Let's welcome back John and Sorel, and they will end our course with an APP Journal Club, so take it away, guys. Well, Sorel, I can't believe that this couple of days has blown by so quickly. It has. It has been a really good course, you know, learning a lot of individualized and specialized care, so it's been good. It really has been amazing. The Journal Club format is kind of relaxed, and so I think Sorel and I want to encourage you to grab a drink, to hang out, and, you know, one thing, Sorel, I don't know what your experience has been with Journal Clubs, but there's been sort of different ways to do it. Some of them, you just kind of sit down and have a couple of assigned journal articles, and you go over those, but, you know, one of the experiences I most enjoyed was when I was actually a medical resident in Cleveland at Case Western Reserve, which is what it was called at the time, and there were three different hospitals in the case system, and we had a thing called Intra-City Grand Browns, where all of the case institutions in the Cleveland network came together at one of the particular locations. And so it kind of started out with a social thing for the first 10 minutes or so before we got down to either having a Journal Club or having one or two case presentations, and that social thing kind of was a lot of fun, particularly at the end of a tough clinical work day. How about you? What's been your experience with Journal Club? I think it's a great way to, you know, to start getting a journal out there and talk about it in kind of a relaxed, almost social environment, and really, you know, give opportunity to share thoughts and have some basic information available on how to treat certain disease conditions. For sure. You and I work together and we see each other a lot in the hospital. And I, as a gastroenterology physician, many times depend on your focused expertise in esophageal diseases and disorders. And I just want to start out by taking a minute to celebrate just the focused expertise you and the other APP faculty on this course have demonstrated. It really, truly is remarkable and definitely is something to celebrate. It is really incredible how expert your fund of knowledge is and how focused you APPs have become in gastrointestinal and other disorders and diseases. It's really a great thing to witness. And I've thoroughly as a physician appreciated the opportunity to learn from all of you. I noticed yesterday, Sorel, that there seemed to be a lot of interest on the part of the audience in the Q&A box, where they were asking about academic pursuits and opportunities for APPs. And I think many of them may have been trainees or people who are early in their careers or, frankly, just haven't been exposed to the academic environment that APPs can work in. And we're fascinated that many of you are repeat authors of journal articles and give talks and teach and are involved with training APP fellows. And I wanted to ask if you could give us, for starters, a bit of a synopsis of how you ended up being a focused expert in the clinical management of patients with esophageal disorders at Mayo Clinic. How you ended up doing things like writing articles, giving talks, and so forth. What your involvement is with our APP fellowship at Mayo as kind of a way to give some insight into how you can develop your career along those lines as an APP. And also as our sessions equivalent of what I used to experience and enjoyed so much as a resident in IntraCity Grand Rounds. This is a social part of our journal club. That's a little bit about my background. I worked as a nurse and thoracic surgery, you know, taking care of all these post-Nissan front application esophagectomy patient and there was also some lung patients. And that really kind of sparked my interest. I was in the middle of going back to grad school. And there happened to be no position available in the esophagus clinic. So I felt it was a good transition for me to go from the surgical standpoint going into medical standpoint in esophagus disease. So I already knew the surgery part of it. Of course, as you know, the learning curve is quite steep as a family nurse practitioner. You don't get much specialty education in there for the first one or two years. There's really not much going on beyond just clinical work. But then there's a point that come that you feel like, well, I want to do more. We really got to elevate the role of APPs in the clinic. And for me, it started with writing up some interesting cases. I was involved in, there was a self-dilation program we have here. I was involved in some of that. And then that really kind of sparked my interest in writing more and being more involved in research and education, not just all clinical work. Of course, it takes a lot of time, which we don't, none of us have, but it's been rewarding so far. Speaking of which, was it all your own initiative then? Or did people invite you to do some of these things? Do you have to chase it on your own? Or are there opportunities to sort of be invited? What's the pathway to doing what you do? I think probably half and half. I mean, you have to be really out there and you're out of your comfort zone and try and take initiative on starting writing up projects and learn about them. It's currently another case that I wanted to write up and I would just start to kind of sit down, get a broad outline, and then invite my physician colleagues in to kind of give their input. And some of them were invited for talks and doing papers and presentations, yes. You touched there on having time or making time. I believe your spouse, isn't she an APP as well? She is. So how do you swing that? I mean, what's life like? I know you have kids that are busy and active in sports and school. It's difficult. It's evening time and weekend times where you try to find the time here and there. And biggest thing, don't put it off. Try to work a bit on it as time permits and to get your research and your products done. But in the end, it's quite rewarding to not be so focused clinically to broaden really your outlook on what else can I do as an APP. And what about APP fellowships? I know we have one at our own institution in GI and you have some participation in training those trainees. Is that the only way to become a focused expert? I mean, you did it when that wasn't available to you. Pros and cons there? Yeah, certainly the APP, the fellowship program here that was started probably a year ago. Now they're taking on two APPs per year. It's really a good program where they get a deep dive into all the specialty clinics. For me, that was not really available. So we kind of had to seek out other educational options. But some of those APPs that go through the residency program, they don't necessarily just teach or work at a tertiary facility. They go down to community centers. Oh, I see. And so clearly some stay in academia, but others go into the community, right? Correct. That's been my experience. Fantastic. Well, the article that we chose for the Journal Club today is one that you authored. And maybe you could start by telling us how you got this opportunity or if it was one that you asked to write. And then while this is a lot of fun, I know that this is a limited time we have to do the Journal Club. So once you do that, I think we probably ought to take it away with the Journal Club, right? Yeah. So this is coming from the HGE in collaboration with Dr. Nowakowski from the Rockford Group. And we were able to do this remotely back and forth. It was a little bit difficult, but we tried to just make it a kind of a practice day-to-day options for treating eosinophilic esophagitis. Well, thank you for the synopsis into your career development and some insight into how APPs these days can go into focused gastroenterology care through different pathways. Shall we start with your article then? Certainly. I have some slides prepared. I'll just go through some of them, skip through others. We'll start with the case here. This is commonly how these eosinophilic esophagitis patients will present. Usually with a history of some food bowls impaction, they can't swallow their saliva. In this case, he was able to get sudden results of the impaction. He was able to get water down. Now he's in the office for evaluation. Several years dysphagia history, describing food really translating slow through esophagus. He doesn't have weight loss. A note, there's a history of asthma as a child and seasonal allergies. He doesn't take much for medication other than antihistamine. What are the possible causes of dysphagia and what do we do next? Great. What would you recommend next in the care of this patient? It's chest CT, barium swallow, high resolution esophageal manometry, EGD, or a trial of proton pump inhibitor for eight weeks. A lot of good choices here. I think the idea behind this question is to go for endoscopy right away because of the dysphagia and the esophagram is certainly an option. CT chest, probably not my first choice, as well as the PPI is likely not the first choice. Here are some endoscopic findings. You can see rings and furrows. Sometimes you can see some exudates and edema. This biopsy showed 60 eosinophils per hypoart field. As we know about diagnosing eosinophils, eosinophilic esophagitis, you want at least 15 eosinophils per hypoart field. What is the most appropriate next step? Do we refer to allergy for skin testing, initiate a long-term elimination diet, perform a pH impedance study, put them on an eight-week trial of PPI or esophageal manometry? I agree that the best choice is to initiate an eight-week trial of PPI. We'll talk more a little bit in another slide about allergy skin testing. A food elimination diet is certainly an option. Manometry won't be a test I'll go to right away. Another polling question, true or false, dilation in EOE treats the underlying inflammation and should be used as a sole treatment? That's correct. Dilation is certainly a treatment, but it's not the only treatment and it doesn't treat the underlying inflammation. That's one of those words kind of like never or always, right? In test questions. Yeah. So, we know that EOE is a chronic immune and antigen-mediated disease, as well as there's a response to these food allergens. It really ends up making the esophagus narrow and sticky, often symptoms of people who have, you know, obviously dysphagia, but they can have foodborne infection, chest pain. As discussed earlier, you want biopsies showing greater than 15 eosinophils per high-powered field, and we usually do an esophagram. Here's some common endoscopic findings. Stretches are common. The ring appearance of the esophagus on the top, and then these longitudinal pharaohs. You can see some X-rays, these whitish plaques almost look like Canada. Some are normal. And then an esophagram, you can see a narrow caliber esophagus, and in some cases, even these rings in the esophagus. Here are treatment options, just kind of an overview. PPI, the response rate is about 40%, then topical steroids. Bruneisenide capsules, that comes as a compound, you mix with honey or syrup, pulmic or respules. Particazone, I think, is now off the market. There's a generic, a little bit difficult to do as it's hard to really to push the inhaler and then try to swallow it. Takeda came out with the first FDA-approved steroid now, just the end of February, so we'll see what the insurance is going to do for coverage on that over the next six months. Then there's food elimination diets, and you can even do the 2, 4, or 6 food elimination diet. But then dupilumab, in our practice, we generally reserve this for refractory EOE. In addition to treatment, it's also important to think about dilation, as you can take the eosinophils out, but you will need to dilate some of these patients, especially if they have a narrow esophagus. Cyril, remind me, particularly with the branded Fluticasone going off the market and now being sort of the captive generic, which is tough to get insurance coverage for, it brings up the issue of Fluticasone versus Budesonide again. And particularly in the adult EOE population, remind us what the deal is with, you know, one versus the other in terms of those steroids. Yeah, it really comes down to insurance. I mean, before, it was really, I think the compound was the most difficult to get covered. The Restyl seems to be covered quite well. It's a little bit more volume for the patients to use. Inhaler is a little bit hard to use, but I think the application is pretty good. Tougher for kids, right? Tougher for kids, yeah. This is a little algorithm that I put together and really how I treat EOE. I'm not going to go through this here, but I'm just going to take you down the pathways of, I generally start them on a high dose PPI, do endoscopy in eight weeks. If they are responsive, then we put them down to once a day dose of PPI and then repeat an endoscopy in about six months to see if they're still in remission. Those who are not, after BID-PPI, I usually switch to a compound or a Restyl formulation. And again, do endoscopy in eight weeks to see if they're in remission. Some people will choose food elimination diet. It's quite difficult, especially the six-food elimination diet. Most of the patients I see here for EOE travel quite a distance, so they don't really—local patients. And we provide them with a whole pamphlet for meal planning on eosinophilic salvagitis, which really goes through the details, and we send them to a dietician to really make sure they understand what to avoid. Can I ask you something about that? Go ahead. So what about—say you have somebody in the ED, and endoscopically, they show all the stigmata of EOE, and they even have a really narrow esophagus. And so you have little doubt in your mind, and the path comes back, and they've got a really high EO count. Are you still going to withhold further management other than PPIs for a couple of months? Do you ever deviate from that protocol that you showed? Yeah, but if they have a very narrow-caliber esophagus and a high eosinophilic count, sometimes you can just go directly to steroids to try to get the disease under control. We know that people that don't really respond to PPI have thin patients with a narrow-caliber esophagus, so those are less likely to respond to PPI. But certainly the option to go to steroids directly to get things under control, in addition to dilation, careful dilation. So this slide just shows—what if we do nothing? You don't put them on medicine, you don't dilate them. So we know up to 70% of patients will get this fibrostatic disease over time, so it just gets worse as it goes on. Just, again, an overview of the treatment. Again, looking at some pedestinite issues, why we use the pancake syrup or honey is because they have obviously a bitter taste. About a third of patients we see with Canada that can be difficult to treat. I have a few patients on a—about every other day, nice statin regimen because of recurrent Canada, not a whole lot. We've talked about the verticozone. Six-foot elimination diet, we know it's effective up to about 70% to get histologic remission, improvement in symptoms, and endoscopic improvement, but really difficult to stay on long-term as soy is in everything. This covers the question we asked about the allergy testing. Oftentimes, we'll get patients come in that have had outside allergy testing, and it's really not specific. There's no correlation between skin or serum testing. We need biopsies from the esophagus wall to really determine, once we take those foods out and put them back in, if there's a reaction. Here, it's going to cover the two, four, and six-foot elimination diet, the response rates. The two big ones are milk and wheat, so you can certainly consider just taking them out and see how people respond. And then as you get to the more restrictive diet, that's the response rate. Certainly, endoscopy can be done as the initial index endoscopy after you take the food elimination diet. And then if we do a reintroduction, we use a esophageal sponge, so that really saves patients a whole day of sedation and not being able to drive. They can just come in here, swallow the sponge. It deploys in a capsule, and they pull it out, and it samples the eosinophilic. It samples the esophagus. It's on a string? It's on a string. Uh-huh. This slide's going to cover why do we do esophagrams. The endoscopy is not good at finding overall narrow caliber esophagus. So in all my patients with eosinophilic esophagitis, I do a esophagram to get and ask for a minimum and maximum diameter of the whole esophagus to really get a sense of, is this a really narrow esophagus? Do we need to put them on steroids first, or do we need to be more aggressive with dilation? And dilation is safe. Here are some studies looking at perforation rate. It's quite low if it's in the hands of a really trained and experienced endoscopist, about 0.2% out of 30 to 50 patients. Some patients can develop chest pain after dilation. It's common. You can get really impressive runs after dilated EOE. That's really all I have for slides. I will take any questions or anything else that comes to mind.

esophageal disorders

specialized care

gastrointestinal diseases

advanced practice providers

eosinophilic esophagitis

early diagnosis