Brijen Shah

Fecal Incontinence in the Elderly: FAQ

Fecal incontinence (FI) is a common gastrointestinal (GI) complaint in patients aged 65 years and older. This evidence-based review article discusses the epidemiology, pathophysiology, evaluation, and management of FI in the geriatric population. We emphasize aging-related changes leading to and impacting evaluation and treatment of this symptom while incorporating the core geriatric principles of functional status and management aligned with patient preference and goals of care.

Current status of monoclonal antibody therapy for the treatment of inflammatory bowel disease

Crohn’s disease and ulcerative colitis are complex diseases that have required the use of multiple modalities to aid in treatment. With an increasing understanding of the underlying pathogenetic mechanisms and identification of specific therapeutic targets, monoclonal antibody treatment has been an ideal strategy for inducing and maintaining remission in these patients. This article addresses approved agents and the supporting data justifying their use in Crohn’s disease and ulcerative colitis, the safety of and immunologic reactions to these agents, as well as newer agents for treatment.

In vivo diagnostic accuracy of high resolution microendoscopy in differentiating neoplastic from non-neoplastic colorectal polyps: a prospective study

OBJECTIVES:High-resolution microendoscopy (HRME) is a low-cost, “optical biopsy” technology that allows for subcellular imaging. The purpose of this study was to determine the in vivo diagnostic accuracy of the HRME for the differentiation of neoplastic from non-neoplastic colorectal polyps and compare it to that of high-definition white-light endoscopy (WLE) with histopathology as the gold standard.METHODS:Three endoscopists prospectively detected a total of 171 polyps from 94 patients that were then imaged by HRME and classified in real-time as neoplastic (adenomatous, cancer) or non-neoplastic (normal, hyperplastic, inflammatory).RESULTS:HRME had a significantly higher accuracy (94%), specificity (95%), and positive predictive value (PPV, 87%) for the determination of neoplastic colorectal polyps compared with WLE (65%, 39%, and 55%, respectively). When looking at small colorectal polyps (less than 10 mm), HRME continued to significantly outperform WLE in terms of accuracy (95% vs. 64%), specificity (98% vs. 40%) and PPV (92% vs. 55%). These trends continued when evaluating diminutive polyps (less than 5 mm) as HRMEs accuracy (95%), specificity (98%), and PPV (93%) were all significantly greater than their WLE counterparts (62%, 41%, and 53%, respectively).CONCLUSIONS:In conclusion, this in vivo study demonstrates that HRME can be a very effective modality in the differentiation of neoplastic and non-neoplastic colorectal polyps. A combination of standard white-light colonoscopy for polyp detection and HRME for polyp classification has the potential to truly allow the endoscopist to selectively determine which lesions can be left in situ, which lesions can simply be discarded, and which lesions need formal histopathologic analysis.

Entrustable Professional Activities for Gastroenterology Fellowship Training

Office of Academic Affairs and Education and Department of Medicine, Division of Gastroenterology, University of Connecticut School of Medicine, Farmington, Connecticut; Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California; Henry D. Janowitz Division of Gastroenterology, and The Brookdale Department of Geriatrics and Palliative Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; American Gastroenterological Association, Bethesda, Maryland; and Division of Gastroenterology, Department of Medicine, State University of New York (SUNY), Upstate Medical University, Syracuse, New York

Informed Consent in the Older Adult: OSCEs for Assessing Fellows’ ACGME and Geriatric Gastroenterology Competencies

OBJECTIVES:The American Gastroenterological Association fellowship curriculum identifies geriatric components for gastroenterology (GI) training; however, few tools are available for this purpose. Using an objective structured clinical examination (OSCE), we aimed to assess ACGME competencies of communication, professionalism, and geriatric-specific patient care among GI fellows.METHODS:We developed an informed-consent case involving a geriatric patient who needs surveillance colonoscopy. We used a validated faculty skills checklist to rate fellows across three competency domains. Fifteen fellows from four GI training programs participated.RESULTS:Although the fellows excelled at communication and professionalism, only 51% excelled at geriatric-specific patient-care skills. Fellows were least likely to demonstrate collaboration with the patient, to assess patient understanding, and to explain the limits of the test. Communication and geriatric-specific skills were correlated.CONCLUSIONS:OSCEs are a feasible method for assessing geriatric-related ACGME competencies for fellows. The results highlight the need for curriculum development.

Psychosocial correlates of HIV-monoinfection and HIV/HCV-coinfection among men who have sex with men

Rates of hepatitis C virus (HCV) among HIV-positive men who have sex with men (MSM) appear to be high and rising. In other demographic groups, HIV/HCV-coinfection is associated with poor physical and psychological outcomes. In this study, we examined health-related and psychosocial correlates of HIV/HCV-coinfection in a clinic sample of MSM. Cross-sectional data were collected from 171 MSM. One-third of the sample was coinfected. Higher rates of depressive and PTSD symptoms were observed in coinfected patients. Coinfected men were more likely to report perfect 30-day medication adherence, but exhibited lower CD4 cell counts and more past year emergency room visits. Despite consistent engagement with care and higher rates of medication adherence, HIV/HCV-coinfected MSM exhibited significantly more mental health problems. Medical and mental health providers should be especially attentive to the mental health status of HIV/HCV-coinfected MSM, despite adequate health behaviors and physical health status.

A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care.

Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link‐to‐care programme with patient navigation in two New York City primary care practices. This was a 2‐year prospective study of patients born between 1945‐1965 (“baby boomers”) with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV‐infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well‐studied principles identifies a large number of undiagnosed baby boomers within hospital‐based primary care and improves access to specialty providers in a timely manner.

Observing handoffs and telephone management in GI fellowship training.

OBJECTIVES:Gastroenterology (GI) training programs are mandated to teach fellows interpersonal communication and professionalism as basic competencies. We sought to assess important skill sets used by our fellows but not formally observed or measured: handoffs, telephone management, and note writing. We designed an Observed Standardized Clinical Examination (OSCE) form and provided the faculty with checklists to rate fellows’ performance on specific criteria.METHODS:We created two new scenarios: a handoff between a tired overnight senior fellow on call and a more junior fellow, and a telephone management case of an ulcerative colitis flare. Fellows wrote a progress notes documenting the encounters. To add educational value, we gave the participants references about handoff communication. Four OSCE stations—handoff communication, telephone management, informed consent, and delivering bad news—were completed by fellows and observed by faculty.RESULTS:Eight faculty members and eight fellows from four GI training programs participated. All the fellows agreed that handoffs can be important learning opportunities and can be improved if they are structured, and that handoff skills can improve with practice.CONCLUSIONS:OSCEs can serve as practicums for assessing complex skill sets such as handoff communication and telephone management.

The changing faces of endoscopic sedation.

The practice of sedation for digestive endoscopy continues to evolve throughout the world. In many countries, there is a trend for increased utilization of sedation during routine endoscopic procedures. Sedation improves patient satisfaction with endoscopy and the willingness to comply with screening guidelines and it improves the quality of examination. Moderate sedation, using a benzodiazepine and an opioid, remains the standard method of sedation in most areas of the world, although propofol, a short-acting hypnotic agent, is being used increasingly in some countries. Controversy regarding the feasibility of endoscopist-directed propofol administration continues, in spite of overwhelming evidence supporting this practice. In the USA, recent revisions in policy by the Centers for Medicare and Medicaid Services may threaten the practice of endoscopist-directed propofol administration. In this article, future trends in sedation practice, including fospropofol and computer-assisted personalized sedation, are discussed.

Introducing the Gastroenterologist-accountable Professionalism in Practice (G-APP) Pathway: Bridging the G-APP-Replacing MOC With a Model for Lifelong Learning and Accountability

University of Connecticut School of Medicine, Academic Affairs and Education and Department of Medicine, Division of Gastroenterology and Hepatology, Farmington, Connecticut; Icahn Mount Sinai School of Medicine, Department of Medicine/ Henry D. Janowitz Division of Gastroenterology and Brookdale Department of Geriatrics and Palliative Medicine, New York, New York; Duke University School of Medicine, Department of Medicine, Division of Gastroenterology, Durham, North Carolina; Department of Medicine, Division of Gastroenterology and Hepatology, University of Rochester, Rochester, New York; American Gastroenterological Association, Bethesda, Maryland; Texas Digestive Disease Consultants, Dallas, Texas; South Denver Gastroenterology, Lone Tree, Colorado; and The Ohio State University College of Medicine, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Columbus, Ohio