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Gastrointestinal Endoscopy Jun 2024Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically...
BACKGROUND AND AIMS
Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a "high-quality" nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs.
METHODS
The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods.
RESULTS
Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures.
CONCLUSIONS
This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education's Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency.
PubMed: 38935016
DOI: 10.1016/j.gie.2024.03.025 -
Neurourology and Urodynamics Jun 2024Urogynecology and Reconstructive Pelvic Surgery (URPS) fellowship can be pursued after completion of either a urology (URO) or obstetrics and gynecology (GYN) residency....
AIMS
Urogynecology and Reconstructive Pelvic Surgery (URPS) fellowship can be pursued after completion of either a urology (URO) or obstetrics and gynecology (GYN) residency. Our aim is to determine differences in graduating fellow cohort (GFC) case logs between URO- and GYN-based URPS programs.
METHODS
Accreditation Council for Graduate Medical Education case logs for URPS GFCs in both GYN- and URO-based programs were analyzed for the 2019-2023 academic years (AY). Unpaired t-tests with Welch's correction were used to compare annual mean logged cases between URO- versus GYN-based GFCs for select surgical categories and the top 11 most logged index cases.
RESULTS
GYN-based GFCs logged more cases for all pelvic organ prolapse (POP) categories including surgery on apical POP, anterior wall POP, and posterior wall POP (all p < 0.01), while URO-based GFCs logged more cases for surgery on the urinary system (p = 0.03). For the top 11 logged procedures, URO-based GFCs logged more sacral neuromodulation cases (p = 0.02), whereas GYN-based GFCs logged more slings, vaginal hysterectomies, minimally-invasive hysterectomies, vaginal apical POP, vaginal posterior POP, vaginal anterior POP, and minimally-invasive apical POP cases (all p < 0.01). There was no difference between URO- and GYN-based GFCs for complex urodynamics, cystoscopy with botox injection, or periurethral injection cases.
CONCLUSIONS
URO-based URPS fellows tend to graduate with more surgery on the urinary system and sacral neuromodulation cases, while GYN-based fellows perform more slings, hysterectomies, and POP surgery. These findings may help fellowships better understand potential differences in training among graduates from URO- and GYN-based programs and encourage collaboration to lessen these discrepancies.
PubMed: 38934488
DOI: 10.1002/nau.25533 -
Journal of Osteopathic Medicine Jun 2024
PubMed: 38932743
DOI: 10.1515/jom-2024-0064 -
Materials (Basel, Switzerland) Jun 2024The investigation into advanced structural materials, such as composite materials, has revealed numerous possibilities within the field of bridge engineering....
The investigation into advanced structural materials, such as composite materials, has revealed numerous possibilities within the field of bridge engineering. Glass-fiber-reinforced polymers (GFRPs) are notable among these materials, particularly in footbridge construction, encompassing both arch and cable-stayed designs. While GFRPs boast advantages, such as their high strength-to-weight ratio, they may exhibit some deficiencies, particularly when subjected to dynamic loads induced by wind or pedestrian forces. Two noteworthy global examples are the Lleida arch bridge (Spain, 2001) and the Aberfeldy cable-stayed bridge (Scotland, 1992). These structures have recently undergone comprehensive studies by the authors to assess their behavior when subjected to specific conditions regarding pedestrian traffic and vibrations induced by under-passing trains, as far as Lleida is concerned. The methodologies employed in these studies are detailed herein, incorporating the relevant scientific literature and technical regulations that provide guidance on fundamental principles for bridge design, pedestrian modelling, and acceleration thresholds aimed at minimizing discomfort. While the framework of principles is clear, the regulations are extensive, requiring designers to have a comprehensive understanding of the diverse outcomes achievable through various approaches. Therefore, the provided state-of-the-art overview serves as a roadmap for assessing the performance of an innovative cable-stayed bridge recently proposed by one of the authors. Initially designed with six spans, this prototype has been reconfigured here as a three-span train station overpass. The analyses conducted allowed for the assessment of induced accelerations. According to current accredited standards, the resulting comfort classification is considered minimal, even if, for crowded conditions, more specific studies are required.
PubMed: 38930211
DOI: 10.3390/ma17122842 -
Genes Jun 2024The quantification of human DNA extracts from forensic samples plays a key role in the forensic genetics process, ensuring maximum efficiency and avoiding repeated...
The quantification of human DNA extracts from forensic samples plays a key role in the forensic genetics process, ensuring maximum efficiency and avoiding repeated analyses, over-amplified samples, or unnecessary examinations. In our laboratory, we use the Quantifiler Trio system to quantify DNA extracts from a wide range of samples extracted from traces (bloodstains, saliva, semen, tissues, etc.), including swabs from touched objects, which are very numerous in the forensic context. This method has been extensively used continuously for nine years, following an initial validation process, and is part of the ISO/IEC 17025 accredited method. In routine practice, based on the quantitative values determined from the extracts of each trace, we use a standard method or a low-copy-number method that involves repeating the amplification with the generation of a consensus genetic profile. Nowadays, when the quantification results are less than 0.003 ng/μL in the minimum extraction volume (40 μL), we do not proceed with the DNA extract analysis. By verifying the limits of the method, we make a conscious cost-benefit choice, in particular by using the least amount of DNA needed to obtain sufficiently robust genetic profiles appropriate for submission to the Italian DNA Forensic Database. In this work, we present a critical re-evaluation of this phase of the method, which is based on the use of standard curves obtained from the average values of the control DNA analysed in duplicate. Considering the various contributions to uncertainty that are difficult to measure, such as manual pipetting or analytical phases carried out by different operators, we have decided to thoroughly investigate the contribution of variability in the preparation of calibration curves to the final results. Thus, 757 samples from 20 independent experiments were re-evaluated using two different standards for the construction of curves, determining the quantitative differences between the two methods. The experiments also determined the parameters of the slope, Y-intercept, R, and the values of the synthetic control probe to verify how these parameters can provide information on the final outcome of each analysis. The outcome of this revalidation demonstrated that it is preferable to use quantification ranges rather than exact quantitative limits before deciding how to analyse the extracts via PCR or forgoing the determination of profiles. Additionally, we present some preliminary data related to the analysis of samples that would not have been analysed based on the initial validation, from which genetic profiles were obtained after applying a concentration method to the extracts. Our goal is to improve the accredited analytical method, with a careful risk assessment as indicated by accreditation standards, ensuring that no source of evidence is lost in the reconstruction of a criminal event.
Topics: Humans; Real-Time Polymerase Chain Reaction; Forensic Genetics; DNA; DNA Fingerprinting; Microsatellite Repeats; Semen
PubMed: 38927695
DOI: 10.3390/genes15060759 -
Surgery For Obesity and Related... May 2024Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Duodenal switch (DS) is a recent...
BACKGROUND
Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Duodenal switch (DS) is a recent MBS procedure with increasing attention in recent years, however the risk of anastomotic or staple line leaks and the lack of efficient surgical expertise hinders the procedure from becoming fully adopted.
OBJECTIVES
To determine the 30-day predictors of leaks following DS and explore their association with other 30-day postoperative complications.
SETTING
Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.
METHODS
Patients who underwent a primary biliopancreatic diversion with DS or single-anastomosis duodenoileostomy with sleeve procedure, categorized as DS, were assessed for 30-day leaks. A multivariable logistic regression was constructed to identify the predictors of leaks. The assessment of postoperative complications arising from leaks was also performed.
RESULTS
A total of 21,839 DS patients were included, of which 177 (.8%) experienced leaks within 30 postoperative days. The most significant predictor of leaks was steroid immunosuppressive use (adjusted odds ratio [aOR] = 3.01, 95% confidence interval [CI] [1.56-5.13], P < .001) and age, with each decade of life associated with a 26% increase in risk (aOR = 1.26, 95% CI [1.09-1.45], P = .001). Operative length was also associated with leaks, with every additional 30 minutes increasing the odds of a leak by 23% (aOR = 1.23, 95% CI [1.18-1.29], P < .001). The occurrence of leaks was correlated with postoperative septic shock (Crude Odds Ratio [COR] = 280.99 [152.60-517.39]) and unplanned intensive care unit (ICU) admissions (COR = 79.04 [56.99-109.59]). Additionally, mortality rates increased 17-fold with the incidence of leaks (COR = 17.64 [7.41-41.99]).
CONCLUSIONS
Leaks following DS are a serious postoperative complication with significant risk factors of steroid use, prolonged operative time and advanced age. Leaks are also associated with other severe complications, highlighting the need for early diagnosis and intervention along with additional studies to further validate our results.
PubMed: 38926021
DOI: 10.1016/j.soard.2024.05.012 -
Academic Medicine : Journal of the... Jun 2024The last 10 years have seen an increase in union representation for residents and fellows across the United States. It is estimated that 15% of residents and fellows are...
The last 10 years have seen an increase in union representation for residents and fellows across the United States. It is estimated that 15% of residents and fellows are represented by unions. With increasing numbers of U.S. residents and fellows in graduate medical education (GME) programs being represented by unions, the authors contend that it is worthwhile to consider the benefits and potential drawbacks of resident unions and how GME and health system leaders can best work to ensure that the educational needs of residents continue to be emphasized in an era of resident unionization. Union bargaining can be a method to secure salary increases and other benefits for residents. Unionization can also provide a mechanism for more rapidly addressing worker protection issues and allows residents to advocate on behalf of patients. Residents participating as union leaders may develop important leadership and negotiation skills as well as gain beneficial knowledge about health system structure, financing, and priorities. However, with all the possible benefits that may come with resident unionization, there are also potential pitfalls. The collective bargaining process may create an adversarial relationship between program and institution leaders and trainees. Additionally, while residents are considered employees and able to collectively bargain, the National Labor Relations Board has also acknowledged that residents are "students learning their chosen medical craft." Program and institution leaders have an obligation to prioritize resident education and adhere to accreditation requirements even when these requirements conflict with union demands. Furthermore, because of the obligation to protect the public, program leaders should maintain control of resident academic due process issues. Program and institutional leaders must continue to prioritize resident education. Furthermore, GME leaders have a joint responsibility to create clinical learning environments that are conducive to quality patient care and promote resident learning and well-being.
PubMed: 38924497
DOI: 10.1097/ACM.0000000000005798 -
Chemical Research in Toxicology Jun 2024In 2012, the U.S. Food & Drug Administration (FDA) published an established list of 93 harmful and potentially harmful constituents (HPHCs) targeting four tobacco...
In 2012, the U.S. Food & Drug Administration (FDA) published an established list of 93 harmful and potentially harmful constituents (HPHCs) targeting four tobacco product types (cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco). In 2016, the FDA finalized the deeming rule to regulate electronic nicotine delivery systems (ENDS). However, knowledge gaps exist regarding whether certain HPHCs are present in ENDS e-liquids and aerosols. We identified and addressed these gaps by conducting literature searches and then experimentally quantifying HPHCs in the e-liquid and aerosol of 37 ENDS brands based on gaps in the literature. The literature searches identified 66 e-liquid HPHCs and 68 aerosol HPHCs that have limited to no information regarding the quantifiability of these constituents. A contracted ISO 17025 accredited laboratory performed the HPHC quantifications. The availability of validated analytical methods in the contracted laboratory determined the HPHCs included in the study scope (63/66 for e-liquids, 64/68 for aerosols). Combining the results from the quantifications and literature searches, 36 (39%) and 34 (37%) HPHCs were found quantifiable (≥limit of quantification [LOQ]) in ENDS e-liquids and aerosols, respectively, with 25 HPHCs being quantifiable in both matrices. Quantifiability results imply potential HPHC transfers between matrices, leaching from components, or formations from aerosol generation. The study results can inform the scientific basis for manufacturers and regulators regarding regulatory requirements for HPHC reporting. The HPHC quantities can also inform evaluations of the public health impact of ENDS and public communications regarding ENDS health risks.
PubMed: 38924487
DOI: 10.1021/acs.chemrestox.4c00093 -
BJU International Jun 2024To explore the topic of Prostate Imaging-Reporting and Data System (PI-RADS) interobserver variability, including a discussion of major sources, mitigation approaches,... (Review)
Review
OBJECTIVES
To explore the topic of Prostate Imaging-Reporting and Data System (PI-RADS) interobserver variability, including a discussion of major sources, mitigation approaches, and future directions.
METHODS
A narrative review of PI-RADS interobserver variability.
RESULTS
PI-RADS was developed in 2012 to set technical standards for prostate magnetic resonance imaging (MRI), reduce interobserver variability at interpretation, and improve diagnostic accuracy in the MRI-directed diagnostic pathway for detection of clinically significant prostate cancer. While PI-RADS has been validated in selected research cohorts with prostate cancer imaging experts, subsequent prospective studies in routine clinical practice demonstrate wide variability in diagnostic performance. Radiologist and biopsy operator experience are the most important contributing drivers of high-quality care among multiple interrelated factors including variability in MRI hardware and technique, image quality, and population and patient-specific factors such as prostate cancer disease prevalence. Iterative improvements in PI-RADS have helped flatten the curve for novice readers and reduce variability. Innovations in image quality reporting, administrative and organisational workflows, and artificial intelligence hold promise in improving variability even further.
CONCLUSION
Continued research into PI-RADS is needed to facilitate benchmark creation, reader certification, and independent accreditation, which are systems-level interventions needed to uphold and maintain high-quality prostate MRI across entire populations.
PubMed: 38923789
DOI: 10.1111/bju.16452 -
Current Oncology (Toronto, Ont.) Jun 2024The COVID-19 pandemic caused major disruptions to healthcare services in 2020, delaying cancer diagnosis and treatment. While early-stage thyroid cancer often progresses...
The COVID-19 pandemic caused major disruptions to healthcare services in 2020, delaying cancer diagnosis and treatment. While early-stage thyroid cancer often progresses slowly, it is crucial to determine whether treatment delays associated with the pandemic have impacted the clinical presentation and management of advanced-stage thyroid cancer. The purpose of our study was to determine the impact of the early COVID-19 pandemic on thyroid cancer presentation and treatment times. Utilizing the National Cancer Database, chi-squared tests and regression analyses were performed to compare patient demographic and clinical characteristics over time for 56,011 patients diagnosed with primary thyroid cancer who were treated at the Commission on Cancer-accredited sites in 2019 and 2020. We found that thyroid cancer diagnoses decreased between 2019 and 2020, with the biggest drop among patients with cT1 disease relative to other T stages. We also found that patients diagnosed with thyroid cancer in 2020 had similar treatment times to patients diagnosed in 2019, as measured by both the time between diagnosis and start of treatment and the time between surgery and start of radioactive iodine therapy. Overall, our study suggests that resources during the pandemic were allocated to patients with advanced thyroid disease, despite a decrease in diagnoses.
Topics: Humans; Thyroid Neoplasms; COVID-19; Female; Male; Middle Aged; Aged; SARS-CoV-2; Adult; Pandemics; Time-to-Treatment; Thyroidectomy
PubMed: 38920746
DOI: 10.3390/curroncol31060263