Can we Improve Doctors’ Colonoscopy Skills with a “Report Card”?

Principal Investigator: Anna Duloy, MD Skills matter when it comes to screening colonoscopies for colon cancer, the second-leading cause of cancer death in the United States. Some doctors are more skilled than others at finding and removing precancerous polyps (known as adenomas) that may lead to cancer if left to grow. Unfortunately, though, the quality of performing this vital procedure varies widely between gastroenterology specialists, even at the best medical institutions. Most commonly, the quality of colonoscopy performance is measured by the adenoma detection rate (ADR):  the frequency of finding adenomas during routine screening colonoscopies. Patients whose physicians have high ADRs are less likely to develop colorectal cancer. While ADR fluctuates among individual doctors, the source of this variability remains a mystery. Constructive criticism can often help improve any endeavor. In prior work, gastroenterology and hepatology fellow Anna Duloy demonstrated that providing feedback regarding polyp detection can significantly improve colonoscopy performance by physicians. Thanks to a Digestive Health Foundation grant, Dr. Duloy’s research team plans to further expand upon on this work by providing new individualized colonoscopy skills feedback to Northwestern Medicine GI specialists. The study will focus on the physicians’ ability to remove polyps (polypectomy) and fully inspect the colon during colonoscopy. Investigators will use video grading by experts to develop pre- and post-scope report cards that will help the specialists to measure their individual performance and ongoing improvement. Patients who overcome their fears and/or other barriers to schedule and undergo a screening colonoscopy expect the very best of care. Increasing colonoscopy competency could further help to stop a common, fatal, digestive disease before it progresses or even...

Does Cannabis Reduce Symptoms or Inflammation in Patients with IBD?

Principal Investigator: Madeline McGuire Bertha, MD, MS Medical marijuana use has grown among patients attempting to tamp down the debilitating effects of Inflammatory Bowel Disease (IBD). However, no one knows if cannabis improves intestinal inflammation—critical to treating IBD. In fact, marijuana could be simply masking symptoms and delaying necessary medical treatment. To determine if that’s the case, Northwestern Medicine researchers led by internal medicine resident Madeline McGuire Bertha, MD, MS, will compare patients in symptomatic remission (feeling well/ without symptoms) who use marijuana to those in symptomatic remission who do not use it. The researchers suspect that while patients using cannabis feel fine, they actually may have a higher level of dangerous, underlying inflammatory activity than their perceived “lack of intestinal distress” might imply.   Supported by a grant from the Digestive Health Foundation, the investigators will use blood and fecal tests to assess levels of intestinal inflammation in the two groups. In particular, they will focus on measuring a blood marker of inflammation, C-Reactive Protein, and a stool marker, fecal calprotectin. If the study hypothesis holds true, the IBD patients using marijuana as a proposed alternative or complementary therapy will be found to have significantly higher levels of these inflammatory markers compared to non-cannabis users who experience no symptoms. Findings of this study will help to advance the limited data assessing the therapeutic efficacy of cannabis on objective markers of intestinal inflammation in patients with IBD. These research efforts could have important clinical and societal implications as medical marijuana becomes more widespread. New knowledge in this area could help both ordering physicians and patients to make more informed...

Can We Use Therapeutic Monitoring of Drug Levels to Improve Long-Term Control of Patients Treated with Infliximab (Remicade) in IBD?

Principal Investigator: Emanuelle Araujo Lima Bellaguarda, MD The drug infliximab (Remicade) offers relief to millions of people with Crohn’s disease and ulcerative colitis. Yet, which dose is the best dose for effectively treating disease? The same dose does not work for all to prevent flare ups and improve quality of life. And how best to calibrate the dosage before the drug loses it efficacy and patients begin to experience the debilitating symptoms of their inflammatory bowel disease? Checking Remicade levels and adjusting the dosage after patients become unresponsive to the drug is already too late. Timing between infusions also becomes critical for modifying the dosage. Checking at the end of a dosage cycle doesn’t allow adequate time to adjust for the next infusion dose since it takes one week to turn around test results. Better personalizing the use of infliximab, Emanuelle Araujo Lima Bellaguarda, MD, a gastroenterology faculty member at Northwestern Medicine and her research team have designed a study to monitor and adjust dosing of the medication. In particular, they are interested in two key times during the therapeutic infusion timeline. The investigators hypothesize that adjusting infliximab at trough levels (the amount of drug present in the body at its lowest therapeutic concentration before the next dose) at weeks 12 and 28 may improve rates of sustained remission. This proactive screening approach has the potential to fully optimize the therapeutic effectiveness of infliximab for each and every patient. A study of this nature will require dedicated logistical coordination. Funding from the Digestive Health Foundation will support a study coordinator to manage patient enrollment, monitoring and outcomes during the...

How to Optimize Control of Acid Reflux to Reduce the Risk of Cancers in Barrett’s Esophagus

Principal Investigator: Sri Komanduri, MD Barrett’s Esophagus (BE) occurs when damaging acid reflux causes the lining of the esophagus to change from normal to pre-cancerous tissue. Although BE can be effectively treated with acid-blocking medications, some patients with more advanced disease often require endoscopic therapy to remove the abnormal tissue. While many experience successful outcomes with this treatment option, some 5 to 25 percent will redevelop the disease; recurrence puts patients at increasing high risk for esophageal cancer or adenocarcinoma. With a five-year survival rate of about 20 percent, this deadly cancer has increased by a factor of more than seven in the past 40 years. Many risk factors contribute to BE, including gender, with men are at higher risk than women; chronic heartburn and acid reflux, especially before age 30; and smoking. Interesting, the disorder has developed with increasing frequency in non-smoking young men between the ages of 20 to 45. Sri Komanduri, MD, Director of Interventional Endoscopy at Northwestern Medicine and his research team previously found that persistent acid reflux in patients who have undergone endoscopic therapy likely causes recurrent BE. Currently, these patients must undergo placement of an uncomfortable transnasal catheter over a 24-hour period to assess and measure persistent acid reflux. This testing helps gastroenterology specialists to determine the best treatment options: a combination of medications and endoscopic treatment or perhaps a referral for surgery. Due to costs and patient intolerance, though, this type of reflux testing has proven to be impractical. Studies of patients without endoscopically-treated BE have suggested consistent changes in the lining of esophageal biopsy samples, which strongly indicate uncontrolled acid reflux....

Molecular Profiling and Associations with Clinical Phenotypes in Adult Eosinophilic Esophagitis

Principal Investigator:  Nirmala Gonsalves, MD Previously thought to be a rare disorder, Eosinophilic Esophagitis (EoE) has emerged as a common cause of swallowing problems (dysphagia) and esophageal dysfunction in adults. The condition arises when inflammatory cells called “eosinophils” wreak havoc on the esophagus by creating inflammation. Over time, the inflamed esophagus begins to undergo abnormal structural changes that can severely impede the passage of food and make it extremely difficult to eat or drink and live a normal life. EoE can lead to increased risk of food impactions, often requiring immediate medical attention. Occurring in 1 to 2 individuals per 10,000, EoE’s prevalence rivals that of other immunologically-related disease such as inflammatory bowel disease and can cause similar debilitating pain and discomfort. While diet changes and medications such as topical corticosteroids work well, matching the best treatment to the right patient remains challenging. Funded by a Digestive Health Foundation grant, Northwestern Medicine researchers led by Nirmala Gonsalves, MD, a faculty member in the Division of Gastroenterology and Hepatology, hope to uncover genetic differences between EoE patients that could lead to better predictors of treatment response and more personalized care. Northwestern Medicine currently has one of the world’s largest cohorts of adults being diagnosed and treated with EoE. Some 700 esophageal tissue samples from these patients, collected at various points in their disease progression, provide an invaluable resource for study. Dr. Gonsalves’ research team plans to mine Northwestern’s comprehensive clinical database (NUCATS) in combination with sophisticated genetic testing and analysis of tissue biopsies. The grant will allow investigators to embark on what will be the largest molecular-phenotype association study of...