Faculty Bibliography

OBJECTIVES: Gastroenterology (GI) training programs must develop the teaching skills of their faculty and provide feedback to their fellows. Many faculty feel uncomfortable offering feedback or identifying specific areas for improvement to the fellows. We developed an Observed Structured Clinical Exam (OSCE) to assess fellows' skills and provided faculty with specific criteria to rate the fellows' performance. We propose that OSCEs can serve as tools for faculty development in delivering effective feedback. METHODS: Faculty completed a Web-based training module and received written guidelines on giving feedback. Four OSCE stations were completed by each fellow with faculty using standardized checklists to assess the fellows' skills. Afterwards, faculty rated each program component and assessed their comfort level with feedback. RESULTS: Eight faculty members and 10 fellows from 5 GI training programs in NYC participated. 100% of the faculty agreed that feedback is an important learning tool, should include the learner's self-assessment, and that feedback skills could improve with practice. Compared to faculty skills prior to the program, 87.5% of the faculty agreed that they focused more on specific behaviors and 75% agreed that giving negative feedback was now easier. CONCLUSIONS: OSCEs can serve as practicums for faculty development in giving constructive feedback.

OBJECTIVES: GI tract CCR5+CD4+ T cells are selectively infected and depleted during acute HIV-1 infection. Despite ART, GALT T cell depletion and activation persists. We hypothesized that ART intensification (INT) with the CCR5 antagonist maraviroc (MVC) could effect immune reconstitution and decrease immune activation if this was due to ongoing viral replication. METHODS AND POPULATION: We enrolled adults infected with CCR5-tropic HIV-1 and treated with ART during acute/early infection for ~4 yrs prior to entry. Subjects were randomized 2:1 to Arm A: INT with MVC for 24 weeks (n=4); or Arm B: NRTI INT for 12 weeks followed by cross-over to MVC for 12 weeks (n=2). RESULTS: Plasma HIV-1 RNA was <50 copies/ml and GI biopsy RNA was <50 copies of HIV-1 NL43 gag (~1.5x106 copies GAPDH/sample) for all subjects at entry through week 24. Immunohistochemistry revealed 5.36 + 0.86 CD4+ T cells/unit area in the lamina propria (LP) at entry in Arm A. This did not increase significantly after 24 weeks. In Arm A, flow cytometry revealed significant differences (p<0.02) between the PBMC and GALT at entry in the CD4+/CD8+ T cell ratio (1.47+0.14 vs 0.91+0.06) and % activated (CD38+) CD8+ T cells (2.61 +/- 0.41 vs 17.61 +/- 5.02). In Arms A and B, no statistically significant change (p>0.32) was noted in %CD38+ or %proliferating (Ki67+) CD4+ or CD8+ T cells in the GALT between entry, weeks 12 and 24. In both arms, serum endotoxin activity did not significantly change after 24 weeks. SIGNIFICANCE OF STUDY: Thus far, we observe no statistically significant effect of intensification of ART with MVC on a variety of immunologic and virologic parameters in the GALT

A novel assay to assess antigen-specific cytokine release from stimulated CD8(+) T cells derived from the mucosal and peripheral blood compartments has been developed and standardized using the influenza A virus matrix protein (MP) peptide, GILGFVFTL. This technology is based on the capacity for the human leucocyte antigen (HLA)-A2:Ig dimeric protein to stimulate CD8(+) T cells in a major histocompatibility complex (MHC) class I-restricted fashion without the necessity for antigen presenting cells (APC). This assay has been optimized utilizing a 9-amino acid residue (9mer) peptide, the optimal peptide length for presenting an epitope to CD8(+) T cells. Compared to existing assays, this more sensitive and specific methodology requires fewer cells, enabling easier and more accurate monitoring of the CD8(+) T-cell response in biological compartments, such as the mucosa during the course of viral infection and may be utilized to assess epitope-specific CD8(+) T-cell responses in vaccine trials.

BACKGROUND: Although non-AIDS defining malignancies are rapidly increasing as HIV-infected subjects live longer, little is know about the results of screening for colonic neoplasms (adenomatous polyps and adenocarcinomas) in this population. METHODS: We conducted a screening colonoscopy study to determine the prevalence of colonic neoplasms in 136 asymptomatic HIV-infected subjects >or=50 years of age and 272 asymptomatic uninfected control subjects matched for age, sex, and family history of colorectal cancer. Advanced neoplasms were defined as adenomas >or=10 mm or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or adenocarcinoma. RESULTS: The prevalence of neoplastic lesions was significantly higher in HIV-infected subjects than in control subjects (62.5% vs 41.2%, p<0.001), and remained highly significant after adjustment for potential confounding variables (odds ratio = 3.00; 95% confidence interval, 1.83 to 4.93). Among patients with colorectal adenocarcinoma, HIV-infected subjects were significantly younger (52.4 (SD 1.3) vs 60.3 (SD 4.0) years, p = 0.002) and were more likely to have advanced cancers (stage III or IV) than control subjects (60.0% vs 16.7%, p = 0.24). Of HIV-infected subjects with advanced neoplasms proximal to the splenic flexure, distal neoplastic lesions were absent in 88.9% of individuals and these would have been missed by flexible sigmoidoscopy. CONCLUSIONS: HIV-infected subjects have a higher prevalence of colonic neoplasms, and adenocarcinomas develop at a younger age and are more advanced than in uninfected subjects. Our findings suggest that screening colonoscopy should be offered to HIV-infected subjects, but the age of initiation and the optimal frequency of screening require further study

BACKGROUND AIMS: Objective structured clinical encounters (OSCEs) are used widely to educate and assess the competence of medical students and residents; they generally are absent from fellowship training. The Accreditation Council for Graduate Education has cited OSCEs as a best practice for assessing the 6 core competencies. This article reports on the use of an OSCE to assess the competence of second-year gastroenterology fellows in the difficult-to-assess core competencies: interpersonal and communication skills and professionalism. METHODS: We developed a 4-station, faculty-observed OSCE with 4 standardized patients. Information gathering, relationship development, patient education, and counseling skills were assessed. Professionalism skills assessed included obtaining informed consent, delivering bad news, managing difficult situations, and showing interdisciplinary respect. In each station, faculty and standardized patients completed an 18- to 24-item checklist evaluating fellows' performance and provided feedback to the fellows. Nine fellows and 5 faculty from 4 gastroenterology training programs in NYC participated. RESULTS: Fellows and faculty generally highly rated the realism of the OSCE and favorably rated the OSCE for its difficulty and their overall experience. Across all cases, fellows were rated as receiving "well dones" for 56.4% of the communication items (SD, 18.3%) and for 79.1% of the professionalism items (SD, 16.4%). CONCLUSIONS: Integrating OSCEs into gastroenterology fellowship training may help enhance communication skills and prepare fellows for dealing with difficult clinical situations and provides mechanisms for constructive feedback. OSCEs developed collaboratively can assist in program self-evaluation and reduce costs by sharing resources, in addition to fulfilling Accreditation Council for Graduate Education mandates.

BACKGROUND: Continued high rates of HIV-1 transmission have fueled interest in the use of antiretrovirals to prevent infection. Attenuated infection with failure of tenofovir as prophylaxis has been reported in animal models. Here, we report a case of HIV-1 infection despite intermittent use of fixed-dose combination tenofovir and emtricitabine (FTC). METHODS: The patient was treated with tenofovir DF/FTC for reported repeated high-risk sexual exposures. After seroconversion, he was subjected to routine laboratory testing, CCR5 and HLA genotyping, and biopsy of gastrointestinal (GI) tissue. Resistance testing was performed both as bulk sequencing of plasma and cloning and sequencing of virus derived from plasma, peripheral blood mononuclear cells, and GI tissue. RESULTS: In this patient with no readily identifiable modifying host factors, acute HIV-1 infection with tenofovir DF/FTC-susceptible HIV-1 was associated with an attenuated clinical course, very low postseroconversion HIV-1 RNA levels, slow kinetics of seroconversion, and relative sparing of mucosal CD4+ T cells in the GI tract. CONCLUSIONS: Despite the failure of tenofovir DF/FTC as prophylaxis, selection for drug-resistant transmission did not occur and the blunting of postinfection levels of viremia likely reduced the probability of subsequent forward transmissions during the acute phase. These results support continued investigations of the use of antiretrovirals as a means to reduce HIV-1 transmission.