction as well as the source of dietary information was asked. Baseline laboratory test were performed, and nutritional status was assessed by BMI normogram. RESULTS: Ninety patients, 58% male were enrolled. Mean age of the patient was 49 ± 11 years. Overall 73% of the patients were restricting fat, meat, fish and eggs in their diet; 53% were in uneducated group and 47% were in educated group (CI, 0.24-1.62, p-0.34). Twenty two patients (62.8%) in uneducated and 21 in educated group (68%) were restricting diet on the advice of their doctors, whereas 13 in uneducated group (37%) and 11 in educated group (32%) believed these dietary components to be harmful for the liver. Thirty two of uneducated patient (71.1%) and 28 of educated patients (62.2%) believed that vegetables, fruits and sugarcane had a beneficial effect on the liver. Main source of dietary information to the patients was the doctor. On sub-group analysis those who restricted diet irrespective of their educational level, had more patients with BMI less than 18.5 kg/m2, (CI 0.01-0.94, p-0.001), haemoglobin less than 12 g/dl (CI 0- 0.03, p-0.001) and serum albumin less than 3 g/dl (CI 0.1- 03, p-0.001). CONCLUSION: Both educated and uneducated classes of the patients have improper knowledge and perception of diet in cirrhosis. Patients with cirrhosis who restricted diet, had relatively low BMI, haemoglobin and albumin as compared to those who did not restrict. Main source of dietary information to cirrhotic patients were health care personnels.

Nutritional status in patients with hepatitis C.

OBJECTIVE: To assess the nutritional status via the SGA (subjective global assessment) screening tool of patients at all stages of hepatitis C virus (HCV) liver disease. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Out-patient Clinics of the Aga Khan University Hospital, Karachi, conducted from October 2009 to January 2011. METHODOLOGY: Patients with hepatitis C virus infection and their HCV-negative attendants were enrolled from the outpatient clinics, and categorized into 4 groups of 100 patients each: healthy controls (HC), those with chronic hepatitis C infection (CHC), compensated cirrhotics (CC) and decompensated cirrhotics (DC). The validated subjective global assessment (SGA) tool was used to assess nutritional status. RESULTS: A total of 400 patients were enrolled. Most of the patients in the HC group were class 'A' (best nutritional status). In contrast, the majority (64%) in the DC group were in the class 'C' (worst status). The compensated cirrhosis (CC) group showed that 90% of patients were malnourished, while 98% of all patients were malnourished in the DC group, predominantly class 'C'. Most importantly, 14% of patients with chronic hepatitis C (CHC) also scored a 'B' on the SGA; which when compared to HC was statistically significant (p=0.005). As the groups progressed in their disease from CHC to DC, the transition in nutritional status from 'A' to 'C' between groups was statistically significant. CONCLUSION: Malnutrition occurs early in the course of HCV, and progresses relentlessly throughout the spectrum of HCVdisease.

Safety and utility of oesophago-gastro-duodenoscopy in acute myocardial infarction.

AIM: To study the safety and utility of performing an oesophago-gastro-duodenoscopy (EGD) in the setting of an acute myocardial infarction (AMI). METHODS: Case records of all patients who underwent an EGD for various indications within 4 weeks of an AMI between January 2001 and April 2006 were analyzed. Demographic data, indications for endoscopy, outcomes and complications were noted. Main outcome measures included safety and utility of endoscopy in AMI. RESULTS: A total of 87 EGDs were performed on 85 patients with AMI. Seventy (83%) patients had a non-ST elevation MI, whereas 15 (17%) had ST elevation MI. Mean time between EGD and AMI was 6+/-1.8 days. Indications for EGD were hematemesis and/or melena on presentation in 38 (44.7%), hematemesis and/or melena post anticoagulation in 27 (31.8%). EGD findings were gastric ulcer/erosions in 30 (34%), oesophago-gastric varices in 20 (22%), erosive oesophagitis in 17 (20%) and duodenal ulcer in 11 (13%). Diagnostic yield of EGD was 88%. Endoscopic interventions were performed in 26 (30%) patients with high risk of bleeding lesion. There were no EGD-related mortality, whereas 14 patients re-bled. A total of 21 patients died, including 7/14 (50%) who re-bled, compared with 14/71 (19%) without rebleed (P=0.008). There were no EGD-related deaths. Fourteen patients were on mechanical ventilation and 6/14 (43%) of these died as compared with 15/88 (17%) who were not ventilated (P=0.027). CONCLUSION: EGD is safe and useful in diagnosis and management of gastrointestinal hemorrhage in patients with AMI, and allows decisions about anticoagulation. Re-bleed and need for mechanical ventilation predicts poor outcome in these patients.

Noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage.

AIM: To identify noninvasive factors predicting the presence of large varices (LV) in patients hospitalized with gastroesophageal variceal hemorrhage (GEVH). METHODS: Case records of patients admitted with GEVH between January 1998 and June 2005 were retrospectively analyzed. Relevant clinical parameters assessed included Child-Pugh class, ascites (clinical and/or on ultrasound), portosystemic encephalopathy (PSE), splenomegaly (clinical and/or on ultrasound), and hemodynamic instability. The laboratory parameters assessed were hemoglobin level, platelet count, prothrombin time, serum bilirubin, and albumin. The ultrasonographic characteristics noted were splenic size, presence of splenic varices, and portal vein diameter. RESULTS: A total of 420 patients (264 men) presented with GEVH during the study period. The mean age, gender distribution, and presence of cirrhosis were similar in the two groups. Liver cirrhosis with hepatocellular carcinoma (HCC), Child-Pugh class C, presence of clinically detectable ascites, grade 3-4 PSE, detectable splenomegaly, previous history of GEVH, hemodynamic instability and platelet count <91,000 were more common in the LV group. The frequency of radiologically detected ascites, splenomegaly, and portal vein diameter were similar in both groups. On multivariate analysis, the independent predictors for the presence of LV were cirrhosis with HCC, clinically detectable splenomegaly, hemodynamic instability, a previous history of GEVH, platelet count <91,000, and splenic size >/=158 mm. CONCLUSION: Cirrhosis with HCC, clinical splenomegaly, hemodynamic instability, a previous history of GEVH, thrombocytopenia (i.e., platelet count <91,000), and splenic size >/=158 mm are independent noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage.

Spectrum of neurological involvement in adult patients with bacterial endocarditis.

OBJECTIVE: To describe the spectrum of neurological involvement, and document in-hospital mortality in adult patients with bacterial endocarditis. DESIGN: Descriptive, non-interventional. PLACE AND DURATION OF STUDY: Department of Gastroenterology, The Aga Khan University Hospital, Karachi from November 1999 to October 2002. PATIENTS AND METHODS: Patients were enrolled from the emergency and outpatient departments, using purposive, non-probability sampling, provided they fulfilled pre-defined inclusion and exclusion criteria. Case records of patients admitted to hospital with a diagnosis of bacterial endocarditis were prospectively analyzed. Data was entered and analyzed on SPSS 11. Frequency, Mean, Mode and Percentage were calculated. RESULTS: Neurological complications were observed in 14 out of 40 patients (35%). The most frequent complication was embolic infarction (33%), followed by intra-cranial hemorrhage (22 %). Seizures, encephalopathy, abscess and meningitis were all observed in decreasing order of frequency. Out of a total of 14 patients who suffered neurological complications, 06 died (42 %). CONCLUSION: The nervous system is frequently involved in patients with bacterial endocarditis. The nature of neurological involvement can vary from a fatal embolic infarction to infective complications, such as cerebral abscess or meningitis, to mild encephalopathy. The most frequently noted complication was embolic infarction. In-hospital mortality is significantly high in patients who suffer neurological complications.