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Editorial: The Yale-Affiliated Gastroenterology Program

A Personal Note

Garsten, Joel

Author Information
Journal of Clinical Gastroenterology: June 1996 - Volume 22 - Issue 4 - p 255-260
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Abstract

In a recent issue of this journal, DeLuca and Spiro outlined the rise and fall of the Yale-Affiliated Gastroenterology Program (YAGP) (1). I was asked, as a graduate of that endeavor, to make some personal comments. That's easy. My fellowship in the Waterbury Hospital—Hospital of St. Raphael YAGP during 1976-1978 gave me much joy.

Being somewhat of a dawdler, I had applied, I was informed, after all the Yale New Haven slots had been filled. Perhaps that was more diplomatic than true. Anyway, a letter listed a few hospitals in the “Affiliated Program” and when my follow-up call to the Gastrointestinal (GI) Unit was answered by Henry Binder, he recommended the Waterbury-St. Raphael program because Hu Sangree and Frank Troncale, two former Yale full time faculty who had become chiefs of gastroenterology at these respective hospitals, were excellent teachers.

Both Waterbury Hospital and the Hospital of St. Raphael were, at that time, busy, modern 450-bed hospitals. Each was staffed by a full complement of well-trained primary care and subspecialist physicians. Waterbury Hospital drew patients from its own “Brass City” of 300,000, somewhat tarnished by the recent southward migration of most of the eponymous major factories, and from several surrounding suburban and semi-rural towns. The Hospital of St. Raphael was Church run and situated in the middle of New Haven, a few blocks from Yale New Haven Hospital. The Emergency Department saw more of the inner city population. The GI fellow spent 10 months of the first year in Waterbury and 10 months of the second year in New Haven.

The Waterbury interview consisted mostly of bedside rounds, including a mandatory sniff into a bucket containing an ongoing 72-h stool collection, and the first St. Raphael interview did not happen at all. Frank Troncale was called away. Eventually things got straightened out, and when the offer came, I accepted it. Besides, I thought, I might at some point get to work with Howard Spiro. A few years earlier he had been a visiting professor at my hospital. I had called out, “Giardia,” he had responded, “Correct,” and for some reason that had given me great pleasure and I wanted to do it again.

During my fellowship my two primary mentors were as good as advertised, one a healthy skeptic and the other an enthusiast. Each hospital had well-established training programs in medicine, surgery, pediatrics, and a few other fellowships. I benefited from the combination of individual attention and interaction with other house staff and faculty.

At St. Raphael's I was paired with a fellow from Yale New Haven Hospital. We would alternate consults and procedures, practice presentations on each other, and sometimes get to eat lunch. Tuesdays Peter Biancanni would come over to review esophageal motility studies. Wednesdays at the Medical-Surgical GI conference we presented cases to Spiro. Thursday afternoons at Yale all of the fellows from the New Haven program and each of the affiliate programs alternated discussing topics in GI physiology. Weeks of work would go into each talk. No one wanted to look like a fool in front of Henry Binder or Robert Donaldson. Fridays the clinical-pathological conferences at Yale brought the entire family together again. Liver, GI, pediatric GI, and surgical cases, and often patients themselves were presented, interviewed, discussed in a free-wheeling, exhilarating fashion before an assemblage of Yale and Yale-affiliated faculty and trainees from all of these disciplines, as well as the pathologists and radiologists, a true statewide gathering orchestrated wonderfully by Howard Spiro.

Rotations at Yale meant even more mixing, working with Eliot Livstone, John Dobbins, Rosemarie Fisher, seeing liver cases with Joseph Bloomer, Caroline Riely, and even the legendary Gerald Klatskin. Night call now included not only Yale but the West Haven Veterans Administration, yet another exposure. Richard McCallum was just getting started and was eager to have fellows from affiliated programs work with him on his research projects.

Each June, on the afternoon before the graduation ceremonies and dinner at the President's Room in Woolsey Hall, fellows from the entire program presented their research projects to a combined assembly. At graduation each of the fellows from Yale New Haven Hospital, Waterbury-St. Raphael's, Bridgeport, St. Vincent's, Norwalk, Griffin, and Danbury stood up to receive a diploma. We all felt part of the whole.

In July 1978 I changed my white coat for a suit and started to practice gastroenterology in Waterbury. The transition to teaching the next GI fellow felt natural, and Hu Sangree dragged me along to a meeting of YAGP directors as an associate. At that time the active members were Howard Spiro, Vincent DeLuca (Griffin), David Frank and Howard Taubin (Bridgeport), Saul Feldman and Ed Grossman (St. Vincent's), Hu Sangree (Waterbury), Frank Troncale (St. Raphael's), and Martin Floch (Norwalk). The meeting was held in a restaurant, with food, wine, and conviviality. It was a setup. Marty Floch had brought Jim Tracey and Vincent DeLuca had brought Pierluigi Marignani. Steve Kingsley had been invited from Danbury Hospital. We were told that it was time for the “younger generation” to look for new directions for YAGP and that we were it.

Over the next few months three major concerns were addressed: reassessing the university-community teaching hospital functions in the program, renewing combined clinical trials using all of the affiliate hospitals as a data base, and finding a method to assess the effectiveness of each component program in training its fellows.

Pierluigi Marignani and I were assigned the task of determining what makes a “quality” GI fellowship. Spiro, DeLuca, and the others had done all the work of conceptualizing and creating an excellent network. How to maintain its excellence and keep it on the cutting edge of changes in the field was the question. During the course of a year we met several times, became acquainted with each other's wives and children, broke bread, and compiled what we could. Letters went back and forth among all the YAGP directors floating ideas and inquiries. Finally a comprehensive format was agreed upon addressing didactics, clinical and research exposure, procedural training, faculty requirements, and institutional support (2). It was time to try it out with a site visit.

John Farrar consented to be our visiting reviewer, and the Waterbury-St. Raphael program was first up at bat. The 2-day review was simultaneously frightening and affirming. Farrar's formal report was fair and contained a number of helpful suggestions. As our format for evaluation became more refined, other site visits were made. We truly wanted to hold ourselves to the highest standards, and because the impetus had been ours, we felt good about it, so good that we wanted to share it with other training programs as a method for their own self-evaluation and improvement. But while we were deciding on how to report this, the Residency Review Committee (RRC) issued its own agenda (3). Although there are several similarities in the evaluation criteria between their agenda and ours, the RRC's has the perverse twist of being obviously slanted against the community teaching hospital programs and the additional cruelty of threatening their existence.

The effect of these requirements was to put each program on the defensive to save itself. At YAGP directors' meetings the change was palpable, from a feeling of positivity to one of disenfranchised commiseration. Who would survive? Who would be the first to go? Articulate challenges to the premise of the RRC, notably those of David Frank, then director of the Bridgeport Hospital program, went unheeded (4). Although the day-to-day life of the fellowships went on, the forward progress of YAGP ceased.

What lessons are to be learned from YAGP?

Physicians formed an association out of perceived need.

  • It increased the base of knowledge in the state and provided a mode of rapid dissemination of new theories and methods and a forum for debate.
  • It created training programs to meet manpower needs.
  • It made new skills and teaching available locally through community hospital programs headed by former Yale fellows and faculty able to transplant and then teach sophisticated patient care, basic science, and procedural techniques.
  • It created a collegial energy statewide, a hybrid vigor.

Out of the YAGP fellowship programs have come pertinent studies of peptic ulcer disease, immunosuppressive and anticoagulant therapies in inflammatory bowel disease, GI bacterial colonization, Clostridium dificile, gastrointestinal malignancy, gastrointestinal motility, and other topics of clinical interest. Their breadth and scope is truly impressive, as can be seen in the appended bibliography (5-24)(25-45)(46-55)(56-65)(66-75)(76-85)(86-95)(96-105)(106-115)(116-125)(126-135)(136-142).

YAGP programs have produced practitioners well versed in basic physiology and pathophysiology, able to appropriately evaluate research studies published in the future, whether or not they ever again personally take part in them, and have produced a number of department chiefs out of proportion to what one might expect from a “clinical” program.

Perhaps even more important, YAGP has made teachers out of all of the participating gastroenterologists in all of the communities with programs. Fellowship programs in those community hospitals have recruited clinicians who otherwise might not have been teachers.

Fellows in the surviving YAGP programs are still exposed to a multiplicity of approaches to a particular patient management problem. Independent thinking is fostered. This can only carry over into improved patient care. And every fellow who graduates from a YAGP program takes with him or her the ingrained natural expectation of teaching and learning and questioning, for this is the example that has been set during training. In an era of ever-increasing standard algorithms appearing in medical journals, as well as workup and treatment according to insurance company guidelines, perhaps this may be viewed as a detriment, but not ot the patient.

YAGP may have been so successful in training gastroenterologists that it put itself out of business. Years have passed. Now a chief, I am asked by other physicians, and more recently by my hospital administration faced with a choice of whether or not to pay the fellow's salary, “Why train your competition?” As a practitioner I am certainly concerned about the economics of competition. All conversations these days seem to have to do with economics. But I am also concerned with the threat of stagnation, both personal and for the field of gastroenterology. The absence of day-to-day exposure to questions from the fellow, from the need to explain the rationale behind dictums otherwise taken for granted, from the pressure to, as Vincent DeLuca and Howard Spiro wrote, “read with more purpose” will render this fertile field barren until the next manpower study, years hence, noting with great alarm a deficit of knowledge and imagination. A committee will be appointed.

The YAGP fellowship program deserves to survive. It produces excellent gastroenterologists who actually do what they were trained to do: treat people in communities. Plans for the future include coordination of seminars, regular visiting professor rounds by each of the directors to each of the other hospitals, workshops for brainstorming clinical research projects from both individual institutions and cooperative ventures involving all of the institutions, reciprocal training of fellows to take advantage of individual institutional strengths, and the evolution of each hospital campus, connected by highways, into a truly integrated statewide university program.

The RRC may yet kill this. This program, with its faculty of over 25 gastroenterologists and hepatologists, is not, unless one considers the ozone layer, all under one roof.

What should be the purpose of YAGP if it loses its fellows? Perhaps to keep us all sane and interested and current. To act as a speaker's bureau, a teacher of new techniques to those already out of training, an interpreter of and collector of outcome data (after all, the whole state is a data base) and eventually a forum to determine if any of it makes sense, if any of it accurately reflects quality of care. And perhaps it will function as a last avenue where a few physicians with insight who perceive a certain need may meet with colleagues, become friends, work on projects together, make decisions together about what is important, and act on them and see them come to fruition with a certain joy.

Joel Garsten, M.D.

Waterbury Hospital and Health Center

Yale University School of Medicine

New Haven, Connecticut, U.S.A.

REFERENCES

1. DeLuca VA, Spiro HM. The Yale-Affiliated Gastroenterology Program: 1965-1995. A community-university model of collaboration. J Clin Gastroenterol 1995;21:179-84.
2. Garsten JJ, Marignani P, DeLuca VA, et al. The Yale-Affiliated Gastroenterology Program: format for evaluation of fellowship programs. Unpublished report, 1979.
3. U.S. Department of Health and Human Services. Report of the Graduate Medical Education National Advisory Committee. Vol. 1. Bethesda, MD: U.S. Department of Health and Human Services. [Publication (HRA) 1981:81-651].
4. Frank HD. Will the new special requirements for fellowship training in gastroenterology impact negatively on community hospitals? Am J Gastroenterol 1988;83:420-1.
5. Brandt IK, DeLuca VA Jr. Type 3 glycogenosis. A family with an unusual tissue distribution of the enzyme lesion. Am J Med 1966;40:779-84.
6. DeLuca VA Jr, Spiro HM, Thayer WR. Ulcerative colitis and scleroderma. Gastroenterology 1965;49:433-8.
7. Groisser VW, Raugh F, Floch M, Bobruff J. Serum esterolytic activity in a wide variety of diseases. With special reference to pancreatic and liver disease. N Engl J Med 1966;274:129-33.
8. Vacca VF, DeLuca VA Jr. A more practical and simplified method of colonic exfoliative cytology. A preliminary report. Conn Med 1966;30:559-61.
9. Floch MH, Van Noorden S, Spiro HM. Differences in epithelial enzyme activity in the duodenum, jejunum, and ileum of the monkey. Am J Dig Dis 1966;11:804-10.
10. Floch MH, Van Noorden S, Spiro HM. Histochemical localization of gastric and small bowel mucosal enzymes of man, monkey, and chimpanzee. Gastroenterology 1967;52:230-8.
11. Spiro HM, DeLuca VA Jr. The trainee as a teacher in the community hospital. N Engl J Med 1967;276:903-5.
12. Kaufman HJ, Spiro HM, Floch MH. Intestinal epithelial enzyme abnormalities induced by 5-fluorouracil: translocation of NADPH2-dehydrogenase. Am J Dig Dis 1967;12:598-606.
13. Gelfand MD, Tepper M, Katz LA, Binder HJ, Yesner R, Floch MH. Acute irradiation proctitis in man: development of eosinophilic crypt abscesses. Gastroenterology 1968;54:401-11.
14. Vacca VF, Pinto A, Spiro HM, DeLuca VA Jr. Colonic exfoliative cytology by an improved technic. Am J Dig Dis 1968;13:727-34.
15. Gryboski JD, Katz J, Sangree MH, Herskovic T. Eleven adolescent girls with severe anorexia. Intestinal disease or anorexia nervosa? Clin Pediatr (Phila) 1968;7:684-9.
16. Thayer WR Jr, Brown M, Sangree MH, Katz J, Hersh T. Escherichia coli O:14 and colon hemagglutinating antibodies in inflammatory bowel disease. Gastroenterology 1969;57:311-8.
17. Elkington SG, Floch MH, Conn HO. Control of chronic portalsystemic encephalopathy by lactulose. Gut 1969;10:416.
18. Khoury KA, Floch MH, Herskovic T. Effects of neomycin and penicillin administration on mucosal proliferation of the mouse small intestine. With morphological and functional correlations. J Exp Med 1969;129:1063-78.
19. Floch MH, Shearman DJ, Herskovic T, Levine RJ, Spiro HM. Iron deficiency anemia and hepatic lesions in weanling rats. Arch Pathol 1969;87:526-32.
20. Elkington SG, Floch MH, Conn HO. Lactulose in the treatment of chronic portal-systemic encephalopathy. A doubleblind clinical trial. N Engl J Med 1969;281:408-12.
21. Khoury KA, Floch MH, Hersh T. Small intestinal mucosal cell proliferation and bacterial flora in the conventionalization of the germfree mouse. J Exp Med 1969;130:659-70.
22. Pitchumoni CS, Dearani AC, Burke AV, Floch MH. Eosinophilic granuloma of the gastrointestinal tract. JAMA 1970;211:1180-2.
23. Wright HK, Hersh T, Floch MH, Weinstein LD. Impaired intestinal absorption in the Zollinger-Ellison syndrome independent of gastric hypersecretion. Am J Surg 1970;119:250-3.
24. Levine SM, Gelfand M, Hersh T, Wyshak G, Spiro HM, Floch MH. Intestinal bacterial flora after total and partial colon resection. Am J Dig Dis 1970;15:523-8.
25. Floch MH. Eosinophilic infiltration of gut. N Engl J Med 1970;282:1213-4.
26. Floch MH, Katz J, Conn HO. Qualitative and quantitative relationships of the fecal flora in cirrhotic patients with portal systemic encephalopathy and following portacaval anastomosis. Gastroenterology 1970;59:70-5.
27. Goyal RK, Sangree MH, Hersh T, Spiro HM. Pressure inversion point at the upper high pressure zone and its genesis. Gastroenterology 1970;59:754-9.
28. Bautista A, DeLuca VA Jr. Endoscopic photography, biopsy, and cytology of the esophagus and stomach with the Olympus fiberesophagoscope. Gastroenterology 1971;60:294-8.
29. Grossman ET. Cholecystocolic-fistula—an unusual cause of diarrhea. Am J Gastroenterol 1971;55:277-83.
30. Floch MH, Gershengoren W, Elliott S, Spiro HM. Bile acid inhibition of the intestinal microflora—a function for simple bile acids? Gastroenterology 1971;61:228-333.
31. Floch MH, Binder HJ, Filburn B, Gershengoren W. The effect of bile acids on intestinal microflora. Am J Clin Nutr 1972;25:1418-26.
32. D'Souza A, Floch MH. Calcium metabolism in pancreatic disease. Am J Clin Nutr 1973;26:352-61.
33. Livstone EM, Greene FL, Troncale FJ. Colonoscopic polypectomy: a caveat. N Engl J Med 1973;288:1304-5.
34. Greene FL, Livstone EM, Troncale FJ. The role of fiberoptic colonoscopy in the diagnosis of colonic and rectal disease. Conn Med 1973;37:439-42.
35. DeLuca VA Jr. A special report on the accreditation of continuing medical education programs in Connecticut. Conn Med 1973;37:449-50.
36. Greene FL, Livstone EM, Troncale FJ. Fiberoptic colonoscopy in the management of colonic disease. South Med J 1974;67:105-10.
37. Greene FL, Livstone EM, McAllister WB Jr, Passarelli NM, Troncale FJ. Reticulum cell sarcoma of the large intestine. The role of fiberoptic colonoscopy. Am J Dig Dis 1974;19:379-84.
38. Troncale FJ. Distant manifestations of colonic carcinoma. Ann N Y Acad Sci 1974;230:332-8.
39. Bodurtha J, Floch MH. Using premedical students in a community hospital summer volunteer program. J Med Educ 1974;49:907-10.
40. DeLuca VA Jr, Eisenman L, Moritz M, et al. A new technique for colonic cytology. Acta Cytol 1974;18:421-4.
41. DeLuca VA Jr, Shapiro BS. Gastric polypectomy via the panendoscope. Conn Med 1974;38:459-60.
42. Myerson P, Myerson D, Miller D, DeLuca VA Jr, Lawson JP. Lymphosarcoma of the bowel masquerading as ulcerative colitis: report of a case. Dis Colon Rectum 1974;17:710-5.
43. Floch MH. Editorial: Human gut microecology. West J Med 1974;121:423-4.
44. Livstone EM, Cohen GM, Troncale FJ, Touloukian RJ. Diastatic serosal lacerations: an unrecognized complication of colonoscopy. Gastroenterology 1974;67:1245-7.
45. Binder HJ, Filburn B, Floch M. Bile acid inhibition of intestinal anaerobic organisms. Am J Clin Nutr 197;28:119-25.
46. Diba AA, Grossman ET, Dolan EP. Afferent loop syndrome: a different picture. Am J Gastroenterol 1976;66:72-5.
47. Calabrese PR, Frank HD, Bartolomeo RS, Taubin HL. An unusual clinical presentation of pancreatic carcinoma: duodenal obstruction in the absence of jaundice. Am J Gastroenterol 1976;66:480-2.
48. Fuchs H-M, Dorfman S, Floch MH. The effect of dietary fiber supplementation in man. II. Alteration in fecal physiology and bacterial flora. Am J Clin Nutr 1976;29:1443-7.
49. Kahaner N, Fuchs H-M, Floch MH. The effect of dietary fiber supplementation in man. I. Modification of eating habits. Am J Clin Nutr 1976;29:1437-42.
50. Dorfman SH, Ali M, Floch MH. Low fiber content of Connecticut diets. Am J Clin Nutr 1976;129:87-9.
51. Bartolomeo RS, Calabrese PR, Taubin HL. Spontaneous perforation of the colon. A potential complication of chronic renal failure. Am J Dig Dis 1977;22:656-7.
52. Calabrese PR, Frank HD, Taubin HL. Lymphangiomyomatosis with chylous ascites: treatment with dietary fat restriction and medium chain triglycerides. Cancer 1977;40:895-7.
53. Mittelmann M, Scholhamer CF. Cancer and malpractice claims. Cancer 1977;39:2573-8.
54. DeLuca VA Jr. Continuing medical education: establishing requirements and coordinating teaching activities. J MEduc 1977;52:926-8.
55. Livstone EM, Troncale FJ, Sheahan DG. Value of a single forceps biopsy of colonic polyps. Gastroenterology 1977;73:1296-8.
56. Moskovitz M, Floch MH. Current clinical aspects of Crohn's disease. Bull Soc Sci Med Grand Duche Luxemb 1977;114:105-7.
57. DeLuca VA Jr, Sheahan GD. The esophagus in patients with gastroduodenitis and peptic ulcer disease. South Med J 1978;71(suppl 1):52.
58. Chang SF, Burrell MI, Brand MH, Garsten JJ. The protean gastrointestinal manifestations of metastatic breast carcinoma. Radiology 1978;126:611-7.
59. Floch MH, Fuchs HM. Modification of stool fiber content by increased bran intake. Am J Clin Nutr 1978;31(suppl):185-9.
60. Frank HD. Traumatic rupture of the gallbladder with massive biliary ascites. JAMA 1978;240:252-3.
61. Nelson A, Frank HD, Taubin HL. Liver abscess. A complication of regional enteritis. Am J Gastroenterol 1979;72:282-4.
62. Frank HD. Primary shunt hyperbilirubinemia with secondary iron overload: a case report. Gastroenterology 1979;77:754-7.
63. Moskovitz M, White C, Barnett RN, et al. Diet, fecal bile acids, and neutral sterols in carcinoma of the colon. Dig Dis Sci 1979;24:746-51.
64. Nelson AM, Frank HD, Taubin HL. Colovesical fistula secondary to foreign-body perforation of the sigmoid colon. Dis Colon Rectum 1979;22:559-60.
65. Goodenberger DM, Lawley TJ, Strober W, et al. Necrolytic migratory erythema without glucagonoma. Arch Dermatol 1979;115:1429-32.
66. Nelson AM, Frank HD, Taubin HL. Colovesical fistula secondary to foreign-body perforation of the sigmoid colon. Dis Colon Rectum 1979;22:559-60.
67. Nelson AM, Taubin HL, Frank HD. Eosinophilia associated with psyllium hydrophilic colloid ingestion [Letter]. JAMA 1988;243:329-30.
68. Vargo D, Moskovitz M, Floch MH. Faecal bacterial flora in cancer of the colon. Gut 1980;21:701-5.
69. Floch MH, Wolfman M, Doyle R. Fiber and gastrointestinal microecology. J Clin Gastroenterol 1980;2:175-84.
70. Lichtenstein JL, Feinstein AR, Suzio KD, DeLuca VA Jr, Spiro HM. The effectiveness of panendoscopy on diagnostic and therapeutic decisions about chronic abdominal pain. J Clin Gastroenterol 1980;2:31-6.
71. DeLuca VA Jr. Preparation of the colon for flexible sigmoidoscopy and colonoscopy. Gastrointest Endosc 1980;26(suppl):7-9.
72. Floch MH, Wolfman M, Doyle R. Fiber and gastrointestinal microecology. J Clin Gastroenterol 1980;2:175-84.
73. Daneshgar S, Eras P, Feldman SM, Cacace VA, Federico FN, Levin RH. Bleeding gastric varices and gastric torsion secondary to a wandering spleen. Gastroenterology 1980;79:141-3.
74. Vargo D, Moskovitz M, Floch MH. Faecal bacterial flora in cancer of the colon. Gut 1980;21:701-5.
75. Meyer CT, McBride W, Goldblatt RS, et al. Clinical experience with flexible sigmoidoscopy in asymptomatic and symptomatic patients. Yale J Biol Med 1980;53:345-52.
76. DeLuca VA Jr. The GI unit as a centralized interdepartmental hospital division [Editorial]. J Clin Gastroenterol 1980;2:219-20.
77. Brand MH, Troncale FJ, Scholhamer CF Jr, McKinley M, Taylor K. Ultrasound-guided liver biopsy: a technique for the tissue diagnosis of hepatic malignancy. Conn Med 1980;44:626-8.
78. Nelson AM, Taubin HL, Frank HD. Prior abdominal surgery does not affect length of insertion of rigid sigmoidoscope. J Clin Gastroenterol 1980;2:371-2.
79. DeLuca VA Jr, Winnan GG, Sheahan DG, et al. Is gastroduodenitis part of the spectrum of peptic ulcer disease? J Clin Gastroenterol 1981;3(suppl 2):17-22.
80. Milstone EB, McDonald AJ, Scholhamer CF Jr. Pseudomembranous colitis after topical application of clindamycin. Arch Dermatol 1981;117:154-5.
81. Mensh RS, Brand MH, Troncale FJ, McKinley MJ, Scholhamer CF Jr. Campylobacter enterocolitis. J Clin Gastroenterol 1981;3:147-51.
82. McKinley MJ, Troncale F, Sangree MH, Scholhamer C, Brand M. Antibiotic-associated colitis: clinical and epidemiological features. Am J Gastroenterol 1982;77:77-81.
83. McKinley MJ, Taylor M, Sangree MH. Toxic megacolon with campylobacter colitis. Conn Med 1980;44:496-7.
84. Meyer CT, Troncale FJ, Galloway S, Sheahan DG. Arteriovenous malformations of the bowel: an analysis of 22 cases and a review of the literature. Medicine (Baltimore) 1981;60:36-48.
85. Petrelli EA, McKinley M, Troncale FJ. Ocular manifestations of inflammatory bowel disease. Ann Ophthalmol 1982;14:356-60.
86. Lopatin RN, Grossman ET, Horine J, Saeedi M, Sreenath B. Whipple's disease in neighbors. J Clin Gastroenterol 1982;4:223-6.
87. Winchenbach CL, Fink SM, Barwick KW, McCallum RW. Significant hemorrhage as a complication of hydraulic suction biopsy of the esophagus. Am J Gastroenterol 1982;77:897-8.
88. Fink SM, Barwick KW, Winchenbach CL, DeLuca V, McCallum RW. Reassessment of esophageal histology in normal subjects: a comparison of suction and endoscopic techniques. J Clin Gastroenterol 1983;5:177-83.
89. Gorelick FS, Deluca VA, Sheahan DG, et al. Duodenal epithelial thymidine uptake in patients with duodenal ulcer or endoscopic duodenitis. Dig Dis Sci 1983;28:392-6.
90. Vender RJ, Marignani P. Salmonella colitis presenting as a segmental colitis resembling Crohn's disease. Dig Dis Sci 1983;28:848-51.
91. Frank HD. Intestinal perforation associated with cytomegalovirus infection in patients with acquired immune deficiency syndrome. Am J Gastroenterol 1984;79:201-5.
92. Caride VJ, Prokop EK, Troncale FJ, Buddoura W, Winchenbach K, McCallum RW. Scintigraphic determination of small intestinal transit time: comparison with the hydrogen breath technique. Gastroenterology 1984;86:714-20.
93. Boland CR, Troncale FJ. Familial colonic cancer without antecedent polyposis. Ann Intern Med 1984;100:700-1.
94. Marano AR, Sangree MH. Acute pancreatitis associated with bulimia. J Clin Gastroenterol 1984;6:245-8.
95. McCallum RW, Meyer CT, Marignani P, Cane E, Contino C. Flexible sigmoidoscopy: diagnostic yield in 1015 patients. Am J Gastroenterol 1984;79:433-7.
96. Duray PH, Marcal JM Jr, LiVolsi VA, Fisher R, Scholhamer C, Brand MH. Gastrointestinal angiodysplasia: a possible component of von Willebrand's disease. Hum Pathol 1984;15:539-44.
97. Duray PH, Marcal JM Jr, LiVolsi VA, Fisher R, Scholhamer C, Brand MH. Small intestinal angiodysplasia in the elderly. J Clin Gastroenterol 1984;6:311-9.
98. Vargo D, Doyle R, Floch MH. Colonic bacterial flora and serum cholesterol: alterations induced by dietary citrus pectin. Am J Gastroenterol 1985;80:361-4.
99. Marano AR, Caride VJ, Prokop EK, Troncale FJ, McCallum RW. Effect of sucralfate and an aluminum hydroxide gel on gastric emptying of solids and liquids. Clin Pharmacol Ther 1985;37:629-32.
100. Moseley RH, Barwick KW, Dobuler K, DeLuca VA Jr. Sulfasalazine-induced pulmonary disease. Dig Dis Sci 1985;30:901-4.
101. Fleming LL, Floch MH. Digestion and absorption of fiber carbohydrate in the colon. Am J Gastroenterol 1986;81:507-11.
102. Marano AR, Lanse SB, Garsten JJ, Thornton GF, Antopol SC, Gannon D. Exudative ascites complicating infectious mononucleosis. Am J Gastroenterol 1986;81:808-11.
103. Floch MH, Maryniuk MD, Bryant C, et al. Practical aspects of implementing increased dietary fiber intake. Am J Gastroenterol 1986;81:936-9.
104. Kaufmann HJ, Taubin HL. Nonsteroidal anti-inflammatory drugs activate quiescent inflammatory bowel disease. Ann Intern Med 1987;107:513-6.
105. Tuso P, McElligott J, Marignani P. Splenic rupture at colonoscopy. J Clin Gastroenterol 1987;9:559-62.
106. Troncale FJ. `For-profit' outpatient i.v. antibiotics [Letter]. Hosp Pract [Off Ed] 1988;23:16.
107. Prokop EK, Caride VJ, Winchenbach K, Troncale FJ, McCallum RW. Scintigraphic determination of the effect of metoclopramide and morphine on small intestinal transit time. Am J Physiol Imaging 1988;3:201-4.
108. Wolfson S, Panullo WT, Scholhamer CF Jr, Troncale FJ, Vender RJ, Brand MH. Use of the Nd:YAG laser in a community hospital to treat lesions of the gastrointestinal tract. Conn Med 1988;52:459-62.
109. Petersen JM, Caride VJ, Prokop EK, Troncale FJ, McCallum RW. Sucralfate delays gastric emptying of liquids and solids in duodenal ulcer patients. Int J Rad Appl Instrum [B] 1989;16:389-95.
110. Yolen SR, Grossman ET. Colonoscopic removal of a post-operative foreign body [Letter]. J Clin Gastroenterol 1989;11:483.
111. Marotta RB, Floch MH. Dietary therapy of steatorrhea. Gastroenterol Clin North Am 1989;18:485-512.
112. Tuso P, Marignani P. Necrotizing duodenitis—a stress-associated lesion? J Clin Gastroenterol 1990;12:29-32.
113. Goldenberg SP, DeLuca VA Jr, Marignani P. Endoscopic treatment of Dieulafoy's lesion of the duodenum. Am J Gastroenterol 1990;85:452-4.
114. Goldenberg SP, Marignani P. The endoscopic diagnosis of colonic enterobiasis. Gastrointest Endosc 1990;36:309-10.
115. Floch M. Soluble dietary fiber and short-chain fatty acids: an advance in understanding the human bacterial flora [Editorial]. Am J Gastroenterol 1990;85:1313-4.
116. Culpepper-Morgan JA. Bowel rest or bowel starvation: defining the role of nutritional support in the treatment of inflammatory bowel diseases [Editorial]. Am J Gastroenterol 1991;86:269-71.
117. Marotta RB. Diet and nutrition in ulcer disease. Med Clin North Am 1991;75:967-79.
118. Afridi SA. Review of duodenal diverticula. Am J Gastroenterol 1991;86:935-8.
119. Tracey JP. Magnetic resonance imaging in cobalamin deficiency [Letter]. Lancet 1992;339:1172-3.
120. Moulis H, Garsten JJ, Marano AR, Elser JM. Tuberous sclerosis complex: review of the gastrointestinal manifestations and report of an unusual case. Am J Gastroenterol 1992;87:914-8.
121. Moulis H. Pancreatitis after endoscopic cholangiography without pancreatography [Letter]. Am J Gastroenterol 1992;87:1888-9.
122. Stagias JG, Marignani P. Diarrhea, constipation, and hypothyroidism [Letter]. J Clin Gastroenterol 1993;16:177-8.
123. Shaw-Stiffel TA, Zarny LA, Pleban WE, Rosman DD, Rudolph RA, Bernstein LH. Effect of nutrition status and other factors on length of hospital stay after major gastrointestinal surgery. Nutrition 1993;9:140-5.
124. Afridi SA, Shaw-Stiffel TA. Evolution of Barrett's esophagus: the jury is still out [Letter, Comment]. Gastroenterology 1993;104:1236.
125. Bernstein LH, Shaw-Stiffel TA, Schorow M, Brouillette R. Financial implications of malnutrition. Clin Lab Med 1993;13:491-507.
126. Culpepper-Morgan JA, Kim K, Floch MH. Using enteral nutrition formulas. Gastroenterologist 1993;1:143-57.
127. Vender RJ, Bienstock B. Bile acid therapy in gallstone management [Letter, Comment]. Hepatology 1993;18:228-30.
128. Moulis H, Vender RJ. Percutaneous endoscopic gastrostomy for treatment of gas-bloat syndrome. Gastrointest Endosc 1993;39:581-3.
129. Pinto MM, Levine RH, Shaw-Stiffel T. Detection of Helicobacter pylori by Papanicolaou-stained touch imprint: a comparison with histologic examination [Letter]. Am J Gastroenterol 1993;88:1300-1.
130. Floch MH, Wald A. Clinical evaluation and treatment of constipation. Gastroenterologist 1994;2:50-60.
131. Byrd D, McKinley MJ, Floch MH, Nair S. Barrett's esophagus [Clinical Conference]. Gastroenterologist 1994;2:160-5.
132. Turhal N, DeLuca VA Jr. Ulcerative colitis and scleroderma. A coincidental relationship? J Clin Gastroenterol 1994;18:218-9.
133. Moulis H, Vender RJ. Antibiotic-associated hemorrhagic colitis. J Clin Gastroenterol 1994;18:227-31.
134. Shaw-Stiffel TA, Walker SE, Ogilvie RI, Leenen FH. Pharmacokinetic and pharmacodynamic interactions during multipledose administration of nisoldipine and propranolol. Clin Pharmacol Ther 1994;55:661-9.
135. Stagias JG, Marignani P. Diarrhea, constipation, and hypothyroidism. J Clin Gastroenterol 1994;18:347.
136. Larson J, Vender R, Camuto P. Cholestatic jaundice due to ackee fruit poisoning. Am J Gastroenterol 1994;89:1577-8.
137. Weiss SA, Davis GL, Shaw-Stiffel TA. Hepatic sarcoidosis presenting as acute abdominal pain [Clinical Conference]. Gastroenterologist 1994;2:247-53.
138. Tracey JP, Traube M. Difficulties in the diagnosis of pseudoachalasia. Am J Gastroenterol 1994;89:2014-8.
139. Sheikh SH, Shaw-Stiffel TA. The gastrointestinal manifestations of Sjogren's syndrome. Am J Gastroenterol 1995;90:9-14.
140. Larson J, Vender R, Camuto P, Scholhamer C, Mansourian V. Phytobezoar of pure vegetable matter causing colonic obstruction. J Clin Gastroenterol 1995;20:176-7.
141. Cunningham ME, Shaw-Stiffel TA, Bernstein LH, et al. Cholecystokinin-stimulated monocytes produce inflammatory cytokines and eicosanoids. Am J Gastroenterol 1995;90:621-6.
142. Patrignelli R, Sheikh SH, Shaw-Stiffel TA. Henoch-Schonlein purpura. A multisystem disease also seen in adults. Postgrad Med 1995;97:123-4,127,131-4.
Keywords:

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