DigestPitt

Inside This Issue

Pages Three and Four

GI Grand Rounds

Page Five

Improving the Impact

of CME

Page Six

• GI’s Impact on the

Medical School Curriculum

• What Is This?

CENTERS OF EXCELLENCE:

• PANCREAS & BILIARY DISEASES

• INFLAMMATORY BOWEL DISEASE

• LIVER DISEASES

• NEUROGASTROENTEROLOGY AND

MOTILITY DISEASES

• INTESTINAL HEALTH &NUTRITION SUPPORT

• GASTROINTESTINAL CANCER

PREVENTION & TREATMENT

• WOMEN’S DIGESTIVE HEALTH

Pitt Digest

is a publication of the

University of Pittsburgh

Division of Gastroenterology,

Hepatology and Nutrition

Editors:

Toby O. Graham, MD

Janet R. Harrison, MD

Daniel Chung, MD

Joy Jenko Merusi, MA

W i n t e r / S p r i n g 2 0 0 6

t present, the word “gastroenterology”appears over 15 million times on the web-

based search engine Google (www.google.com);“gastroenterology education” returns 4.1 millionhits. While it takes Google less than onesecond to find all of these links, more time isconsumed by a gastroenterologist searchingfor specific educational resources on the web.The Laboratory for Educational Technology(http://labedutech.medschool.pitt.edu) at theUniversity of Pittsburgh School of Medicinehas been working with the Division ofGastroenterology, Hepatology and Nutrition(http://dom.pitt.edu/gi) and national profes-sional societies to advance the accessibilityand quality of online learning.

The same principles of adult educationapply to online education as with any otherlearning medium. Research has shown thatlectures and slide presentations are able todisseminate knowledge but do not translate toimproved clinical care. Conversely, case-solving,role-playing, and small group discussion aremore effective learning styles and

A improve clinical outcomes. When multimedia isadded, the learning is improved further. Thisarticle will highlight significant examples ofonline educational tools for students, traineesand practicing physicians.

Medical students at the University of Pittsburghuse a comprehensive curriculum website calledNavigator (http://navigator.medschool.pitt.edu)developed by the Lab. Navigator contains classschedules, course documents, physiologyanimations, videos of physical findings,interactive case studies, etc. This websiteis connected to a school-wide portal whichintegrates all online resources for studentsinto one, searchable, secure location(http://www.zone.medschool.pitt.edu).

The Lab for Educational Technology andDivision faculty has developed gastroenterologytrainee and CME resources in conjunction withthe American Gastroenterological Association(AGA, www.gastro.org). The Online Educationsection of their website has interactive case

studies, self-study multimediaprograms, electronic reproductionsof live educational sessions andprofessionally developed PowerPointslides on major scientific andclinical topics. The AmericanSociety for GastrointestinalEndoscopy website (www.asge.org)has a library of endoscopy videopresentations. MassachusettsGeneral Hospital’s DAVE website(http://dave1.mgh.harvard.edu)has over 150 high-quality videosof endoscopic and EUS findingsas well as audio slide presen-tations from grand rounds.

continued on page two

Online Education for the Gastroenterologist

Tips on locating online education from

the millions of Google references:

Try Google Scholar (http://scholar.google.com)

when searching for a literature-based source;

Narrow your search to just educational

and nonprofit sites by adding “site:edu”

or “site:org,” respectively;

Add “site: + domain name” to your search

(e.g., “celiac disease site:pitt.edu”

searches for the words celiac and disease

on University of Pittsburgh website only).

fundamental mission of the Division of Gastro-enterology, Hepatology and Nutrition at the

University of Pittsburgh is to discover new knowledgeabout digestive diseases and share it with the world.Important to this mission is the role of ContinuingMedical Education (CME). Our CME programs educatephysicians and other healthcare professionals aboutkey advances in research enabling them to incorporatechallenging research breakthroughs into their clinicalpractices. Delivery of high quality CME programs ischanging related to the flexibility and convenience ofthe Internet. Technologic advances can enhance CME,and our Division has supported the development ofDr. J.B. McGee’s award-winning efforts in educationaltechnology (see cover story).

Each year, our Division sponsors twoCME programs in addition to specializedevening meetings. This year’s first majorprogram, to be held on June 23 & 24,will highlight key Digestive DiseaseWeek (DDW) abstracts with a focus onGI cancers. Our annual autumn CME program,GI & Hepatology: What’s New & What to Do, focuses onpractical aspects of diverse GI topics with highlightsfrom the ACG and AASLD annual meetings.

Attendee CME evaluations are closely monitoredprompting the inclusion of more interactive case studiesand small group discussions, moving our programs beyondtypical classroom lectures. Additionally, special talks onbilling and emerging legal issues have been added.

The Division’s faculty takes great pride in deliveringsome of the best CME programs available anywhere.We hope that professionals requiring CME credits indigestive diseases, or with an interest in an area inwhich our faculty excel, will attend our upcomingprograms. Each course is designed to deliver CMEcredit which minimally disrupts clinical practice andprovides a high quality educational experience.

In good health,

David C. Whitcomb, MD, PhDGiant Eagle Foundation Professor of

Cancer GeneticsProfessor of Medicine, Cell Biology &

Physiology and Human GeneticsChief, Division of Gastroenterology,

Hepatology and Nutrition

A

D i v i s i o n H i g h l i g h t s

2

Online Education continued from page one

The El Salvador Atlas of Gastrointestinal Video Endoscopy(http://www.gastrointestinalatlas.com/) is the largestonline collection with 1744 videos.

Virtual Patients is a computer-based simulation of clinicalencounters, during which the learner plays the role of ahealthcare provider. More sophisticated versions areimmersive experiences where you can ask free-formquestions, perform a physical exam,order diagnostic tests, recommendtherapy and observe the outcome.Examples include Pitt’s GI Rounds

Online (http://girounds.pitt.edu) andNew York University’s Surgical Interactive Multimedia

Modules (http://simms.med.nyu.edu) which includesHollywood-quality animations of colon surgery displayednext to synchronized videos from the procedure. The cost tocreate a Virtual Patient program ranges from $30,000 to$250,000. Other national experts and I, through the Con-sortium on Medical Education Technology, have joined withthe American Association of Medical Colleges and MedBiquitousto promote sharing through a database of over 100 virtualpatients (http://www.aamc.org/meded/mededportal/vp)and creation of an international technical standard forexchanging virtual patient data.

Having grown up with the Internet and video games, currentstudents and trainees expect high-quality and effective digitallearning experiences with technology playing an increasinglyimportant role in their professional lives. To meet thischallenge, my lab recently launched online Collaborative

Learning Portfolios with NIH funding to document and shareresearch and learning experiences. We are connecting PDA’sto Learning Portfolios and Navigator to push just-in-timelearning to the bedside. We are creating Adaptive Virtual

Patients, which detect a user’s skill level and change dynami-cally based on his or her educational needs. Lastly, the Labis investigating the use of video game technology and virtualworlds to create “serious games” for health education.

Dr. McGee is an Associate Professor of Medicine

with the University of Pittsburgh Division of Gastro-

enterology, Hepatology and Nutrition and is the

Assistant Dean for Medical Education Technology

for the University of Pittsburgh School of Medicine.

Dr. McGee also serves as the Chairman of the Web-

based Education Subcommittee for the American

Gastroenterological Association and the Chairman

of the Consortium on Medical Education Technology

for the American Association of Medical Colleges.

University of Pittsburgh School of Medicine

http://girounds.pitt.edu

—

Post-Digestive Disease Week Update:Clinical Advances with anEmphasis on GI CancersFor more information contact:CCEHS@upmc.edu or (412) 647-8232

MARK YOUR CALENDAR:Friday, June 23 and Saturday, June 24, 2006

3

G R A N D R O U N D S

Arthralgias in a Patienton Infliximab

by Daniel K. Mullady, MDGastroenterology Fellow, Division ofGastroenterology, Hepatology and Nutrition,University of Pittsburgh

C a s e P r e s e n t a t i o n

20-year-old female with Crohn’s disease presentedwith diffuse arthralgias several months after starting

infliximab. Two years earlier, she was diagnosed withmoderate to severe ileocolonic Crohn’s disease with noextraintestinal manifestations and was treated with oralmesalamine and mesalamine enemas without improvement.Intolerant to 6-mercaptopurine (6-MP), she was maintainedon oral corticosteroids for the next year. Her diseasequickly went into remission on infliximab monotherapy.Shortly after her first maintenance dose, she developedtotal body arthralgias which recurred approximately sixweeks after each infusion. Initially thought to be related toher IBD, her arthralgias recurred despite an increased doseof infliximab. She had no synovitis and had full range ofjoint motion. Laboratory evaluation revealed a markedlypositive antinuclear antibody (ANA) titer at 1:1280 and amarkedly positive anti-double-stranded DNA (anti-dsDNA).Because of concern for drug-induced lupus, infliximabwas stopped. Repeat laboratory studies several weekslater revealed a persistently positive ANA and a positiveanti-histone antibody, but the anti-dsDNA antibody wasnegative. Though arthralgias resolved, she had recurrenceof abdominal pain and diarrhea similar to her initialCrohn’s disease symptoms.

D i s c u s s i o n

Infliximab is a chimeric monoclonal antibody to TNF whichis used to treat rheumatoid arthritis and Crohn’s disease andhas been approved recently for ulcerative colitis. Because itis 25 percent mouse protein, immunogenicity (antibodies toinfliximab or ATI) is common but is of unclear clinical signifi-cance. In a recent study, 61 percent of patients had ATI, andthose with ATI had an increased risk of infusion reactions andlower antibody titers at four weeks. Those on concomitantimmunosuppressants had lower titers of ATI and higherinfliximab concentrations. In a separate study, approximately75 percent of those who lost initial response to infliximabhad ATI while no continuous responders had ATI.

Infusion reactions to infliximab are categorized asimmediate or delayed and immune- or non-immune-mediated (see Figure 1).

The incidence of positive ANA titers with infliximab isbetween 25 to 50 percent. Development of anti-dsDNA anti-bodies is less common. Drug-induced lupus, however, is avery rare complication of infliximab therapy. In a retrospectivestudy of 500 patients treated with infliximab, only threepatients developed an antibody profile and symptoms consis-tent with infliximab-induced lupus. Diagnosis should includeautoantibodies as well as myalgias, arthralgias, arthritis, rashand/or fevers. The diagnostic difficulty results from a lack ofdiagnostic criteria for drug-induced lupus.

The relationship of this patient’s symptoms to infliximabdosing, positive serologies (especially antihistone antibodies)and the resolution of symptoms with inflximab withdrawalsuggest infliximab-induced lupus. This patient was not on animmunomodulator, predisposing her to an immune-mediatedreaction. Treatment options include methotrexate andadalimumab, an entirely humanized anti-TNF which seems tobe less immunogenic.

References available upon request.

A

Infusion Reaction

Within 24 Hours (Acute)

Immune Mediated

Type I hypersensitivity

Nonimmune Mediated

Rate relatedHeadacheNauseaNonspecific

Serum Sickness-Like

Antibodies to infliximabType III hypersensitivity?

Other

Lupus-like reactionViral syndromeIBD flareNonspecific

After 48 Hours (Delayed)

Figure 1 Inflixamab Infusion Reactions

4

G R A N D R O U N D S

Preparation for WirelessCapsule Endoscopy –Is It Necessary?

by Benjamin Siemanowski, MDGastroenterology Fellow, Division ofGastroenterology, Hepatology and Nutrition,University of Pittsburgh

C a s e P r e s e n t a t i o n

79-year-old white female with multiple medicalproblems presented with a three-day history of

melena and increasing fatigue. During the prior six months,she had two similar episodes, after which upper endoscopy,colonoscopy and small bowel series did not reveal a sourceof gastrointestinal bleeding. Physical examination wasunremarkable, with the exception of black stool foundon digital rectal exam. The patient’s hemoglobin was8.5 g/dL (baseline 10.5 g/dL). Repeat upper endoscopyand colonoscopy revealed mild gastritis and scattereddiverticuli, but no source of recent bleeding. Wirelesscapsule endoscopy (WCE) was ordered to evaluate thesmall bowel as a bleeding source. Prior to the procedure,the need for bowel prep was questioned.

Preparation for WCE: Since becoming readily availablein 2001, WCE has provided the ability to visualize the smallintestine and has gained popularity with expanding indica-tions. Conventional preparation requires only eight hoursof fasting prior to capsule ingestion, as was used in theoriginal studies comparing WCE to the previous goldstandard, push enteroscopy. Over the past 24 months,there have been seven publications in peer reviewed jour-nals addressing the issue of optimal preparation for WCE.

The cost of preparation (Fleet’s PhosphoSoda $2,GoLytely $22) seems negligible compared to the overallcost of the procedure (WCE $728 to $1,250). Many practi-tioners argue that preparation for WCE subjects patients tounnecessary discomfort. However, a lack of preparationand suboptimal WCE results may subject patients torepeated invasive testing.

More importantly, does preparation improve the quality ofWCE? The literature reports a 75 percent overall successrate of the capsule reaching the cecum with adequate visual-ization. Two retrospective studies, one using phosphosodaand one using polyethylene glycol (PEG) 4L, suggest thatpreparation improves the overall quality of WCE. A small,nonrandomized study showed no benefit of using 2L of PEG16 hours prior to WCE. A randomized, prospective, con-trolled trial compared 40 patients prepped with 2L of PEGand 40 control patients prepped with clear liquids and NPO.Patients in the PEG arm had a statistically significantimprovement in both image quality and diagnosis.

Other medications studied include simethicone anderythromycin. A recent study consecutively enrolled 18patients to receive 80mg of simethicone 20 minutes priorto capsule ingestion with an additional 18 patients receivingno simethicone. Those receiving simethicone had astatistically significant improvement in the quality of WCE.Low cost, minimal side effect profile and ease of usemake simethicone an attractive option for improving WCEquality. Erythromycin 250mg 1 hour prior to ingesting thecapsule decreases the gastric emptying time of the capsule,but provided no change in image quality. Erythromycinmay lead to improved ability of the capsule to reachthe cecum and should be considered in patients withdecreased gastric motility.

Summary: Initial data from randomized trials suggeststhat overall quality of the exam can be improved by usingPEG solution 2L, 16 hours prior to the exam and simethicone80 mg, 20 minutes prior to capsule ingestion.

References available upon request.

A

Answer to What Is This photo on page six: Clostridium difficile colitisClostridium difficile associated diarrhea is increasingly common in the hospital setting. Immunosuppressed patients

and those on antibiotics are particularly vulnerable. In severe cases,pancolonic thickening can be seen on CT scan.Additionally,the finding of pseudomembranes on flexible sigmoidoscopy is virtually diagnostic of Clostridium difficile colitis.Treatment mainstays include metronidazole and oral vancomycin. Intravenous immunoglobulin (IVIG),a poorly studied drugaimed at boosting the humoral immunity,has been prescribed in severe cases.

C O N T I N U I N G M E D I C A L E D U C A T I O N

5

Improving the Impact of CMEby Barbara E. Barnes, MD, MS

lthough the United States has the world’s largestand best organized system of continuing medical

education (CME), common venues such as lecturesand formal courses may have little impact on physicianperformance and patient outcomes. As consumers andpayers become increasingly concerned about the quality,cost, and safety of healthcare, there is an emerging expec-tation that healthcare professionals not only continue tolearn about new developments and standards of care butalso incorporate this infor-mation into their practices.

A variety of regulatoryforces are reshaping CME.Because of new AmericanBoard of Medical Special-ties (ABMS) requirementsfor maintenance of pro-fessional competence,physicians are participat-ing in educational activi-ties to prepare for boardexaminations and toimprove their performance in practice. State licensingboards are also becoming more prescriptive about educa-tion through mandates for CME in specific domains such asrisk management, HIV and domestic violence. In addition,many hospital medical staffs require skills training for cre-dentialing in certain procedures, and insurance networksare offering economic incentives for education related toquality improvement and cost containment initiatives.

In response to these environmental trends, accreditationbodies are setting expectations for CME providers todemonstrate the impact of their programs and expandCME activities. Credit can now be earned for boardrecertification, manuscript review, test item writing,performance improvement activities, Internet searchingand learning, and committee work containing a professionaldevelopment component. An innovative program launchedby the American Academy of Family Practitioners knownas Metric, allows physicians to earn 20 CME credits forcomparing their practices to established guidelines andassessing intervention outcomes to improve care.

How can gastroenterologists improve the effectiveness oftheir CME activities? One strategy involves the determination

of specific learning needs. Using electronic health recordsand data provided by health systems and insurers, it is nowpossible to define gaps in competency and performance thatmight be addressed through CME. This information canassist in selecting educational activities and topics that aremost relevant to practice and that demonstrate results.

Physicians must also ensure that their CME addressesthe full scope of professional competence. The ABMS andAccreditation Council for Graduate Medical Education haveidentified the following six core competency areas: patientcare, medical knowledge, practice-based learning andimprovement, systems-based practice, interpersonal andcommunications skills, and professionalism. Unfortunately,

much CME focuses on thefirst two categories, ignoringmany dimensions of carethat impact quality, cost-effectiveness and patientsatisfaction. New optionsand venues for CME such asquality improvement activitiesand team-based simulationtraining can be used toaddress the broad range ofrequired competencies.

There is growing concernabout the role of commercial interests in CME. Accordingto the Accreditation Council for CME (ACCME), over 60percent of CME revenue is derived from commercial supportor industry-sponsored exhibits. Evidence suggesting thatsuch relationships can affect clinical decision making hasprompted calls for elimination of such funding and hasspawned more stringent regulatory requirements formanagement of conflict of interest among CME facultyand course directors. Participants in educational activitiesmust understand the impact of these industry relationshipson content development and delivery, by avoiding undueeconomic incentives for participation in CME programs(such as lavish meals and entertainment) and by criticallyevaluating content credibility.

Dr. Barnes is the Assistant Vice Chancellor

for Continuing Education in the Health

Sciences and is the Associate Dean for

Continuing Medical Education at the

University of Pittsburgh.

A

The ABMS and Accreditation Council for Graduate

Medical Education have identified the following

six core competency areas: patient care, medical

knowledge, practice-based learning and improvement,

systems-based practice, interpersonal and

communications skills, and professionalism.

6

GI’s Impact on theMedical School Curriculumby Patricia K. Eagon, PhD

ne of the most critical missions of the Division ofGastroenterology, Hepatology, and Nutrition is each

autumn’s production of the Digestion and Nutrition Course for thesecond year medical students. Digestion and Nutrition, or “Digand Nut” according to the students, is a team-taught, one-montheffort directed by Georgia Duker, PhD, James B. McGee, MD andmyself. GI faculty contribute lectures, serve as problem-basedlearning (PBL) facilitators, design cases for discussion and teachreview sessions with contributing faculty from the Departmentsof Pathology, Pediatrics, Molecular Genetics and Biochemistry,Cell Biology, and Pharmacology.

Using various learning formats including traditional lectures,several histology lectures and laboratories, pathology lectures,student-directed small group learning sessions and online caseworkshops, lecture notes generate a 600-page syllabus, whichserves as the major student reference.

Student course ratings continue to rise each year. One of themost important course quality improvements is the Navigatorwebsite, http://navigator.medschool.pitt.edu, developed byDr. James B. McGee (see cover story). All Navigator coursematerials can be viewed by both students and faculty, includinglecture notes and slides, quizzes and self-teaching caseworkshops. Overall course success is credited to the facultyteam, which contributes its time and expertise to train futurephysicians and physician-researchers.

Dr. Eagon is an Associate Professor of Medicine with

the Division of Gastroenterology, Hepatology and

Nutrition and the Department of Molecular Genetics

and Biochemistry at the University of Pittsburgh.

O

What Is This?Presentation: An 18-year-old woman with

a history of Crohn’s disease presented witha two week history of abdominal pain andnon-bloody diarrhea. She was treated withsteroids for a presumed flare of Crohn’sdisease with no improvement. A CT scanand colonoscopy were performed.

Images and explanation provided by Mark

Lazarev, MD, a Gastroenterology Fellow with the

Division of Gastroenterology, Hepatology and

Nutrition at the University of Pittsburgh.

Compare your answer to Dr. Lazarev’s

answer on page four.

Digestive Health Network

Division of Gastroenterology, Hepatology and Nutrition

200 Lothrop Street

Pittsburgh, PA 15213

�

Figure 1CT abdomen

�

Figure 2Flexible

sigmoidoscopy

Information concerning Pitt Digest or requests for additional newsletter copies may be directed to Joy Jenko Merusi at

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