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This White Paper shares guidance on the important principles of training endoscopy teachers, the focus of an American Society for Gastrointestinal Endoscopy (ASGE)/World Endoscopy Organization Program for Endoscopic Teachers and Leaders of Endoscopic Training held at the ASGE Institute for Training and Technology. Key topics included the need for institutional support and continuous skills development, the importance of consensus and consistency in content and approach to teaching, the role of conscious competence and content breakdown into discreet steps in effective teaching, defining roles of supervisors versus instructors to ensure teaching consistency across instructors, identification of learning environment factors and barriers impacting effective teaching, and individualized training that incorporates effective feedback and adapts with learner proficiency. Incorporating simulators into endoscopy teaching, applying good endoscopy teaching principles outside the endoscopy room, key principles of hands-on training, and effective use of simulators and models in achieving specific learning objectives were demonstrated with rotations through hands-on simulator stations as part of the program. A discussion of competency-based assessment was followed by live sessions in which attendees applied endoscopy teaching principles covered in the program. Conclusions highlighted the need for the following: formal training of endoscopy teachers to a level of conscious competence, incorporation of formal training structures into existing training curricula, intentional teaching preparation, feedback to trainees and instructors alike aimed at improving performance, and competency-based trainee assessment. The article is intended to help motivate individuals who play a role in training other endoscopists to develop their teaching abilities, promote discussions about endoscopy training, and engage both endoscopy trainers and trainees in a highly rewarding learning process that is in the best interest of patients.
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Competência Clínica , Endoscopia Gastrointestinal/educação , Gastroenterologia/educação , Treinamento por Simulação , Capacitação de Professores , Currículo , Feedback Formativo , Humanos , Ensino/educaçãoRESUMO
BACKGROUND & AIMS: Lynch syndrome is a genetic disorder that greatly increases risk for colorectal and other cancers, although it is underdiagnosed. Prediction of MLH1, MSH2, and MSH6 (PREMM1,2,6) is a web-based tool that analyzes individuals' personal/family histories of cancer to quantify their likelihood of carrying a germline mutation associated with Lynch syndrome. We investigated the feasibility of systematic risk assessment for Lynch syndrome in a community gastroenterology practice using a patient-completed version of PREMM1,2,6. METHODS: PREMM1,2,6 was adapted into a computer tablet version designed for self-administration by patients. Individuals presenting to a community gastroenterology office and endoscopy facility in California completed the PREMM1,2,6 assessment before their visit (n = 3134). The total study duration (8 months) comprised a 2-month initiation period (May 1-June 30, 2013) and a 6-month study period (July 1-December 31, 2013). Genetic counseling and germline analysis for mutations in genes associated with Lynch syndrome (MLH1, MSH2, MSH6, PMS2, and EPCAM) were offered to individuals with PREMM1,2,6 scores of 5% or higher. Patients and providers completed surveys to evaluate the feasibility and satisfaction with the process. RESULTS: Of the 3134 individuals assessed by PREMM1,2,6 during the 6-month study period, 177 individuals (5.6%) had scores of 5% or higher. Of these, 146 individuals underwent genetic testing, along with 28 additional participants recruited nonconsecutively during the initiation period. Mutations associated with Lynch syndrome were detected in 3 of the 146 individuals (2.1%) with PREMM1,2,6 scores of 5% or higher who underwent germline testing, and 3 of the 28 patients (10.7%) recruited during study initiation with PREMM1,2,6 scores of 5% or higher. Of the participants who underwent genetic analysis, 98.6% stated that they understood the information provided to them. All of the surveyed providers stated that they were satisfied with the incorporation of PREMM1,2,6 into their clinical practice, and that they would continue using it to assess risk for Lynch syndrome. CONCLUSIONS: A patient self-administered version of the PREMM1,2,6 Lynch syndrome risk assessment model can be used systematically in community-based gastroenterology and endoscopy practices.
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Neoplasias Colorretais Hereditárias sem Polipose/diagnóstico , Anamnese/métodos , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , California/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto JovemRESUMO
BACKGROUND & AIMS: Alcohol has been implicated in the development of chronic pancreatitis (CP) in 60%-90% of patients, although percentages in the United States are unknown. We investigated the epidemiology of alcohol-related CP at tertiary US referral centers. METHODS: We studied data from CP patients (n = 539) and controls (n = 695) enrolled in the North American Pancreatitis Study-2 from 2000 to 2006 at 20 US referral centers. CP was defined by definitive evidence from imaging or histologic analyses. Subjects and physicians each completed a study questionnaire. Using physician-assigned diagnoses, patients were assigned to an etiology group: alcohol (with/without other diagnoses), nonalcohol (any etiology of CP from other than alcohol), or idiopathic (no etiology identified). RESULTS: The distribution of patients among etiology groups was: alcohol (44.5%), nonalcohol (26.9%), and idiopathic (28.6%). Physicians identified alcohol as the etiology more frequently in men (59.4% men vs 28.1% women), but nonalcohol (18% men vs 36.7% women) and idiopathic etiologies (22.6% men vs 35.2% women) more often in women (P < .01 for all comparisons). Nonalcohol etiologies were equally divided among obstructive, genetic, and other causes. Compared with controls, patients with idiopathic CP were more likely to have ever smoked (58.6% vs 49.7%, P < .05) or have a history of chronic renal disease or failure (5.2% vs 1.2%, P < .01). In multivariate analyses, smoking (ever, current, and amount) was independently associated with idiopathic CP. CONCLUSIONS: The frequency of alcohol-related CP at tertiary US referral centers is lower than expected. Idiopathic CP and nonalcohol etiologies represent a large subgroup, particularly among women. Smoking is an independent risk factor for idiopathic CP.
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Consumo de Bebidas Alcoólicas/efeitos adversos , Pancreatite Crônica/epidemiologia , Fumar/efeitos adversos , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite Crônica/diagnóstico , Fatores de Risco , Inquéritos e Questionários , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: There are few comparative data as to whether plastic or self-expanding metallic stents are preferable for palliating malignant hilar biliary obstruction. METHODS: Thirty-day outcomes of consecutive endoscopic retrograde cholangiopancreatographies performed for malignant hilar obstruction at 6 private and 5 university centers were assessed prospectively. RESULTS: Patients receiving plastic (N=28) and metallic stents (N=34) were similar except that metallic stent recipients more often had: Bismuth III or IV tumors (16/34 vs. 5/28 P=0.043), higher Charlson comorbidity scores (P=0.003), metastatic disease (P=0.006), and management at academic centers (P=0.018). The groups had similar rates of bilateral stent placement (4/28 vs. 5/34), and similar frequency of opacified but undrained segmental ducts (7/28 vs. 5/34). Adverse outcomes including cholangitis, stent occlusion, migration, perforation, and/or the need for unplanned endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography occurred in 11/28 (39.3%) patients with plastic versus 4/34 (11.8%) with metal stents (P=0.017). By logistic regression, factors associated with adverse outcomes included plastic stent placement (odds ratio 6.32; 95% confidence interval 1.23, 32.56) and serum bilirubin (1.11/mg/dL above normal: 1.01, 1.22) but not center type or Bismuth class. CONCLUSIONS: Metallic stent performance was superior to plastic for hilar tumor palliation with respect to short-term outcomes, independent of disease severity, Bismuth class, or drainage quality.
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Neoplasias dos Ductos Biliares/complicações , Ductos Biliares/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Stents , Idoso , Neoplasias dos Ductos Biliares/patologia , Ductos Biliares/patologia , Bilirrubina/sangue , Estudos de Coortes , Drenagem/métodos , Feminino , Humanos , Modelos Logísticos , Masculino , Metais , Pessoa de Meia-Idade , Metástase Neoplásica , Cuidados Paliativos/métodos , Plásticos , Estudos Prospectivos , Índice de Gravidade de Doença , Stents/efeitos adversosRESUMO
Percutaneous endoscopic gastrostomy (PEG) or PEG tube with transgastric jejunostomy tube (PEG-J) feeding has not been shown to decrease aspiration pneumonia. The aim of this study was to determine if direct percutaneous endoscopic jejunostomy (DPEJ) tube placement results in a decreased incidence of aspiration pneumonia in high-risk patients. The design was a retrospective review of all patients receiving DPEJ tube for aspiration pneumonia from 1999 to 2005. Demographics, incidence of aspiration pneumonia, and outcomes were collected and compared before and after the DPEJ placement. Eleven patients (4 women, 7 men) were identified; their mean age was 44.9 years (range, 18-94 years). The etiologies for recurrent aspiration pneumonia were neurologic disease (9), esophageal surgery (1), and severe debilitation (1). The mean follow-up was 20.9 months (range, 6-48 months). The patients' mean weight increased from 43.8 kg (range, 19-55 kg) to 48.3 kg (range, 30-65 kg) after placement (P < .001). The total number of documented aspiration pneumonia episodes for all patients decreased from 29 (mean, 3.64; range, 1-6) before DPEJ placement to 3 (mean, 0.27; range, 0-2) after DPEJ placement (P < .001). The mean number of aspiration pneumonia events per month prior to the DPEJ placement was 3.39 and postplacement was 0.42 (P < .001). DPEJ placement appears to decrease recurrent aspiration pneumonia in patients with history of aspiration pneumonia.
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Nutrição Enteral/instrumentação , Gastrostomia/efeitos adversos , Intubação Gastrointestinal/métodos , Jejunostomia , Pneumonia Aspirativa/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Gastroscopia , Humanos , Intubação Gastrointestinal/efeitos adversos , Intubação Gastrointestinal/normas , Masculino , Pessoa de Meia-Idade , Pneumonia Aspirativa/etiologia , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Sessile serrated polyps (SSPs) have emerged as important precursors for a large number of sporadic colorectal cancers. They are difficult to detect during colonoscopy due to their flat shape and the excessive amounts of secreted mucin that cover the polyps. The underlying genetic and epigenetic basis for the emergence of SSPs is largely unknown with existing genetic studies confined to a limited number of oncogenes and tumor suppressors. A full characterization of the genetic and epigenetic landscape of SSPs would provide insight into their origin and potentially offer new biomarkers useful for detection of SSPs in stool samples. METHODS: We used a combination of genome-wide mutation detection, exome sequencing and DNA methylation profiling (via methyl-array and whole-genome bisulfite sequencing) to analyze multiple samples of sessile serrated polyps and compared these to familial adenomatous polyps. RESULTS: Our analysis revealed BRAF-V600E as the sole recurring somatic mutation in SSPs with no additional major genetic mutations detected. The occurrence of BRAF-V600E was coincident with a unique DNA methylation pattern revealing a set of DNA methylation markers showing significant (~3 to 30 fold) increase in their methylation levels, exclusively in SSP samples. These methylation patterns effectively distinguished sessile serrated polys from adenomatous polyps and did so more effectively than parallel gene expression profiles. CONCLUSIONS: This study provides an important example of a single oncogenic mutation leading to reproducible global DNA methylation changes. These methylated markers are specific to SSPs and could be of important clinical relevance for the early diagnosis of SSPs using non-invasive approaches such as fecal DNA testing.
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Pólipos Adenomatosos/genética , Pólipos do Colo/genética , Metilação de DNA , Mutação , Proteínas Proto-Oncogênicas B-raf/genética , Pólipos Adenomatosos/patologia , Pólipos do Colo/patologia , Ilhas de CpG/genética , Regulação Neoplásica da Expressão Gênica , Humanos , Recidiva Local de Neoplasia , Sequenciamento Completo do Genoma/métodosRESUMO
Enteral is preferred to parenteral nutritional support for acute and chronic diseases because it is more physiological and associated with fewer infection complications. Nasal tube feedings are generally used for 30 days or less and percutaneous access for the longer-term. Feeding by naso-gastric tubes is appropriate for most critically ill patients. However, trans-pyloric feeding is indicated for those with regurgitation and aspiration of gastric feeds. Deep naso-jejunal tube feeding is appropriate for patients with severe acute pancreatitis. There are several methods for endoscopic placement of naso-enteric tubes. Percutaneous endoscopic gastrostomy is used for most persons requiring long-term support. Long-term jejunal feeding is most often used for persons with chronic aspiration of gastric feeds, chronic pancreatitis intolerant to eating, or persons in need of concomitant gastric decompression. Percutaneous endoscopic gastrostomy with a jejunal tube extension is fraught with tube dysfunction and dislocation. Direct percutaneous endoscopic jejunostomy tubes may be more robust, but are less commonly performed.
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Endoscopia Gastrointestinal , Nutrição Enteral/métodos , Intubação Gastrointestinal/métodos , Gastrostomia , Humanos , JejunostomiaAssuntos
Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Esfinterotomia Endoscópica/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Recidiva , Reoperação , Estudos Retrospectivos , Esfinterotomia Endoscópica/métodos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Secondary prevention of colorectal cancer with FOBT and endoscopy with polypectomy decreases cancer deaths. Other available modalities include genetic tests and imaging studies, but outcomes data are not yet available. Issues remain concerning the most appropriate test, the optimal intervals, and cost-efficacy. Patients may be stratified by personal and family risk, and specific strategies may be used. Newer developments in genetic tests and imaging, including virtual colonoscopy, hold promise for the future. The most important issue at present is to have people screened or surveilled by any of the recommended modalities.
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Neoplasias do Colo/prevenção & controle , Neoplasias Retais/prevenção & controle , Adenoma/diagnóstico , Adenoma/prevenção & controle , Carcinoma/diagnóstico , Carcinoma/prevenção & controle , Carcinoma/cirurgia , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/cirurgia , Pólipos do Colo/diagnóstico , Pólipos do Colo/prevenção & controle , Pólipos do Colo/cirurgia , Colonografia Tomográfica Computadorizada , Colonoscopia , Família , Humanos , Programas de Rastreamento , Pessoa de Meia-Idade , Sangue Oculto , Neoplasias Retais/diagnóstico , Neoplasias Retais/cirurgia , Fatores de Risco , SigmoidoscopiaRESUMO
OBJECTIVE: To determine the optimal methods for pancreatic adenocarcinoma surveillance in high-risk patients with familial melanoma and cyclin-dependent kinase inhibitor 2A (CDKN2A) mutations. DESIGN: Case report with pedigree analysis and literature review, with an emphasis on guideline development for high-risk kindreds with familial pancreatic adenocarcinoma. SETTING: A university-affiliated familial melanoma research clinic. Patients The proband was referred as a participant in a research clinic protocol and was found to carry a germline CDKN2A mutation and have a history of melanoma and pancreatic adenocarcinoma. A total of 179 family members were identified through the Utah Population Database and underwent evaluation for history of melanoma and pancreatic adenocarcinoma.Intervention/ METHODS: Comprehensive family history and pedigree analysis performed by means of personal interview, medical record review, and use of cancer registry and population database records. Mutation status was confirmed by results of DNA sequence analysis. Tumor identity was confirmed with immunohistochemical markers. MAIN OUTCOME MEASURES: Estimated risk for pancreatic adenocarcinoma in a high-risk family with CDKN2A-positive melanoma. Guidelines for surveillance in these families were based on review of the literature. RESULTS: Sequence analysis confirmed a CDKN2A mutation, and immunohistochemical evaluation confirmed the diagnoses of metastatic melanoma and metastatic pancreatic adenocarcinoma. Pedigree analysis showed an observed-expected ratio of 8.9 to 12.6 for pancreatic adenocarcinoma and 16.4 to 20.8 for melanoma in this family. Guidelines used for surveillance of kindreds at high risk for pancreatic adenocarcinoma were applied to families with CDKN2A melanoma. Conclusion Patients with melanoma and a germline CDKN2A mutation should be considered for pancreatic adenocarcinoma surveillance that is based on the most recent published studies.
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Adenocarcinoma/diagnóstico , Adenocarcinoma/genética , Inibidor p16 de Quinase Dependente de Ciclina/genética , Melanoma/diagnóstico , Melanoma/genética , Mutação/genética , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/genética , Vigilância da População/métodos , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/genética , Adenocarcinoma/etiologia , Adulto , Humanos , Masculino , Melanoma/complicações , Pessoa de Meia-Idade , Neoplasias Pancreáticas/etiologia , Linhagem , Fatores de Risco , Neoplasias Cutâneas/complicaçõesRESUMO
Colorectal cancer is very common and is closely related to patient age. After age, the second most common risk factor is family history of colon cancer. In fact, it is one of the most hereditable cancers. Colon cancer is preventable and screening has demonstrated efficacy in the reduction of both the incidence and the mortality from colorectal cancer. Several screening techniques are currently available, including endoscopy and nonendoscopic-based techniques. Screening strategies vary according to the individual risk of colon cancer. This paper will focus on the screening recommendations for patients with high-risk colon cancer.
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Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/prevenção & controle , Programas de Rastreamento , Vigilância da População , Colonoscopia/métodos , Colonoscopia/tendências , Neoplasias Colorretais/genética , Humanos , Programas de Rastreamento/métodos , Programas de Rastreamento/tendências , Vigilância da População/métodos , Fatores de RiscoRESUMO
The medical literature supports the use of enteral feeding to provide nutrition and improve patient outcomes. A major complication of enteral feeding is aspiration and associated morbidity and mortality. Many knowledge gaps exist that inhibit our ability to define and diagnose aspiration, identify patients at risk, and develop prevention techniques. Several areas of inquiry should be explored to help us define and prevent the disorder--for instance, standardized criteria should be developed for diagnosing aspiration pneumonia and for differentiating it from other types of pneumonia, and accurate tests should be devised for detecting it. Research also is needed to evaluate the influence of (1) various enteral feeding sites on aspiration risk, (2) the effects of risk reduction techniques such as selective decontamination and use of promotility agents, and (3) potential benefits of immunonutrition. Current parameters used in decisions about when to initiate enteral feeding in critically ill patients are defined.
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Nutrição Enteral/efeitos adversos , Nutrição Enteral/tendências , Pneumonia Aspirativa/prevenção & controle , HumanosRESUMO
Aspiration is the leading cause of pneumonia in the intensive care unit and the most serious complication of enteral tube feeding (ETF). Although aspiration is common, the clinical consequences are variable because of differences in nature of the aspirated material and individual host responses. A number of defense mechanisms normally present in the upper aerodigestive system that protect against aspiration become compromised by clinical events that occur frequently in the critical care setting, subjecting the patient to increased risk. The true incidence of aspiration has been difficult to determine in the past because of vague definitions, poor assessment monitors, and varying levels of clinical recognition. Standardization of terminology is an important step in helping to define the problem, design appropriate research studies, and develop strategies to reduce risk. Traditional clinical monitors of glucose oxidase strips and blue food coloring (BFC) should no longer be used. A modified approach to use of gastric residual volumes and identification of clinical factors that predispose to aspiration allow for risk stratification and an algorhythm approach to the management of the critically ill patient on ETF. Although the patient with confirmed aspiration should be monitored for clinical consequences and receive supportive pulmonary care, ETF may be continued when accompanied by appropriate steps to reduce risk of further aspiration. Management strategies for treating aspiration pneumonia are based on degree of diagnostic certainty, time of onset, and host factors.
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Estado Terminal/terapia , Nutrição Enteral/efeitos adversos , Inalação/fisiologia , Pneumonia Aspirativa , Humanos , América do NorteRESUMO
Patients with chronic pancreatitis (CP) often have maldigestion and malnutrition. Nutrition support during acute and CP traditionally has been provided by parenteral nutrition. In acute pancreatitis, jejunal feeding may accelerate resolution of the inflammatory process, protect against infection, and improve outcomes at a reduced cost when compared with parenteral nutrition. Jejunal feeding may also be beneficial for patients with CP. Prolonged jejunal access may be achieved via a direct percutaneous endoscopic jejunostomy (DPEJ). This article will review the rationale and evidence for jejunal feeding, indications and contraindictions for DPEJ placement, and the technique and outcomes of DPEJ in patients with CP.
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OBJECTIVE: This study aims to describe the frequency of use and reported effectiveness of endoscopic and surgical therapies in patients with chronic pancreatitis treated at US referral centers. METHODS: Five hundred fifteen patients were enrolled prospectively in the North American Pancreatitis Study 2, where patients and treating physicians reported previous therapeutic interventions and their perceived effectiveness. We evaluated the frequency and effectiveness of endoscopic (biliary or pancreatic sphincterotomy, biliary or pancreatic stent placement) and surgical (pancreatic cyst removal, pancreatic drainage procedure, pancreatic resection, surgical sphincterotomy) therapies. RESULTS: Biliary and/or pancreatic sphincterotomy (42%) were the most common endoscopic procedure (biliary stent, 14%; pancreatic stent, 36%; P < 0.001). Endoscopic procedures were equally effective (biliary sphincterotomy, 40.0%; biliary stent, 40.8%; pancreatic stent, 47.0%; P = 0.34). On multivariable analysis, the presence of abdominal pain (odds ratio, 1.82; 95% confidence interval, 1.15-2.88) predicted endoscopy, whereas exocrine insufficiency (odds ratio, 0.63; 95% confidence interval, 0.42-0.94) deterred endoscopy. Surgical therapies were attempted equally (cyst removal, 7%; drainage procedure, 10%; resection procedure, 12%) except for surgical sphincteroplasty (4%; P < 0.001). Surgical sphincteroplasty was the least effective (46%; P < 0.001) versus cyst removal (76% drainage [71%] and resection [73%]). CONCLUSIONS: Although surgical therapies were performed less frequently than endoscopic therapies, they were more often reported to be effective.