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Most US states have now legalized medical marijuana (MMJ) use, giving new hope to families dealing with chronic illness, despite only limited data showing efficacy. Access to MMJ has presented several challenges for patients and families, providers, and pediatric hospitals, including the discrepancy between state and federal law, potential patient safety issues, and drug interaction concerns. Colorado was one of the first states to legalize MMJ and has remained at the forefront in addressing these challenges. Children’s Hospital Colorado has created and evolved its MMJ inpatient use policy and has developed a unique consultative service consisting of a clinical pharmacist and social worker. This service supports patients and families and primary clinical services in situations in which MMJ is actively being used or considered by a pediatric patient. The first 50 patients seen by this consultative service are reported. Eighty percent of patients seen had an oncologic diagnosis. Symptoms to be ameliorated by active or potential MMJ use included nausea and vomiting, appetite stimulation, seizures, and pain. In 64% of patients, MMJ use was determined to be potentially unsafe, most often because of potential drug-drug interactions. In 68% of patients, a recommendation was made to either avoid MMJ use or adjust its administration schedule. As pediatric hospitals address the topic of MMJ use in their patients, development of institutional policy and clinical support services with specific expertise in MMJ is a recommended step to support patient and families and hospital team members.

OBJECTIVE: To compare 3 methods of weight determination for medication dose calculations in obese children and to discuss feasibility for use in routine care. METHODS: This was a patient safety and quality improvement study evaluating patients (2–19 years old) admitted to the pediatric intensive care unit during a 13-month period (July 2010–July 2011). Patients identified as obese (≥95th percentile body mass index [BMI] for age), including severely obese (≥99th percentile BMI for age), were included in the weight method comparison portion of this study. Lean body mass estimations, using equations derived by the Peters and Foster methods, were compared to ideal body weight estimates by using the BMI method. Absolute differences between values generated by the 3 methods, intraclass correlation (ICC), and Bland-Altman plots were calculated. RESULTS: A total of 1369 patients met initial criteria; 176 met criteria for the dosing weight comparison (age ± SD = 9.28 ± 5 years; actual weight ± SD = 55.5 ± 33.9 kg; 46% female). Sixty were severely obese and 116 were obese. Mean ICC between methods was 0.968 (95% Confidence interval (CI): 0.959, 0.975). The Peters method estimated higher weights than the Foster or BMI method. Bland-Altman plots illustrated good agreement between methods in children with weight below 50 kg, but decreased agreement above 50 kg, which was influenced by sex. CONCLUSIONS: All methods demonstrated strong correlation and acceptable agreement in children below 50 kg. Systematic biases were identified in children above 50 kg where variance was higher. The BMI method was least complex to calculate and the most feasible method for daily use.

Background Skills decay without practice, but the degree is task specific. Some experts believe that it is essential to teach endoscopy longitudinally to build and maintain endoscopic skills. Objective To determine whether breaks in gastroenterology fellow endoscopy training are associated with a decrement in competency in independent intubation of the cecum. Design Observational cohort of colonoscopies performed by gastroenterology fellows. Setting Academic fellowship program from July 2010 to March 2012. Subjects Twenty-four fellows. Main Outcome Measurements The adjusted change in the slope of cumulative summation learning curves for cecal intubation after breaks in training and the slope at the end of the subsequent endoscopy rotation. Results A total of 6485 colonoscopies were performed by 24 fellows with 87 breaks in training. The average break was 6 weeks (range 2-36 weeks). Seventy-five percent of the breaks were 8 weeks or less. For every additional 4 weeks, the slope after the break worsened by 0.022 ( P = .06, maximum possible change = −1.0 to +1.0). By the end of the subsequent rotation, there was no association between the slope of the learning curve and the length of the break ( P = .68). Limitations This was an observational study of only 24 fellows with relatively few long breaks. Cecal intubation is only 1 component of overall competency in colonoscopy. Conclusions There may be a very small decrement in fellows' abilities to intubate the cecum after a break in endoscopy training. Because these changes are so small, teaching endoscopy in blocks is probably adequate, if necessary to balance other clinical and research experience. However, further research is needed to determine whether a longitudinal endoscopy experience is superior for attaining and maintaining competency, to evaluate the effects of breaks longer than 8 weeks, and to determine whether the effects of breaks depend on the previous volume of experience with colonoscopy.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

Patients undergoing ERCP receive nontrivial doses of radiation, which may increase their risk of developing cancer, especially young patients. Radiation doses to patients during ERCP correlate closely with fluoroscopy time.The aim of this study was to determine whether endoscopist experience is associated with fluoroscopy time.Retrospective analysis of a prospectively collected database.Data from 69 providers from 6 countries.9,052 entries of patients undergoing ERCP.Percent difference in fluoroscopy time associated with endoscopist experience and fellow involvement.For procedure types that require less fluoroscopy time, compared with endoscopists who performed200 ERCPs in the preceding year, endoscopists who performed100 and 100 to 200 ERCPs had 104% (95% confidence interval [CI], 85%-124%) and 27% (95% CI, 20%-35%) increases in fluoroscopy time, respectively. Every 10 years of experience was associated with a 21% decrease in fluoroscopy time (95% CI, 19%-24%). For fluoroscopy-intense procedures, compared with endoscopists who performed200 ERCPs in the preceding year, endoscopists who performed100 and 100 to 200 ERCPs had 59% (95% CI, 39%-82%) and 11% (95% CI, 3%-20%) increases in fluoroscopy time, respectively. Every 10 years of experience was associated with a 20% decrease in fluoroscopy time (95% CI, 18%-24%).Database used is a voluntary reporting system, which may not be generalizable. Data is self-reported and was not verified for accuracy.Fluoroscopy time is shorter when ERCP is performed by endoscopists with more years of performing ERCP and a greater number of ERCPs in the preceding year. These findings may have important ramifications for radiation-induced cancer risk.

e17567Background: Locally advanced endometrioid adenocarcinoma (EAC) is an aggressive disease with the potential of metastatic spread and local recurrence after initial surgical resection. Adjuvant...

e17571Background: Twenty to fifty percent of patients with breast, colon and lung cancers are diagnosed in the emergency department globally. The objective of our study was to characterize the asso...

e17517Background: Unplanned hospital admission following chemotherapy is a measure of quality cancer care. Large retrospective datasets have shown admission rates of 10-35% for women with ovarian c...

Trainees learn colonoscopy skills at varying speeds. We hypothesized that a fellow’s ability to reliably reach the splenic flexure early in training could predict the number of procedures required to achieve competency in intubating the cecum. This was a retrospective analysis of prospectively collected data. The most proximal site in the colon reached independently by GI fellows was recorded on consecutive colonoscopies. The number of procedures required to achieve splenic flexure intubation rate (SFIR) ≥ 90 % by cumulative summation learning curve and cecal intubation rate (CIR) ≥ 90 % by rolling average was calculated. Fellows were then dichotomized into “Early” versus “Late” learners based on the median number of procedures required to achieve SFIR ≥ 90 %. The number of procedures required to achieve CIR ≥ 90 % was then compared between the groups. Fellows achieved SFIR ≥ 90 % at a median of 37 colonoscopies. Fellows who achieved SFIR competency early achieved CIR ≥ 90 % at a mean of 208 procedures versus 352 procedures in the fellows who achieved SFIR competency late (p = 0.03). Data from a single academic medical center show that whether a trainee will learn endoscopy quickly compared to his/her peers can be predicted early in their endoscopy training by tracking SFIR. This knowledge could be used to customize endoscopy curriculum.

Purpose The development and use of a decision support tool to help formulate recommendations for dosing of commonly prescribed medications in critically ill obese children are described. Methods Medications prescribed in 2010 to critically ill infants and children (younger than 18 years) were identified from the Pediatric Health Information System. The most commonly prescribed and therapeutically monitored medications were extracted. Supportive evidence for obesity dosing was identified through a standardized computerized search involving medical subject heading terminology and age filters using PubMed and Ovid. A usefulness scoring system was developed to rate the strength and applicability of the literature to critically ill obese children. A decision supporttool was then created to aid in the formulation of a dosing weight for each medication based on the usefulness score, published pharmacokinetic properties, clinical studies available in the primary literature, and consideration of clinical consequences of underdosing or overdosing. Results A total of 113 medications were evaluated, and 122 discrete citations, supporting 66 medications, were reviewed. Seventy-two percent of citations had general obesity dosing information, and 13% had pediatric-specific information. The overall mean usefulness score was 5.1 ± 4.7 (median, 7). The decision support tool was incorporated to make final dosing weight recommendations for obese children. Ultimately, total body weight was recommended for 52 medications, adjusted weight for 43 medications, and ideal body weight for 18 medications. Conclusion The inadequacy of obesity dosing information for most medications commonly ordered for children admitted to a pediatric intensive care unit led to the development of a decision support tool to aid in formulating dosing recommendations.

1589 Background: BRCA testing has become an integral component of ovarian cancer management; however, low testing uptake remains an obstacle. This study evaluated the impact of an oncologist-led counseling and testing model on BRCA testing uptake. Methods: The ENGAGE study (NCT02406235) is a prospective study of an oncologist-led BRCA counseling and testing model in patients with epithelial ovarian, primary peritoneal and fallopian tube cancer (EOC). The United States lead accruing gynecologic oncology sites were Montefiore, an urban academic medical center; and Winthrop, a suburban teaching hospital. Oncologists were trained in BRCA counseling prior to site activation, and directly submitted patients’ samples for BRCA testing. Prior to the ENGAGE study, EOC patients were referred to genetics professionals for counseling and testing. We determined the number of BRCA tests performed, and simple descriptive statistics were used to summarize the data. Results: A combined total of 141 EOC patients underwent BRCA testing during the 20 consecutive months analyzed. In the 10 months pre-ENGAGE, 8 Montefiore patients had BRCA testing, all submitted through the genetics division. Nineteen Winthrop patients had BRCA testing, 16 from their oncologist’s office and 3 from an external genetics office. During the 10-month ENGAGE trial, 64 Montefiore patients and 50 Winthrop patients had BRCA testing. This represents a four-fold increase in BRCA testing uptake, with 114 patients tested during ENGAGE versus 27 patients tested pre-ENGAGE. Of these 114, 99 had BRCA counseling and testing through their oncologist’s office. Conclusions: Implementation of an oncologist-led genetic counseling and testing model was associated with increased BRCA testing among ovarian cancer patients in both the urban and suburban hospitals. Increased BRCA testing could be related to increased patient convenience and standardized training of the clinical team. These findings may guide other institutions as they implement streamlined genetic counseling and testing protocols.

Background Biliary complications are the second leading cause of morbidity and mortality in orthotopic liver transplant (OLT) recipients. Endoscopic retrograde cholangiography (ERC) is considered the diagnostic criterion standard for post-orthotopic liver transplantation biliary obstruction, but incurs significant risks. Objective To determine the diagnostic accuracy of MRCP for biliary obstruction in OLT patients. Design A systematic literature search identified studies primarily examining the utility of MRCP in detecting post-orthotopic liver transplantation biliary obstruction. A meta-analysis was then performed according to the Quality of Reporting Meta-Analyses statement. Setting Meta-analysis of 9 studies originally performed at major transplantation centers. Patients A total of 382 OLT patients with clinical suspicion of biliary obstruction. Interventions MRCP and ERCP or clinical follow-up. Main Outcome Measurements Sensitivity and specificity of MRCP for diagnosis of biliary obstruction. Results The composite sensitivity and specificity were 0.96 (95% CI, 0.92-0.98) and 0.94 (95% CI, 0.90-0.97), respectively. The positive and negative likelihood ratios were 17 (95% CI, 9.4-29.6) and 0.04 (95% CI, 0.02-0.08), respectively. Limitations All but 1 included study had significant design flaws that may have falsely increased the reported diagnostic accuracy. Conclusions The high sensitivity and specificity demonstrated in this meta-analysis suggest that MRCP is a promising test for diagnosing biliary obstruction in patients who have undergone liver transplantation. However, given the significant design flaws in most of the component studies, additional high-quality data are necessary before unequivocally recommending MRCP in this setting.

660 Do Breaks in Endoscopy Fellowship Training Decrease Colonoscopy Competency? Jennifer Jorgensen*, Grace H. Elta, Joseph C. Kolars, Joel H. Rubenstein Gastroenterology, University of Michigan, Ann Arbor, MI Background: Some experts believe it is essential to teach endoscopy longitudinally to build and maintain endoscopic skills, fearing that breaks in training will result in loss of skills. However, limited surgical data has demonstrated that concentrated educational experiences can provide lasting improvement in skills. There are no prior studies on the effects of breaks in endoscopy training on competency in colonoscopy. Cecal intubation is frequently used as a surrogate for overall competency in colonoscopy because it is easily measured and objective. Aim: Determine if breaks in gastroenterology fellow endoscopy training cause decrements in cecal intubation rates. Methods: Prospective data on independent extent reached for all colonoscopies performed by our gastroenterology fellows were collected over 16 months. Cumulative summation (CUSUM) learning curves, which identify changes in competency over shorter numbers of procedures than traditional learning curves, were constructed. The changes in the CUSUM slope for the ten colonoscopies after a break in training minus the slope before the break were calculated. The maximum possible difference is /-1.0, with a negative difference signifying improvement. Chi-square test was conducted for the association of length of breaks, fellowship year, and number of colonoscopies performed with the change in the slope of the CUSUM learning curve. Linear regression was conducted to estimate the effect of the length of the break on the change in slope before and after a break and the slope at the end of the rotation, adjusting for fellowship year and number of colonoscopies performed prior to the break. Results: 5,685 colonoscopies were performed by 24 fellows with 57 breaks in training. The median length of a break was 5 weeks (range 2, 36). The mean change of the slope after a break was 0.01 (range -0.57, 0.49). Breaks in endoscopy training of 8 weeks or longer were associated with decrements in cecal intubation competency compared to shorter breaks (46% vs. 19%, p 0.05; mean slope differences 0.07 vs. 0.00). However, breaks in training were not associated with worse cecal intubation competency at the completion of the subsequent rotation, adjusting for number of prior colonoscopies and fellowship year ( 8 weeks vs. 8 weeks: -0.05 slope, p 0.29). Conclusions: Breaks in endsocopy training of at least 8 weeks are associated with decrements in cecal intubation competency. However, these effects are small and do not persist to the end of the subsequent endoscopy rotation. Teaching endoscopy in blocks rather than as a longitudinal experience is probably adequate, especially if it is necessary to balance other clinical and research experiences. However, the effects of longer breaks on competency deserves further study. Funding: ASGE Quality in Endoscopy Research Award