Comprehensive volumetric optical microscopy in vivo

Comprehensive volumetric microscopy of epithelial, mucosal and endothelial tissues in living human patients would have a profound impact in medicine by enabling diagnostic imaging at the cellular level over large surface areas. Considering the vast area of these tissues with respect to the desired sampling interval, achieving this goal requires rapid sampling. Although noninvasive diagnostic technologies are preferred, many applications could be served by minimally invasive instruments capable of accessing remote locations within the body. We have developed a fiber-optic imaging technique termed optical frequency-domain imaging (OFDI) that satisfies these requirements by rapidly acquiring high-resolution, cross-sectional images through flexible, narrow-diameter catheters. Using a prototype system, we show comprehensive microscopy of esophageal mucosa and of coronary arteries in vivo. Our pilot study results suggest that this technology may be a useful clinical tool for comprehensive diagnostic imaging for epithelial disease and for evaluating coronary pathology and iatrogenic effects

A prospective multicenter study evaluating EUS and ERCP competence during advanced endoscopy training and subsequent independent practice: The rapid assessment of trainee endoscopy skills (rates2) study.

Background: We have shown that AETs achieve EUS and ERCP competence at varying rates, validating the shift from defining competence based on an absolute number of procedures to well-defined metrics. However, there are no data to confirm that advanced endoscopy trainees (AETs) who achieve competence during training subsequently perform high quality EUS and ERCP in their 1st year of independent practice. Aims: To report the outcomes of AETs during their 1st year of independent practice using ASGE established quality indicator (QI) thresholds To measure the relationship between achieving competence benchmarks during training and reported outcomes during independent practice. Methods: ASGE recognized advanced endoscopy training programs (AETPs) were invited to participate. In Phase I, AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCPs using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves using cumulative sum (CUSUM) analysis. Learning curves were created using CUSUM for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable (Table presented) failures rates were set a priori and AETs with \u3c20 evaluations were excluded. During Phase II, AETs provided QI performance data on all EUS and ERCP procedures during the 1st year of independent practice. Results: Of the 62 programs invited, 37 AETs from 32 AETPs participated in this study and 24 AETs were included in the final analysis (Phase I). At the end of training, median number of EUS and ERCPs performed/ AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP-biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (70%) and ERCPs for ASGE biliary grade of difficulty 1 (72.1%). Majority of trainees achieved overall technical (EUS: 91.6%; ERCP: 73.9%) and cognitive (EUS: 91.6%, ERCP: 95.6%) competence at conclusion of training (Table 1). 22 of 24 AETs participated in (Phase II) and median EUS and ERCP procedures completed in independent practice/AET were 136 (IQR 102-204) and 116 (48-169), respectively. Table 2 highlights QI performance in EUS and ERCP during Phase II. Majority of AETs crossed the QI threshold for obtaining adequate samples (overall rate: 94.4%), diagnostic yield of malignancy (83.8%), and cannulation rates overall (94.9%) and native papilla cases (93.1%). Conclusions: Majority of AETs achieved EUS and ERCP competence by the end of training. Moreover, these AETs achieved QI thresholds for routine EUS and ERCP during their 1st year of independent practice, affirming the effectiveness of AETPs

Setting minimum standards for training in EUS and ERCP: Results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees (AETS).

Background: Despite the dramatic increase in advanced endoscopy training programs (AETPs), there is no fixed mandatory curriculum and minimal standards as to what constitutes a “high quality” AETP has not been defined. Understanding the mean number of procedures required to achieve competence in all aspects of EUS and ERCP would help structure AETPs. Aims: To define the mean number of procedures required by an “average” AET to achieve competence in technical and cognitive EUS and ERCP tasks. Methods: ASGE recognized AETPs were invited and AETs were graded on every 5th EUS and ERCP exam after completion of 25 hands-on EUS and ERCP exams using the validated EUS and ERCP Skills Assessment Tool (TEESAT). Grading for each skill was done using a 4-point scoring system. A comprehensive data collection and reporting system was used to create learning curves (LCs) using cumulative sum (CUSUM) analysis for overall and technical and cognitive components of EUS and ERCP and shared with AETs and trainers quarterly. Acceptable and unacceptable failures rates were set a priori. In order to generate aggregate CUSUM LCs across AETs, we used generalized linear mixed effects models with a random intercept for each AET and an AR1 covariance structure. This allowed us to use data from all AETs to estimate the average learning experience for trainees with 95% CIs. We then fit a spline to the modeled estimates with knots at 40 and 80 evaluations to smooth the results and estimate the mean number of procedures needed to achieve competence. Results: Of the 62 AETPs invited, 37 AETs from 32 AETPs participated in this study; 24 AETs were included in the final analysis. Prior to AETP, 52% reported hands-on EUS (median 20 cases) and 68% hands-on ERCP (median 50 cases) experience prior to AETP. At the end of training, median number of EUS and ERCPs performed/AET was 400 (range 200-750) and 361 (250-650), respectively. Overall, 2616 exams were graded (EUS: 1277, ERCP-biliary 1143, pancreatic 196). Majority of graded EUS exams were performed for pancreatobiliary indications (69.9%) and ERCP exams for ASGE biliary grade of difficulty 1 (72.1%). Table 1 highlights the substantial variability in EUS and ERCP learning curves. The majority of trainees achieved overall technical (EUS: 91.7%; ERCP: 73.9%) and cognitive (EUS: 91.7%, ERCP: 95.7%) competence at the end of training. Table 1 and Figure highlight the number of procedures required by an average AET to achieve competence in all aspects of EUS and ERCP. Conclusions: The results of this study confirm the substantial variability in achieving competence in EUS and ERCP. The thresholds provided for an average AET to achieve competence in EUS (w225 cases) and ERCP (w250) may be used by ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training