There are some questions actually that have come in. One is about PPIs and steroids. Do you use them in series or do you use them concurrently? So you start with a PPI and then you add the steroid or you do one at a time? We do one at a time and see, really start with a high dose PPI, do an endoscopy in eight weeks. If they are not in remission, I would either have them stop the PPI or keep them on a low dose if they have heartburn symptoms. I see. Then we would next move on to a topical steroid. So you really want to try one treatment at a time. Oftentimes we see people on a PPI, a steroid and food elimination diet and it really makes it difficult to say, well, what do we do now? Understood. And how long after the elimination diet do you recommend performing the initial EGD? So we have them do that for about six weeks and do the endoscopy. And if they're in remission, they start introducing food back in. And for clarification, yeah. I'm sorry to interrupt you. Keep going. And then you do another either a sponge or an EGD every four weeks. That's how we do it in our practice. Yeah. And one of our journal club attendees says, I'm a little confused. Is Fluticasone not first line after PPI? And basically whatever steroid the insurance wants to cover is after PPI. It's so the theme, right? It's such the theme that what gets paid for is what gets done. Yeah, we hope with the new, actually FDA approved, but that's tonight and that the coverage will be better with time. Got it. And then another question here, really good one. What about Dupixent? When do you reach for that? And when do you stop it in refractory EOE? Yeah, so the Dupixent is the new kit about a year or two now. We use it mostly for refractory, they don't respond to, to pedestinite or the patients that have, you know, atopic, significant atopic disease. I find that the insurance covered better in that situation. I'm firing questions at you here because you're getting a lot of them because you're stimulating interest here as an esophageal expert. So do you recommend food elimination diet while the patient's on treatment, PPI, steroid, Dupixent? Can they eat what they want? And I assume what they mean is once you've got them on treatment, can you back off on the elimination diet? Yeah, so I saw a young patient about a week ago who came in on BID-PPI, BID-steroid and the six food elimination diet. So what we did with him is backed off of the PPI and dose to control his heartburn and have him liberalize his diet, get off the food elimination diet and keep him on the steroids. You really want to find one treatment that works that keeps the eosinophils out of the esophagus. Good to know. And how do you differentiate between EOE versus reflux as the etiology for the eosinophil count elevation on the biopsies again? Yeah, that's a good question. You know, you can sometimes see some lower numbers of EOE. So the recommendation is to take MIT and proximal esophageal biopsies for the evaluation of the EOE. But you can see some lower eosinophil counts in patients with significant reflux. It can sometimes be a little bit difficult to sort through that. John and Srel, you guys are doing great. So I'm gonna let you go a few more minutes before we go to the round table. So keep going and maybe I'll hit the buzzer in about five minutes or so. We really appreciate that, Joe, because there are some more questions and we were just about to sign off. So we will keep going until you give us the flag and shut us down, okay? Sounds great. All right, thank you so much. So Srel, can you explain the physiology behind how the PPIs help with EOE? Is that known? Well, I think, I'm not a physiology expert on this, but it has to do with decreasing the inflammation and closing some of that gap junctures in the setting of reflux. But that's part of it. And I think I know what you're gonna say here, but do you see much refractory EOE after adequate long-term management? And you may, I think, wanna also talk about diagnosing early and the importance of that. I see much refractory EOE. The example for that I can use is a patient that was on, we found that she had a milk. She responded to milk, meaning she avoided milk, and then she became unresponsive to milk. So we're kind of putting her through the food elimination diet again to see if we can find a different culprit. But I see much refractory EOE. I see more people on two or three therapies than I see refractory EOE. I see. And another one of our journal club compadres asks, I could have missed it, but do we use terms such as PPI responsive or PPI non-responsive in these patients? Yeah, I think they are trying to go away from that term. And why is that? Is it because it's imprecise nomenclature or is it misguided? Yeah, I'm not sure exactly the reason why they're going away from that terminology. If they're trying to separate more of the reflux part of it, separate from the EOE, but likely that. And here's a curve ball. I don't know if this is sort of idiosyncratic or what, but I had a patient diagnosed with EOE shortly after starting Denture Cream. He came in curious as to whether this could have any association. Yeah, I have no idea. That's a great question. Right, talk about a curve ball. And for EOE, repeat the EGD in what, three months or six months? So if you start them on one therapy, I usually do two months. And if they're responsive to that, I decrease the dose to either modesinide, a nightly dose or a PPI once daily dose and repeat it in about six months to see if they stay in remission. And after that, it's really clinical judgment based on symptoms. And practically speaking, what, eight biopsies, mid and distal esophagus total all in the same bottle or you feel differently? It depends on cost. And I think probably all in the same bottle is fine. Yeah, I mean, I think two bottles equals two times the cost, right? Isn't that how it works? Yeah, yeah. So, well, we probably have time for one or two more. I think two more questions would be great, guys. Sounds good. Okay, that sounds great. Is a PPI appropriate to start if the patient has stricturing already? I think it is. I tend to rely more on modesinide, but I think a PPI is fine. You know, some of those patients with a narrow caliber esophagus are not likely to respond as we look at the evidence, but I think it's okay, yes. So here's an interesting morphologic question. Are the corrugated rings that you see in the esophagus a contributing factor to the dysphagic symptoms and do they smooth out after successful treatment or not? They tend to do, yes. I mean, it's the rings with the edema and the overall fibrosis that cause the dysphagia. And you see, you know, endoscopically improvement after treatment of these findings, yes. So then to some extent, what you see is what you get. That's comforting to know. Correct. I'm feeling generous, Scott. I'm feeling generous. There's maybe a couple of quick ones as I look. So maybe one or two more. Seriously? That's awesome. We'll keep going. This is the fun of doing this course. I think there's a couple of quick ones, do them, and then we can move on. Here's a question on the death side after confirming diagnosis. If they're in remission, I usually put them on a low-dose bedtime dose. I see. And what about- Cytochrome for EOE versus EGD, both. And this is really practical. How about referring to an allergist? Is that ever indicated? If they have uncontrolled erinitis and or asthma, yes. I see. And what does the allergist usually work up and what do they treat in that setting? Yeah, good question. I think they work up this, see their allergies, see if there's something specific they can zone into that they can treat that will help the EOE. I see. But that's a little bit of last resort kind of thing. Yes. I think this was really fantastic, guys. And I think we got to a lot of questions. There are four left, so we'll do our best, everyone in the audience, we'll do our best to get those answered behind the scenes. But I think it's time for our round table. So I'll ask everyone that is on to turn their cameras on. John and Sorel, please keep your cameras on. And I think Sarah and I will maybe throw around a few ideas first. Anybody, first we'll start with the faculty, some comments, some thoughts, and then for our colleagues in the audience, if you have any questions that are kind of beyond this last session, general questions, thoughts about how getting involved with the society or anything you want to ask, please send it in the QA. But I'll ask the faculty thoughts, comments, pearls for the audience that they could take away as they move on through their careers and education for life. I'm dying to make a comment, so I'm gonna jump in, I'm gonna dive in and just take over for a second. I would guarantee you that if you took all of our titles and stuff off of everything related to the course, and nobody knew what schooling we had, none of you would be able to tell who here is an APP and who here is a physician. And I think that says a whole heck of a lot. And I think that is a congratulatory statement. I think it's the here and now, and it's the future too. And I just think that is incredible. Thanks, I just wanted to say that. I couldn't agree more, John. And the word that I use over and over again in all my talks is, first, two things, teamwork, teamwork, teamwork. We are providers, we are a team. I really don't distinguish between MD, PA, NP. I just look at providers in a team approach. Second, if we do look at APPs, you are indispensable to the successful practice of GI. We have an access problem. We have all types of weights and difficulties with patient care and quality care. And one of the most important is not getting timely care. So you are indispensable to the practice of GI. We do have a hand raised. As you guys on the faculty know, I'm not very technologically advanced. So I'm gonna turn it over to Michelle and see how we get to the person who's got their hand raised. Sure, it looks like Saritha Kunath has her hand raised. So I think I have allowed you to speak. Let me know if I have. Hi, can you hear me? Yes. Hi, no, I had my hand raised for the previous topic of eosinophilic esophagitis, but I got my answer. I got my answer through the thing. But regardless, this has been such a amazing seminar and to learn through so much. I'm an APP myself, working with GI, but I'm quite new. It's only a year and a half, but this is so informative and very encouraging to go forward in this field. Well, we're glad to hear those words and tell your friends about us. We'd love to have you and more of your friends back next year. Absolutely. Okay, any other, and Michelle- We have one more hand raised. Oh, absolutely, go ahead. Cecilia Bean, floor is yours, Cecilia. That's actually a mistake. Just, but since I have you, I'll just make a comment. I thought the workshop and the conference was excellent. This is my first time attending. I learned a lot and I actually appreciate the physician colleagues and their respect for the APP because that's not always the case. So I applaud you and I thank you. And thank you for letting us know that and we hope your experience changed. I know many of these people, many of the faculty, they're friends and they're sincere and we say we enjoy working with you. We do and I was the culprit in asking Sorel to write the article on eosinophilic esophagitis. I knew I'd create more work for him, but I knew he was up to the task and he did a fantastic job. Any more hands raised at the moment, Michelle? No. All right, other faculty members, please chime in. I will mute for a moment. I think I just wanna jump in real fast and just say for any of those that are actually attending the course right now, I know Jill, myself, Sorel, I know Sarah. If you happen to see us at another conference, don't feel shy, walk up and ask us a question. Ask us if there's something that you wanna be involved in and looking for further development of your career outside the clinic, as I like to call it. I think all of us are amazingly great resources, but I just want to always say, please don't ever, like if you see one of us walking by, please just kind of pull us to the side and ask us a question if you didn't feel comfortable asking it today. Because I'll tell you, that's where I started. I started by asking somebody 17 years ago, how do I do this? And as Dr. Bakari just pointed out, I think our physician partners are so imperative in what we do, our physician champions, as I like to call them. Because I'll tell you without them, there have been many of opportunity that maybe wouldn't have come, that they challenged me to actually do. So Dr. Bakari, I agree. I don't know if you know Nasir Khan, but Nasir Khan was the gentleman who really pushed me into getting more and more involved with the Crohn's and Colitis Congress and actually being a member of one of the committees. And that's kind of what really transitioned a lot of what I've done. And it really came from a physician champion. So keep that in mind as well. I do know Nasir, you couldn't ask for a nicer guy and he's a great mentor. I'll follow up for a moment what Kim had to say. We would really like to have you involved if you're interested. From last year's course, we had two people get involved, each co-authored a APP case of the month. And one is going to write with her physician team, write an article for our December edition of IGIE. And if Caitlin's on, I'll try not to embarrass her too much, but I'll tell you her story. I know Caitlin's mentor and colleague, Shelby Sullivan, and Caitlin's name came up. Caitlin started by writing a case report for the APP case of the month. Last year at DDW, she was a co-moderator of a APP session. And she's back now, she's now lecturing or educating at this course for the first time. And she will be speaking at this year's APP session at DDW. So it starts off very simply. We've already had one request from this course. So if you're interested, we will do our best to get you involved. And we do have plenty of work. So I'm sure we'll find something. The only thing I'd like to add is that as a new advanced practice provider and specialty of gastroenterology, you're not expected to know everything. So it's okay when you're having a conversation with a patient and you're starting that workup, you don't have to pretend to know everything in front of the patient. You can say, well, the way I practice my pattern is, I'm going to go ahead and I'll speak to my physician collaborator. We're going to go ahead and both together, we're going to go over your history and physical, and we're going to come up with the best plan for you. So let me step out. I'm going to walk over to the endoscopy department. I'm going to speak with him and then I'll be back with you shortly. And patients love the idea that there's a team approach and that you're collaborating with another gastroenterologist. They know that two heads are better than one and they don't expect you to know everything. So there was a question that came up yesterday. It was an attendee who had a question and she functioned at an academic center. And she said, well, how am I supposed to know how to take care of a patient when two other gastroenterologists have already seen this patient and they don't know what's wrong with them? I mean, what you're good at is listening to patients and hearing their story. And that's what they want to hear. And you may not change the plan of care. It's just the patient's perception of how they received that previous plan of care. So you have no idea how important and how impactful you are in that patient's life, just listening to their story and then getting another set of ears to hear that history and help guide their care. Any other hands raised, Michelle? No, Joe, not at this time. Okay, it's been a long two days. So we realize everybody's probably getting tired. It's Saturday night. They want to go out and as Vivek said, have a good time. Any other comments by faculty members, words of wisdom? You know, Joe and team, I think this is needless to say, I mean, it's always an amazing two days. Very well done again. The team at ASGE needs to be congratulated. The folks who stayed on, I still see about 150 folks on at this hour. So that's itself is a testament. And you heard a couple of comments, although there weren't any real hands, right? We had fake hands, but people did make very, very positive and real comments that are testimonials. And I dare say, we'll see a few more of those, but we're also interested in comments that make us better. So when you provide the feedback, please be objective and let us know where we can do better. What went well, what didn't go well, what can we do better next time? And all options are on the table in my mind. I think the course is flexible in its design, its framework, a lot of new elements were introduced this year, including the radiology piece, the journal club. So I think the success of any such endeavor relies in constantly reinventing portions that need modification, improvement, and enhancement. And that's the way I've learned in the last quarter century in this field. You gotta adapt and evolve and get better and better. That's one box. The second box is, if we had time, we would do end of day summaries, but this is already a dense course in terms of material and time. What I suggest for the attendees is you have access to these enduring materials. Look at the summary slides from each lecture and compile them separately into a separate PowerPoint and maybe do like a one binder for a unit or for your practice setting. And that represents the state-of-the-art information for that particular collection of titles. And that way you have an easy reference when you're seeing a patient, you have a question around a guideline recommendation or something state-of-the-art that's a pearl or a caveat that the subject matter expert left with you this weekend, that's easily available. So I find the summary slides, the key messages, the pearls readily available in your clinical practice setting. It's even faster than logging into up-to-date or logging into an online portal. So those are my suggestions for once you're done with this course. I'm very grateful to have been part of this again. And I don't know if you're taking any, are there any questions left in the chat, Joe and Sarah, but obviously other faculty should comment as well, but a fantastic event as usual. I think we'll get to the questions kind of behind the scenes, give faculty, anyone else has some comments before Sarah and I make some final comments. And if at some point or when we have no hands left and from the audience and when the faculty is done, if we're done a few minutes early, I don't think anybody will complain on a Saturday night. It's just been a fantastic two days. I'll take that silence as my cue to make some closing remarks and then pass it off to Sarah. And then Michelle will have a few moments of housekeeping. So for those of you faculty who've been around from the beginning, we started this in 2020 and we had 72 people. And I believe as of yesterday, we had about 278. So it's really been a remarkable run for us. And you can tell we all are very passionate about teaching and about educating and informing. And again, there is no lecturing here. It's just a collegial atmosphere to discuss and we can all learn. Having said that, in addition to the APP course, we have the APP case of the month and that is in practical solutions from the ASGE. Some other education items, it's under APP ANGLE. In IGIE, it is a newer journal from ASGE. It's open access. So I believe everybody should have access to it. There's a section in that called APP ANGLE and you'll see a number of articles that have been published over the last year and more will be coming. It's a section dedicated to APPs. At DDW, we do have a session, how to succeed and thrive as an APP. Kim and I will be the co-moderators. Sarah and Caitlin will speak. And we now will have, or we do officially have an APP committee, which will allow us to be more focused in our tasks and create more education content, focusing on practical items and not overwhelming you. I think it's been a great two days. Please, as Vivek said, send your comments. We wanna hear them all. I think the radiology section was, it was new, it was great. Same with the journal club, but give us some ideas so we can mix it up next year and make it more interesting and bring in new topics. I will end with a huge thanks to the faculty. Your passion for teaching and learning is very impressive and you're all great. And we've become friends over the years. So it's been an enjoyable process for me. Thanks to Eden and for their work on this over these last two days. And a big, big thanks to the maestro, Michelle Akers. She is the maestro behind the scenes, scenes from an operational standpoint and from an execution standpoint. I think we'd all be lost without Michelle. So thank you, thank you, thank you. And most importantly, thank you to our APP colleagues. We are here for you. We really enjoy this course and enjoy teaching. And if you need something from us or wanna get involved, please contact us. So thank you. And I will pass it to Sarah for the final closing remarks and then Michelle for some housekeeping. Thank you, Joe. I'm actually gonna do the opposite of what you did. I'm gonna start with the thank yous. Like Joe said, thank you to all of the faculty. The presentations were outstanding. We know the time and effort that gets put into those to share your expertise. And thank you all for spending these last two days with us. Michelle, Eden, ASG staff, thank you for all of your support and certainly to the audience. We had well over 200 questions that were answered. I think we had 150 today alone. The way that we can make virtual courses successful is through the polling and through the questions. So thank you for remaining online and engaged with us throughout. Our agenda is a direct reflection of the feedback we got. So absolutely any feedback on things that you guys want to see. I think also the individual feedback. We all learn and grow from that. And so please fill out those questionnaires. They are very helpful. We do read them all. And then finally, I'm gonna leave it with a little bit of advice. For the early career APPs, it's okay to feel uncomfy. It's normal. It takes about two years before you really start to feel like this is something that you are confident in. Stick with it. Embrace that uncomfiness. Find your boundaries between being confident and where to ask questions and don't be afraid to ask questions. And to steal it from Kim, I'm gonna call the mature APPs. No better way to say it. For anybody, really find your mentors. And we are lucky that we have our physician champions who are here as faculty on the course. Find a physician and ideally an APP and really lean on them to help you to continue to learn and grow. Challenge yourself, look for opportunities, ask questions and don't hesitate to ask to get involved. And with that, I'll turn it back to Michelle. Thanks, Sarah. And again, to all the faculty and course directors, congratulations on a wonderful course. And again, our thanks to the faculty as well as to you, our participants. As a reminder, each of you will have ongoing access to the recordings from the course via GILeap and that's ASGE's online learning management system. I think most of you have gotten access to it. The course evaluation for today is now live in GILeap. And once you complete it, you can download your certificate. If you need assistance logging in, please email practicemanagementatasge.org. This concludes the ASGE Annual GI Advanced Practice Provider Course. We hope this information is useful to you in your practice. Have a great weekend. Thank you. Congratulations to the course directors. Thank you. Have a great weekend, everyone. Indeed. Have a great weekend. Thank you for everything.

PPIs

steroids

Eosinophilic Esophagitis

endoscopy

Dupixent

teamwork