Faculty Bibliography

Introduction: Patients with inflammatory bowel disease (IBD) have many unique health maintenance needs and often require therapy necessitating close monitoring. Gastroenterologists often serve as the primary care provider for these patients and therefore must be familiar with the health maintenance needs of IBD patients. In this study, we investigated whether implementing a multimodal educational intervention could improve providers' rates of addressing healthcare maintenance measures. Methods: A retrospective chart review was performed in 2013-2014 on 208 IBD patients to determine adherence to performance practice measures. From February-April 2016, fellows received a recurring in-service lecture and an IBD clinic note template outlining the 2011 healthcare maintenance recommendations by the American Gastroenterological Association. An iBook was also introduced, which provided a comprehensive overview of IBD practice guidelines. Retrospective chart review was then performed 1 year afterwards. For each patient, performance measures were assessed in both pre- and post-intervention notes in the following categories: vaccinations, bone health, therapy-specific maintenance, tobacco cessation counseling, and cancer screening. Each performance measure was given a score of 0 (not addressed), 1 (addressed), or N/A (irrelevant to subject). The primary outcome was improvement in rates of adherence to performance measures. The adherence rates for pre- and post-intervention groups were compared using a chi-squared test. Results: A total of 208 pre-intervention clinic visits and 40 post-intervention visits were included for analysis. After the interventions, the rate of healthcare maintenance measures addressed overall increased from 37% to 52% (p < .001) (Figure 1). There were statistically significant improvements in addressing bone health (29% to 63%, p < .001), vaccination (33% to 47%, p < .001), and therapy-specific measures (53% to 74%, p=.01). There were no statistically significant changes in addressing cancer screening (66% to 58%, p=.19) or smoking (23% to 30%, p=.59). Conclusion: The use of multiple educational interventions to enhance delivery of IBD healthcare maintenance resulted in improved adherence to healthcare maintenance measures. Targeted educational programs and a multi-modal approach may be an effective method for teaching GI fellows and reinforcing the importance of addressing these measures to optimize the care of their IBD patients

Patients with inflammatory bowel disease (IBD) are well known to be at increased risk of venous thromboembolism. Systemic thrombotic events are rare, but likely more common among IBD patients as well. We describe a case of Crohn's colitis complicated by spontaneous pulmonary vein thrombosis eventually resulting in systemic embolism and acute mesenteric ischemia. A 25-year-old female with stricturing Crohn's colitis presented to the emergency department with one week of back pain and pleuritic chest pain. She was initially diagnosed with Crohn's disease three years prior, when she presented with large bowel obstruction requiring emergent transverse colostomy. Infliximab was begun after surgery, and she achieved complete clinical remission. She continued to feel well until the present illness. Upon hospital admission, a computed tomography (CT) scan revealed multiple right sided pulmonary emboli as well as a large pulmonary vein thrombus extending into the left atrium. Echocardiogram revealed no evidence of right heart strain. Anticoagulation was initiated with unfractionated heparin, and the patient was eventually transitioned to apixaban. On the evening prior to anticipated discharge, she developed sudden onset fever and epigastric pain. A CT scan of the abdomen revealed acute thrombosis of the superior mesenteric artery. The patient underwent emergent laparotomy with thrombectomy, initially without small bowel resection. Subsequent second-look laparotomy revealed 75cm of ischemic small bowel, which was resected. The patient continued to have fever and abdominal pain, however, and further exploration revealed necrosis of the entire remaining small bowel, which was resected leaving only a duodenal stump. The patient was eventually transferred to another center for consideration of intestinal transplant. Pulmonary vein thrombosis is an extremely rare condition usually precipitated by intrathoracic neoplasm or thoracic surgery, particularly lung transplantation. There is an associated risk of pulmonary hypertension as well as systemic arterial embolization. To our knowledge, this is the first reported case of spontaneous pulmonary vein thrombosis with IBD as the inciting factor. Due to the risk of catastrophic complications from systemic embolism, rapid diagnosis and treatment are essential. Anticoagulation alone may not be sufficient in all cases, and thrombectomy may be considered if the thrombus does not resolve with medical management

BACKGROUND:The Accreditation Council for Graduate Medical Education has described 6 core competencies with which trainees should demonstrate proficiency. Using the Objective Structured Clinical Examination (OSCE), we aimed to assess 4 of these competencies among Pediatric Gastrointestinal (GI) fellows (PGs). METHODS:Eight first-year PGs from 6 medical centers in the New York area participated in a 4-station OSCE with trained standardized patient (SP) actors. The cases included an emergency department (ED) consult, or "ED Consult" for lower gastrointestinal bleeding; "Breaking Bad News" focusing on CF nutritional complications; "Second Opinion" for abdominal pain; "Transition of Care" for inflammatory bowel disease. At each station, attending faculty observed the encounters behind a 1-way mirror. SPs and faculties provided immediate feedback to the examined fellows. Previously validated OSCE checklists were used to assess performance. On completion, fellows attended debriefing sessions and completed surveys about the educational value. RESULTS:Median overall milestone competency scores were 6.9 (PC1), 4.8 (PC2), 5.9 (MK1), 5.7 (MK2), 6.4 (ICS1), 6.9 (Prof1), and 6.7 (Prof3). Overall, fellows score highest (7/9) on the inflammatory bowel disease "Transition of Care" case, found the "Breaking Bad News" Cystic Fibrosis OSCE to be the most challenging, and were most comfortable with the "ED Consult" OSCE, as a commonly encountered scenario. Overall, the fellows rated the educational value of the program highly. CONCLUSIONS:To our knowledge, although the OSCE has been validated in other medical fields, this is the first OSCE program developed for PGs fellows. These OSCEs have included Accreditation Council for Graduate Medical Education competencies, serving to assess fellows' skills in these areas while exposing them to challenging medical and psychosocial cases that they may not frequently encounter.

Background: The rising incidence of antibiotic-resistant disease is partially attributable to the extensive use and misuse of antibiotics. Ecuador has the second highest rate of per-capita antibiotic consumption in Latin America. The purpose of this study is to identify factors that contribute to self-prescribed antibiotic use in a low-income neighborhood of Guayaquil, Ecuador's largest city, where antibiotics are frequently available over-the-counter. Methods: Qualitative, oral interviews were conducted with local residents who had seen a physician in the last two years (group A, 101 subjects) and those who had not for two years or more (group B, 100 subjects). Subjects were recruited at a local medical clinic and a nearby food market. Findings: Although 71% of subjects overall report that they believe antibiotics could be dangerous for them, 74% have self-medicated with antibiotics in their lifetime, and 43% have taken antibiotics in the last month. 73% of subjects report taking just one or two antibiotic pills when they self-medicate. There were no differences between groups for these findings, but subjects in group A were more than twice as likely to have spoken with a physician before starting antibiotics the last time they took them (56% vs. 25% p<0.001), and more than three times as likely to complete a full course of antibiotics that had been prescribed by a physician (41% vs. 13% p<0.001). Overall, 78% of subjects who had children under the age of 18 reported self-medicating with antibiotics, but 85% said they would not give antibiotics to their children without taking them to a physician first. Subjects in group B were more than twice as likely to give antibiotics to their children without seeking the advice of a physician (21% vs. 9% p=0.04). Interpretation: Lifetime patterns and perceptions of self-prescribed antibiotic use were generally the same between groups, but when looking at recent behavior, subjects who had seen a physi-cian in the last two years were more likely to get a prescription and take the full course as prescribed. Further studies should be conducted to determine whether improving healthcare access and/or enforc-ing regulations on antibiotic sales could reduce antibiotic misuse in the region

BACKGROUND: Inflammatory bowel diseases (IBD) are believed to be driven by dysregulated interactions between the host and the gut microbiota. Our goal is to characterize and infer relationships between mucosal T cells, the host tissue environment, and microbial communities in patients with IBD who will serve as basis for mechanistic studies on human IBD. METHODS: We characterized mucosal CD4 T cells using flow cytometry, along with matching mucosal global gene expression and microbial communities data from 35 pinch biopsy samples from patients with IBD. We analyzed these data sets using an integrated framework to identify predictors of inflammatory states and then reproduced some of the putative relationships formed among these predictors by analyzing data from the pediatric RISK cohort. RESULTS: We identified 26 predictors from our combined data set that were effective in distinguishing between regions of the intestine undergoing active inflammation and regions that were normal. Network analysis on these 26 predictors revealed SAA1 as the most connected node linking the abundance of the genus Bacteroides with the production of IL17 and IL22 by CD4 T cells. These SAA1-linked microbial and transcriptome interactions were further reproduced with data from the pediatric IBD RISK cohort. CONCLUSIONS: This study identifies expression of SAA1 as an important link between mucosal T cells, microbial communities, and their tissue environment in patients with IBD. A combination of T cell effector function data, gene expression and microbial profiling can distinguish between intestinal inflammatory states in IBD regardless of disease types.

Receptive anal intercourse and its association with sexually transmitted infections and human papillomavirus-related anal dysplasia has been well studied in various at-risk groups including men who have sex with men. However, the relationship between receptive anal intercourse and its potential complications in patients with inflammatory bowel disease is not fully understood. This narrative review discusses sexually transmitted infections and anal dysplasia in patients with inflammatory bowel disease who engage in receptive anal intercourse and the lack of evidence-based data to guide clinical practice. It addresses the psychosocial effects of stigmatization in these patients and its consequences in the clinical encounter. We review the need for sufficient data on infection, cancer prevention, and precoital and postcoital hygienic practices with hopes that future studies establish standardized guidelines and recommendations.

AIM: To assess first-year gastroenterology fellows' ability to address difficult interpersonal situations in the workplace using objective structured clinical examinations (OSCE). METHODS: Two OSCEs ("distracted care team" and "frazzled intern") were created to assess response to disruptive behavior. In case 1, a fellow used a colonoscopy simulator while interacting with a standardized patient (SP), nurse, and attending physician all played by actors. The nurse and attending were instructed to display specific disruptive behavior and disregard the fellow unless requested to stop the disruptive behavior and focus on the patient and procedure. In case 2, the fellow was to calm an intern managing a patient with massive gastrointestinal bleeding. The objective in both scenarios was to assess the fellows' ability to perform their duties while managing the disruptive behavior displayed by the actor. The SPs used checklists to rate fellows' performances. The fellows completed a self-assessment survey. RESULTS: Twelve fellows from four gastrointestinal fellowship training programs participated in the OSCE. In the "distracted care team" case, one-third of the fellows interrupted the conflict and refocused attention to the patient. Half of the fellows were able to display professionalism despite the heated discussion nearby. Fellows scored lowest in the interprofessionalism portion of post-OSCE surveys, measuring their ability to handle the conflict. In the "frazzled intern" case, 68% of fellows were able to establish a calm and professional relationship with the SP. Despite this success, only half of the fellows were successfully communicate a plan to the SP and only a third scored "well done" in a domain that focused on allowing the intern to think through the case with the fellow's guidance. CONCLUSION: Fellows must receive training on how to approach disruptive behavior. OSCEs are a tool that can assess fellow skills and set a culture for open discussion.

BACKGROUND: Despite the effectiveness of fecal microbiota transplantation (FMT) for treating recurrent Clostridium difficile (C. difficile) infection, some patients are reluctant to accept this therapy. Our study examined attitudes towards FMT and factors that contribute to patients' acceptance of this treatment. METHODS: We distributed patient surveys at a Veterans Affairs hospital, a public hospital, and an academic faculty practice. Multivariable logistic regression was performed, adjusting for factors associated with FMT acceptance on univariate analysis and prior experience with C. difficile infection. RESULTS: Of 267 patients, only 12% knew of FMT prior to the survey, but 77% would undergo the procedure if medically indicated. On multivariable analysis, those with children and with college degrees or higher were more likely to agree to FMT (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.02-4.35; OR 2.27, 95% CI 1.11-4.60 respectively). Sixty-five respondents (71%) chose colonoscopy as the preferred vehicle for FMT, while nasogastric tube was least preferred. Disease transmission was the most common concern (30%, n=242), and FMT success rate was the least selected concern (9.1%). CONCLUSIONS: Most patients in a diverse sample of gastroenterology clinics had no prior knowledge of FMT, but were receptive to the procedure. Having children and higher education levels were predictors for FMT acceptance. Our findings suggest that barriers to FMT utilization may be overcome with counseling about safety concerns. More data on the risk of transmitting diseases or clinical characteristics, such as obesity, through FMT are needed and will be important for the acceptance of this procedure.