Raffals, Laura E.

Abstract Background The level of inflammatory bowel disease (IBD) training in general gastroenterology fellowship is often insufficient to prepare trainees to deliver advanced IBD care in practice. Advanced IBD fellowships have been developed to fill this training gap, but there is no established curriculum, and significant variability exists across programs. Entrustable professional activities (EPAs) are practical and realistic objectives that define essential tasks of a specialty that physicians should master to be competent during independent practice. The American College of Gastroenterology (ACG) and Crohn’s & Colitis Foundation (Foundation) established a task force to develop and appraise EPAs for advanced IBD fellowship. Methods Entrustable professional activities were developed using a multistep approach in a similar manner to other specialties. Initial EPAs identified via focus groups were evaluated, critiqued, and changed using an iterative model of feedback. The final EPAs were selected after the task force conducted a 3-phase modified Delphi method consisting of 2 sequential rounds of web-based voting and an in-person consensus meeting. Results Ten EPAs for advanced IBD fellowship were established including detailed descriptions with the associated knowledge, skills, and attitudes for each that can serve as curricular milestones. Conclusion Ten EPAs describing the core work of an advanced IBD fellowship–trained physician have been established by a multisociety task force. Creating EPAs for an advanced curriculum comes with unique challenges, particularly the need to prevent duplication of prior training competencies while demonstrating the potential for unique milestones.

SummaryBackgroundHyperbaric oxygen has been reported to improve disease activity in hospitalised ulcerative colitis (UC) patients.AimTo evaluate dosing strategies with hyperbaric oxygen for hospitalised UC patients.MethodsWe enrolled UC patients hospitalised for acute flares (Mayo score 6‐12). Initially, all patients received 3 days of hyperbaric oxygen at 2.4 atmospheres (90 minutes with two air breaks) in addition to intravenous steroids. Day 3 responders (reduction of partial Mayo score ≥ 2 points and rectal bleeding score ≥ 1 point) were randomised to receive a total of 5 days vs 3 days of hyperbaric oxygen.ResultsWe treated 20 patients with hyperbaric oxygen (75% prior biologic failure). Day 3 response was achieved in 55% (n = 11/20), with significant reductions in stool frequency, rectal bleeding and CRP (P < 0.01). A more significant reduction in disease activity was observed with 5 days vs 3 days of hyperbaric oxygen (P = 0.03). Infliximab or colectomy was required in only three patients (15%) despite a predicted probability of 80% for second‐line therapy. Day 3 hyperbaric oxygen responders were less likely to require re‐hospitalisation or colectomy by 3 months vs non‐responders (0% vs 66%, P = 0.002). No treatment‐related adverse events were observed.ConclusionHyperbaric oxygen appears to be effective for optimising response to intravenous steroids in UC patients hospitalised for acute flares, with low rates of re‐hospitalisation or colectomy at 3 months. An optimal clinical response is achieved with 5 days of hyperbaric oxygen. Larger phase 3 trials are needed to confirm efficacy and obtain labelled approval.

Abstract Background We sought to compare the dysplasia detection rate of high-definition white light endoscopy (HDWLE) with that of chromoendoscopy in patients with long-standing inflammatory bowel disease (IBD). Methods This is a retrospective observational cohort of patients with IBD who underwent surveillance colonoscopy between October 1, 2016 and September 30, 2017. We assessed the association between dysplasia detection and multiple variables. Results A total of 808 unique colonoscopies were performed, of which 150 (18.6%) included chromoendoscopy. Primary sclerosing cholangitis was a comorbid diagnosis in 24.5% of patients. The performing endoscopist was an IBD specialist with 37.1% of patients and had &gt;10 years’ experience with 64.9% of patients. Prior dysplasia had been seen in 245 (30.3%) patients: 102 (68.0%) and 143 (22.0%) among patients who had chromoendoscopy and HDWLE, respectively. Dysplasia in polyps was found in 129 procedures (15.1%). Among patients who had chromoendoscopy and HDWLE, polypoid dysplasia was identified in 50 (33.0%) and 79 (12.0%) patients, respectively, P &lt; 0.01. Dysplasia in random biopsies was found in 39 patients (4.8%): 15 (10%) who had chromoendoscopy and 24 (3.6%) who had HDWLE (P &lt; 0.001). On multivariate analysis, patient and disease characteristics significantly associated with an increased odds for polypoid dysplasia included older age at diagnosis (odds ratio [OR] = 1.3 per 10 years; 95% confidence interval [CI], 1.07-1.60), having an IBD physician endoscopist (OR = 1.6; 95% CI, 1.01-2.67), having an endoscopist with less than 10 years’ experience (OR = 1.8; 95% CI (1.16-2.89), and prior random dysplasia (OR = 4.2; 95% CI (1.93-9.17). Concomitant primary sclerosing cholangitis was significantly associated with random dysplasia (OR = 2.3; 95% CI, 1.02-5.07). After multivariate analysis adjusting for these variables, chromoendoscopy was no more likely to identify dysplasia than was HDWLE. Conclusions Chromoendoscopy and HDWLE had a similar diagnostic yield for dysplasia detection in patients with chronic IBD-colitis after adjusting for multiple known risk factors.

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for patients with medically-refractory ulcerative colitis or ulcerative colitis with associated dysplasia. Although most patients after ileal pouch-anal anastomosis experience good functional outcomes, a number of complications may develop. Of the long-term complications, pouchitis is most common. Although most respond to antibiotic treatment, some patients develop chronic pouchitis, leading to substantial morbidity and occasionally pouch failure. In patients with pouchitis who are not responsive to conventional antimicrobial therapy, secondary causes of chronic pouchitis need to be considered, including Crohn's disease of the pouch. In recent years, more literature has become available regarding the medical management of chronic pouchitis and Crohn's disease of the pouch, including the use of newer biologic agents. We herein provide a concise review on inflammatory complications involving the ileal pouch, including a focused approach to diagnosis and medical management.

Abstract Background Medical education encompasses many activities (e.g., teaching, supervision, mentorship, and administration). Little research has explored what the term "medical education" means to trainees or assessed the importance postgraduate medical trainees place on education as part of their career plans. Methods We conducted a survey of fellows in all subspecialty training programs at a three-site academic institution. We asked multiple choice and Likert scale questions to characterize fellows’ perception of, interest and training in medical education. Results One hundred sixty-nine of 530 (31.9%) fellows responded. Fellows were training in subspecialties of internal medicine (49.7%) and surgery (13.0%), among others. Most fellows planned careers in academic medicine (38.5% clinician-educator, 22.5% clinician-investigator, 17.2% academic clinician). Fellows reported that their conception of medical education involved supervising trainees in a clinical capacity (93.5%), teaching in the classroom (89.3%), and providing mentorship for trainees (87.6%). Respondents identified “being an educator” as extremely (43.8%) or moderately (43.2%) important for their future careers. Only 30.2% had received formal training in medical education, but 61.5% felt that formal training should be required for those pursuing careers with strong educational components. Conclusions Most subspecialty fellows surveyed planned careers in academics and felt that medical education was important to their professional future. While less than a third received formal training in education, almost two thirds felt that such training should be required for a career as an educator. This study provides evidence for the creation and promotion of educational training programs for trainees interested in careers involving medical education.

Abstract Background and Aims We aimed to evaluate the relationship of serum adalimumab trough levels (ATL) with disease activity of inflammatory bowel disease (IBD) patients in a large, well-characterized referral center-based cohort. Methods We compared serum ATL between those with clinical, biochemical, or endoscopic/radiologic disease activity and those without. Results A total of 236 patients with IBD were included. Higher cutoff levels were associated with endoscopic and/or radiologic responses (cutoff value: 5.3 mcg/mL, P = 0.003) compared with improvement in C-reactive protein (cutoff value: 4.3 mcg/mL, P = 0.031). Conclusions Higher cutoff ATL was associated with endoscopic and/or radiologic response.

AbstractIntroductionUlcerative colitis (UC) associated with primary sclerosing cholangitis (PSC) is a rare phenotype. We aimed to assess patients with UC-PSC or UC alone and describe differences in clinical and phenotypic characteristics, antitumor necrosis factor (TNF) therapy, and long-term clinical outcomes.MethodsThis retrospective multicenter cohort study included patients who received a diagnosis of UC from 1962 through 2015. We evaluated clinical factors associated with UC-PSC vs UC alone and assessed associations by using multivariable logistic regression models.ResultsAmong 522 patients with UC, 56 (10.7%) had PSC. Compared with UC alone, patients with UC-PSC were younger (younger than 20 years) at diagnosis (odds ratios [OR], 2.35; adjusted P = 0.02) and had milder UC severity (adjusted P = 0.05), despite having pancolonic involvement (OR, 7.01; adjusted P &lt; 0.001). In the biologics era (calendar year 2005 to 2015), patients with UC-PSC less commonly received anti-TNF therapy compared with patients with UC (OR, 0.38; adjusted P = 0.009), but their response rates were similar. Fewer patients with UC-PSC received corticosteroids (OR, 0.24; adjusted P = 0.005) or rectal 5-aminosalicyte acid (OR, 0.26; adjusted P &lt; 0.001). Other differences were identified that were not statistically significant in a multivariable model: patients with UC-PSC more commonly were male, had lower rates of smoking, and had higher rates of colorectal cancer and colectomy.DiscussionThis study identified a unique phenotype of UC with concurrent PSC, which had different clinical behavior compared with UC only. These phenotypic characteristics can help identify high-risk patients with UC before PSC is diagnosed and guide different management and monitoring strategies.

AbstractBackgroundAn association between inflammatory bowel disease (IBD) and obesity has been observed. Little is known about the effect of weight loss on IBD course. Our aim was to determine the impact of bariatric surgery on long-term clinical course of obese patients with IBD, either Crohn's disease (CD) or ulcerative colitis (UC).MethodsPatients with IBD who underwent bariatric surgery subsequent to IBD diagnosis were identified from 2 tertiary IBD centers. Complications after bariatric surgery were recorded. Patients were matched 1:1 for age, sex, IBD subtype, phenotype, and location to patients with IBD who did not undergo bariatric surgery. Controls started follow-up at a time point in their disease similar to the disease duration in the matched case at the time of bariatric surgery. Inflammatory bowel disease medication usage and disease-related complications (need for corticosteroids, hospitalizations, and surgeries) among cases and controls were compared.ResultsForty-seven patients met inclusion criteria. Appropriate matches were found for 25 cases. Median follow-up among cases (after bariatric surgery) and controls was 7.69 and 7.89 years, respectively. Median decrease in body mass index after bariatric surgery was 12.2. Rescue corticosteroid usage and IBD-related surgeries were numerically less common in cases than controls (24% vs 52%; odds ratio [OR], 0.36; 95% confidence interval [CI], 0.08–1.23; 12% vs 28%; OR, 0.2; 95% CI, 0.004–1.79). Two cases and 1 control were able to discontinue biologics during follow-up.ConclusionsInflammatory bowel disease patients with weight loss after bariatric surgery had fewer IBD-related complications compared with matched controls. This observation requires validation in a prospective study design.

INTRODUCTION: IgA vasculitis (IgAV) is an immune-mediated systemic vasculitis characterized by palpable purpura, arthralgias, abdominal pain, and renal disease. Approximately 90% of cases occur in children; however, adults are at increased risk for more severe disease. The pathogenesis of IgAV is associated with inflammatory, infectious, autoimmune, and medication triggers, including tumor necrosis factor (TNF) alpha inhibitors. We describe a case of a man with Crohn’s disease (CD) who developed IgAV in the setting of a perirectal abscess, recurrent Clostridioides difficile infection (CDI), and anti-TNF therapy. CASE DESCRIPTION/METHODS: A 20 year old man with ileocolonic Crohn’s disease and perianal involvement, inflammatory arthropathy, and recurrent CDI presented to an outside ED with increased abdominal pain and rash on the extremities, trunk, and soft palate. Medications included etanercept, vedolizumab, and prednisolone. In the ED, the patient was hypotensive and tachycardic. CT abdomen/pelvis noted multifocal active inflammatory disease and a 3.2 cm abscess in the left ischiorectal fossa. He was initiated on broad spectrum antibiotics for septic shock and underwent emergent perirectal drain placement; post-operatively, his shock resolved. He was transferred to our institution for further management. Upon arrival, the patient was hemodynamically stable and remained on broad spectrum antibiotics and high dose prednisolone. Review of systems was notable for worsening abdominal pain and hematuria. Biopsy of the rash demonstrated IgA vasculitis. C. difficile toxin PCR was positive. Repeat urinalysis demonstrated nephrotic range proteinuria and hematuria, consistent with IgA nephropathy. ACE-inhibitor therapy was initiated, and skin lesions gradually improved with topical triamcinolone. DISCUSSION: We report a case of a patient with ileocolonic and perianal Crohn’s disease on TNF-alpha inhibitor therapy who developed IgA vasculitis in the setting of septic shock secondary to perirectal abscess and recurrent CDI. This case highlights anti-TNF therapy, infection and inflammatory bowel diseases as potential causes of systemic vasculitis. A high clinical suspicion is needed in order to obtain an early histopathologic diagnosis for IgAV and prompt evaluation of other organ system involvement.