Catharine M. Walsh

Severe paediatric ulcerative colitis: incidence, outcomes, and optimal timing for second line therapy

Background: Despite the predominance of extensive disease in children with ulcerative colitis, data concerning severe paediatric ulcerative colitis are sparse. We reviewed rates and predictors of response to intravenous-corticosteroid therapy in a single-centre cohort with long-term follow-up. Methods: 99 children (49% males; age 2–17 years) were hospitalised (1991–2000) for treatment of severe ulcerative colitis (90% extensive; 49% new onset ulcerative colitis). Clinical, laboratory and radiographic data were reviewed. A population-based subset was used to assess incidence. Predictors of corticosteroid response were analysed using univariate and multivariate analyses at days 3 and 5 of therapy. Colectomy rates were calculated using Kaplan–Meier survival analyses. Results: 28% (95% CI, 23 to 34%) of children with ulcerative colitis resident in the Greater Toronto Area required admission for intravenous corticosteroid therapy, of whom 53 (53%; 95% CI, 44 to 63%) responded. Several predictors were associated with corticosteroid failure, but in multivariable modelling only C-reactive protein [OR = 3.5 (1.4 to 8.4)] and number of nocturnal stools [OR = 3.2 (1.6 to 6.6)] remained significant at both days 3 and 5. The Pediatric Ulcerative Colitis Activity Index (PUCAI), Travis and Lindgren’s indices strongly predicted non-response. Radiographically, the upper range of colonic luminal width was 40 mm in children younger than 11 years versus 60 mm in older patients. Cumulative colectomy rates at discharge, 1 year and 6 years were 42%, 58% and 61%, respectively. Conclusions: Children with ulcerative colitis commonly experience at least one severe exacerbation. Response to intravenous corticosteroids is poor. The PUCAI, determined at day 3 (>45 points) should be used to screen for patients likely to fail corticosteroids and at day 5 (>70 points) to dictate the introduction of second-line therapies.

Concurrent Versus Terminal Feedback: It May Be Better to Wait

Background Feedback is an important feature of simulation-based education. This study investigated the optimal timing of feedback for technical skills learning in novices. Method Thirty novice endoscopists were pretested on a colonoscopy simulator task. Participants then received feedback either during (concurrent) or after (terminal) each of their 12 practice trials. Effectiveness of training was assessed using an immediate posttest and one week later on retention and transfer tests. Measures included execution time and blinded expert assessments. Results Both groups performed similarly on the pre-, post-, and retention tests. At transfer, the terminal feedback group performed significantly better as measured by execution time, checklist, and global rating scores. The concurrent feedback group’s performance decreased significantly on the transfer test as compared with the posttest and retention test. Conclusions Not all feedback conditions seem equally effective. The use of terminal feedback resulted in better learning as demonstrated by superior performance during transfer.

Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy.

BACKGROUND Ensuring competence remains a seminal objective of endoscopy training programs, professional organizations, and accreditation bodies; however, no widely accepted measure of endoscopic competence currently exists. OBJECTIVE By using Delphi methodology, we aimed to develop and establish the content validity of the Gastrointestinal Endoscopy Competency Assessment Tool for colonoscopy. DESIGN An international panel of endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform colonoscopy. After each round, responses were analyzed and sent back to the experts for further ratings until consensus was reached. MAIN OUTCOME MEASUREMENTS Consensus was defined a priori as ≥80% of experts, in a given round, scoring ≥4 of 5 on all remaining items. RESULTS Fifty-five experts agreed to be part of the Delphi panel: 43 gastroenterologists, 10 surgeons, and 2 endoscopy managers. Seventy-three checklist and 34 global rating items were generated through a systematic literature review and survey of committee members. An additional 2 checklist and 4 global rating items were added by Delphi panelists. Five rounds of surveys were completed before consensus was achieved, with response rates ranging from 67% to 100%. Seven global ratings and 19 checklist items reached consensus as good indicators of the competence of clinicians performing colonoscopy. LIMITATIONS Further validation required. CONCLUSION Delphi methodology allowed for the rigorous development and content validation of a new measure of endoscopic competence, reflective of practice across institutions. Although further evaluation is required, it is a promising step toward the objective assessment of competency for use in colonoscopy training, practice, and research.

Development of the gastrointestinal endoscopy competency assessment tool for pediatric colonoscopy (GiECAT KIDS).

Objectives: Many aspects of pediatric colonoscopy differ from adult practice. To date, there is no validated measure of endoscopic competence for use in pediatrics. Using Delphi methodology, we aimed to determine expert consensus regarding items required on a checklist and global rating scale designed to assess the competence of clinicians performing colonoscopy on pediatric patients. Methods: A total of 41 North American pediatric endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform pediatric colonoscopy. Responses were analyzed and re-sent to the panel for further ratings until consensus was reached. Items that ≥80% of experts rated as ≥4 out of 5 were included in the final instrument. Consensus items were compared with those items deemed by adult endoscopy experts as fundamental to assessing the performance of adult colonoscopy. Results: Five rounds of surveys were completed with response rates ranging from 76% to 100%. Seventy-five checklist and 38 global rating items were reduced to 18 checklist and 7 global rating items that reached consensus. Three pediatric checklist items differed from those considered to be critical adult indicators, whereas 4 items on the latter did not reach consensus among pediatric experts. Conclusions: Delphi methodology allowed for achievement of expert consensus regarding essential items to be included in the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECATKIDS), a measure of endoscopic competence specific to performing pediatric colonoscopy. Key differences in the checklist items, compared with items reaching consensus during a separate adult Delphi process using the same indicators, emphasize the need for a pediatric-specific tool.

Publication of Results of Abstracts Presented at Medical Education Conferences

Publication of Results of Abstracts Presented at Medical Education Conferences Conferences represent an important forum for presentation of scholarly activity; however, dissemination beyond meeting registrants is limited. Peer-reviewed publication facilitates knowledge translation,1 and failure to publish may lead to unnecessary duplication and publication bias that can compromise future scholarship.2 This study aimed to determine the rate and time course of peer-reviewed journal publication of abstracts presented at the 2 largest North American medical education conferences (Research in Medical Education Conference [RIME] and the Canadian Conference on Medical Education [CCME]) and to identify characteristics associated with publication.

In-training gastrointestinal endoscopy competency assessment tools: Types of tools, validation and impact

The ability to perform endoscopy procedures safely, effectively and efficiently is a core element of gastroenterology practice. Training programs strive to ensure learners demonstrate sufficient competence to deliver high quality endoscopic care independently at completion of training. In-training assessments are an essential component of gastrointestinal endoscopy education, required to support training and optimize learners capabilities. There are several approaches to in-training endoscopy assessment from direct observation of procedural skills to monitoring of surrogate measures of endoscopy skills such as procedural volume and quality metrics. This review outlines the current state of evidence as it pertains to in-training assessment of competency in performing gastrointestinal endoscopy as part of an overall endoscopy quality and skills training program.

The gastrointestinal endoscopy competency assessment tool for pediatric colonoscopy

Objectives: Validated assessment tools are required to support competency-based education. We aimed to assess the reliability and validity of the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECATKIDS), an instrument developed by 41 North American experts using Delphi methodology. Methods: GiECATKIDS consists of a 7-item global rating scale (GRS) and an 18-item checklist (CL). An attending physician assessed 104 colonoscopies performed at 3 North American hospitals by 56 endoscopists, including 25 novices (<50 previous procedures), 21 intermediates (50–250), and 10 advanced endoscopists (>500). Another observer rated procedures to assess interrater reliability using intraclass correlation coefficient (ICC). Test–retest reliability was measured with ICC comparing endoscopists’ first and second procedure scores. Discriminative validity was examined by comparing experience level with scores. Concurrent validity was assessed by correlating scores with colonoscopy experience, cecal and terminal ileal intubation rates, and physician global assessment. Results: Interrater reliability of the GiECATKIDS was high (total: ICC = 0.88; GRS: ICC = 0.79; CL: ICC = 0.89). Test–retest reliability was excellent (total: ICC = 0.94; GRS: ICC = 0.94; CL: ICC = 0.84). GiECATKIDS total, GRS, and CL scores differed significantly among novice, intermediate, and advanced endoscopists (P < 0.001). There was a significant positive correlation (P < 0.001) between scores and number of previous colonoscopies (total: &rgr; = 0.91, GRS: &rgr; = 0.92, CL: &rgr; = 0.84), cecal intubation rate (total: &rgr; = 0.82, GRS: &rgr; = 0.85, CL: &rgr; = 0.77), ileal intubation rate (total: &rgr; = 0.82, GRS: &rgr; = 0.82, CL: &rgr; = 0.80), and physician global assessment (total: &rgr; = 0.95, GRS: &rgr; = 0.94, CL: &rgr; = 0.89). Conclusions: The GiECATKIDS demonstrates strong reliability and validity as a measure of performance of pediatric colonoscopy that can be used to support training and assessment.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Assessment of Competence in Pediatric Gastrointestinal Endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.

Training non-physicians to do endoscopy: Feasibility, effectiveness and cost-effectiveness.

Colorectal cancer (CRC) is one of the most common cancers in women and men worldwide. Training non-physicians including nurses, nurse practitioners, and physician assistants to perform endoscopy can provide the opportunity to expand access to CRC screening as demand for endoscopic procedures continues to grow. A formal program, incorporating didactic instruction and hands-on practice in addition to oversight, is required to train non-physicians to perform endoscopy as safely and effectively as physicians. Additionally, the context in which the non-physician endoscopy program is organized will dictate key program characteristics including remuneration, participant recruitment and professional and legal considerations. This review explores the evidence in support of non-physician based endoscopy, potential challenges in implementing non-physician endoscopy and requirements for a high-quality program to support training and implementation.