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11/19/2020
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Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.
Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.
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American College of Gastroenterology
11/19/2020
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Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.
Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.
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American College of Gastroenterology
11/19/2020
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www.gi.org/research‐awards
Read the Grant Flyer, FAQs, or visit the webpage for the RFAs.
Application Deadline: December 4, 2020
SEVEN different award types; INCREASED Junior Faculty FUNDING; NEW Mid‐Career Bridge Funding; Med Resident and Student Awards
Welcome to the Virtual Grand Rounds Waiting Room – The educational activity will begin promptly at 12 Noon Eastern.
Participating in the Webinar
All attendees will be muted and will remain in Listen Only Mode.
Type your questions here so that the moderator can see them. Not all questions will be answered but we will get to as many as possible.
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American College of Gastroenterology
11/19/2020
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How to Receive CME and MOC Points
LIVE VIRTUAL GRAND ROUNDS WEBINAR
ACG will send a link to a CME & MOC evaluation to all attendees on the live webinar.
ABIM Board Certified physicians need to complete their MOC activities by December 31, 2020 in order for the MOC points to count toward any MOC requirements that are due by the end of the year. No MOC credit may be awarded after March 1, 2021 for this activity.
MOC QUESTION
If you plan to claim MOC Points for this activity, you will be asked to: Please list specific changes you will make in your
practice as a result of the information you received from this activity.
Include specific strategies or changes that you plan to implement.THESE ANSWERS WILL BE REVIEWED.
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American College of Gastroenterology
11/19/2020
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ACG Virtual Grand RoundsJoin us for upcoming Virtual Grand Rounds!
Visit gi.org/ACGVGR to Register
Week 35: Vaccinations for the Immunocompromised in the Era of COVID Francis A. Farraye, MD, MSc, FACGDecember 3, 2020 at Noon EDT
Week 36: New Therapeutic Options for EoE and EGIDs on the HorizonIkuo Hirano, MD, FACG December 10, 2020 at Noon EDT
NOTE: There will be no Virtual Grand Rounds on November 26 due to Thanksgiving
Disclosures:
Speaker: Timothy B. Gardner, MD, MS, FACGDr. Gardner has no conflicts of interest related to this talk.
Moderator: Linda S. Lee MDDr. Lee has no conflicts of interest related to this talk.
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Timothy B. Gardner, MD, MS, FACGAssociate Professor of Medicine
Geisel School of Medicine at DartmouthSection of Gastroenterology and Hepatology
Dartmouth-Hitchcock Medical Center
ACG Virtual Grand Rounds
ACG Clinical Guideline:Chronic Pancreatitis
Virtual Grand Rounds universe.gi.org
Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Objectives
Hermits are still out there…
North Pond Hermit, Maine
Virtual Grand Rounds universe.gi.org
Chief Complaint: Chronic abdominal pain
Case Presentation
History of Present Illness:
- 42-year-old male- Insidious onset of pain for several years- Epigastric with radiation to the back- 20-30 ounces of alcohol daily- Unremarkable lab testing- Normal fecal elastase- CFTR ΔF508 heterozygote
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Case Presentation
Serology: Normal amylase, lipase, TTG, IgG4, CA 19-9
Virtual Grand Rounds universe.gi.org
Case Presentation
4 EUS Morphologic Criteria
• Hyperechoic duct wall (body)
• Hyperechoic foci (head, body, tail)
• Hyperechoic strands (head, body, tail)
• Lobularity in body and tail
Hyperechoic strands and foci
Lobularity
Hyperechoic duct wall
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Virtual Grand Rounds universe.gi.org
Case Presentation
How does one interpret these results?
Does he have chronic pancreatitis?
How should he be treated?
Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
Literature Search – major databases from 1946-present
Best evidence – i.e. RCTs, systematic review and meta-analysis
PICO questions for answerable questions- Population/Problem- Intervention- Comparison- Outcome
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Designing Clinical GuidelinesPICO QUESTIONS
Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
Once you have designed the PICO questions…
- Evaluate the literature to answer your questions
- If you have enough evidence to answer the questions, start the GRADE evaluation process
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Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
A few reminders about guidelines…
- They are limited by the amount of clinical trial evidence available
- There are multiple types of guidelines – beware of those that do not follow the GRADE system (i.e. beware of expert opinion)
- Not all important clinical questions can be answered – or even addressed – if using evidence-based guidelines
Virtual Grand Rounds universe.gi.org
Designing Clinical Guidelines
Two Types of Statements
1. Recommendations- Evidence- Grade System
2. Key Concepts- Not amenable to Grade- Often expert opinion
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Virtual Grand Rounds universe.gi.org
Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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DiagnosisRecommendation Statements
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Virtual Grand Rounds universe.gi.org
EUS Diagnosis: The Perfect Storm
No gold standard
Highly sensitive test
Confusing nomenclature
Increasing availability
Heavy reliance on expert opinion
Lack of specificity
Wide interobserver
variation
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DiagnosisRecommendation Statements
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DiagnosisRecommendation Statements
Gardner and Levy. GIE 2010;71(7):1280-90.
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DiagnosisKey Concepts
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Diagnosis
Virtual Grand Rounds universe.gi.org
Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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American College of Gastroenterology
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Etiology and Natural HistoryRecommendation Statements
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Etiology and Natural HistoryRecommendation Statements
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Etiology and Natural HistoryKey Concepts
Virtual Grand Rounds universe.gi.org
Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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Management of PainRecommendation Statements
Virtual Grand Rounds universe.gi.org
Management of PainRecommendation Statements
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Virtual Grand Rounds universe.gi.org
Management of PainRecommendation Statements
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Management of PainRecommendation Statements
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Virtual Grand Rounds universe.gi.org
Management of PainKey Concepts
Virtual Grand Rounds universe.gi.org
Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
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11/19/2020
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Virtual Grand Rounds universe.gi.org
Management of EPIRecommendation Statements
Gardner TB et al. Am J Gastroenterol 2014109:624-5.
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Management of EPIKey Concepts
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Objectives
2. Diagnosis
1. Designing Clinical Guidelines
5. Management of EPI
4. Management of Pain
3. Etiology and Natural History
Virtual Grand Rounds universe.gi.org
Future Areas of InvestigationInvestigate the Mechanistic Definition of CP…
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American College of Gastroenterology
11/19/2020
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Virtual Grand Rounds universe.gi.org
Future Areas of Investigation
Further comparative effectiveness treatment trials…
Virtual Grand Rounds universe.gi.org
Future Areas of Investigation
A reckoning of how these patients are demonized, mistreated, and cared for by our profession…
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Virtual Grand Rounds universe.gi.org
Thank You“Man cannot discover new oceans unless he has the courage to lose sight of the shore”
- Andre Gide 1947 Nobel prize for literature
Virtual Grand Rounds universe.gi.org
Questions?
Speaker: Timothy B. Gardner, MD, MS, FACG
Moderator: Linda S. Lee MD
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American College of Gastroenterology