Evaluating learning curves and competence in colorectal EMR among advanced endoscopy fellows: a pilot multicenter prospective trial using cumulative sum analysis.

BACKGROUND AND AIMS: Data on colorectal EMR (C-EMR) training are lacking. We aimed to evaluate C-EMR training among advanced endoscopy fellows (AEFs) by using a standardized assessment tool (STAT). METHODS: This multicenter prospective study used a STAT to grade AEF training in C-EMR during their 12-month fellowship. Cumulative sum analysis was used to establish learning curves and competence for cognitive and technical components of C-EMR and overall performance. Sensitivity analysis was performed by varying failure rates. AEFs completed a self-assessment questionnaire to assess their comfort level with performing C-EMR at the completion of their fellowship. RESULTS: Six AEFs (189 C-EMRs; mean per AEF, 31.5 ± 18.5) were included. Mean polyp size was 24.3 ± 12.6 mm, and mean procedure time was 22.6 ± 16.1 minutes. Learning curve analyses revealed that less than 50% of AEFs achieved competence for key cognitive and technical C-EMR endpoints. All 6 AEFs reported feeling comfortable performing C-EMR independently at the end of their training, although only 2 of them achieved competence in their overall performance. The minimum threshold to achieve competence in these 2 AEFs was 25 C-EMRs. CONCLUSIONS: A relatively low proportion of AEFs achieved competence on key cognitive and technical aspects of C-EMR during their 12-month fellowship. The relatively low number of C-EMRs performed by AEFs may be insufficient to achieve competence, in spite of their self-reported readiness for independent practice. These pilot data serve as an initial framework for competence threshold, and suggest the need for validated tools for formal C-EMR training assessment.

Bariatric Surgery, Clinical Outcomes, and Healthcare Burden in Hispanics in the USA.

INTRODUCTION/PURPOSE: Bariatric surgery (BS) has emerged as a cornerstone procedure to prevent and treat obesity-related comorbidities. As the Hispanic population continues to grow in the USA, their importance to the healthcare system cannot be understated. We aimed to assess the use of BS and related healthcare outcomes in Hispanics using a national database. MATERIALS AND METHODS: Case-control study using the 2010 to 2014 National Inpatient Sample datasets. BS use in Hispanics compared to non-Hispanics was the primary outcome. Secondary outcomes included inpatient mortality, morbidity, resource use, length of hospital stay, hospital costs, and total hospitalization charges. Propensity scores were used to match Hispanic patients with BS with non-Hispanic patients with BS using sex, age, and Charlson Comorbidity Index as covariates. A multivariate model was then used to adjust for additional confounding factors. RESULTS: From the 105,435 patients who underwent BS, a propensity-matched cohort of 20,440 was created (10,945 Hispanics). Mean (SD) age was 45 (17.2) years, and 73,594 (69.8%) were women. The prevalence of BS in Hispanics was 21/100,000 persons (281/100,000 admissions) compared to 36/100,000 persons (337/100,000 admissions) for non-Hispanics. On multivariate analysis, Hispanics displayed adjusted propensity-matched odds of 0.88 of having BS (P < 0.01). No differences were seen in the surgical approach performed. Hispanics and non-Hispanics had similar mortality, morbidity, hospital length of stay, and costs. CONCLUSION: Despite higher obesity rates, the use of BS is lower in Hispanics. For those who underwent BS, no difference in clinical outcomes and minor differences in resource use were observed.

An Argument for Vitamin D, A, and Zinc Monitoring in Cirrhosis.

Malnutrition is prevalent in cirrhosis. Vitamin and mineral deficiencies, including vitamin D, vitamin A, and zinc, are common and have been shown to correlate with survival. Our aim was to review the mechanisms of vitamin D, vitamin A, and zinc deficiencies in cirrhosis and the clinical assessment of affected patients, their outcomes based on the current literature, and management. This is a narrative review including the relevant literature for cirrhosis and vitamin D, vitamin A, and zinc deficiencies. Vitamin D deficiency has important effects in cirrhosis, regardless of the cause of chronic liver disease.These effects include associations with fibrosis and outcomes such as infections, hepatocellular carcinoma, and mortality. Vitamin A deficiency is associated with liver disease progression to cirrhosis and clinical decompensation, including occurrence of ascites or hepatic encephalopathy. Zinc deficiency can lead to hepatic encephalopathy and impaired immune function. Such deficiencies correlate with patient survival and disease severity. Caution should be applied when replacing vitamin D, vitamin A, and zinc to avoid toxicity. Identification and appropriate treatment of vitamin and mineral deficiencies in cirrhosis may reduce specific nutritional and cirrhosis-related adverse events. Routine monitoring of vitamin A, vitamin D and zinc levels in cirrhosis should be considered.