March 14, 2013 Home|Journals & Publications|  AGA eDigest
AGA eDigest

News from the Literature | Practice | Research | Policy | Journals & Publications | Education & Meetings

LEADING THE NEWS

AGA Creates Center for Gut Microbiome Research and Education

microbiomeIn a healthy adult, microbial cells are estimated to outnumber human cells 10 to one. Many microbes maintain our health, while others cause illness. Recent investigations of the human gut microbiome have discovered important ways in which gut microbes may influence a number of important disease states including obesity, inflammatory bowel disease, functional GI disorders, GI cancers and liver disease.

Recognizing the major influence the gut microbiome is likely to have on the future of GI research and patient care, the AGA Governing Board is pleased to announce the creation of the AGA Center for Gut Microbiome Research and Education.

“The gut microbiome is among the most exciting and promising areas of research today. As gastroenterologists we are in an excellent position to perform gut microbiome research and translate basic discoveries into new methods to maintain and improve the health of our patients,” says Loren Laine, MD, AGAF, president of the AGA Institute. “The gut microbiome offers a myriad of possibilities to GI basic and translational researchers, clinicians and patients.”

The AGA Center for Microbiome Research and Education will be a virtual “home” for the AGA’s activities related to the gut microbiome. The mission of the center is “To advance research and education on the gut microbiome in human health and disease.”

To provide guidance on gut microbiome-related issues, the AGA has convened a scientific advisory board comprised of world leaders in computational biology and metagenomics, microbiome animal models, microbiology translational research, nutrition, and pertinent regulatory and policy issues. These advisors will make strategic and programmatic recommendations to the AGA Governing Board.

“This is an incredibly exciting time in science, where technological advances in DNA sequencing, transcriptomics, proteomics and metabolomics provide an unprecedented opportunity to explore not only the composition, but also the function of the microbial communities that live in our intestinal tract. It is hoped that the knowledge gained will provide new insights into disease pathogenesis and innovative therapeutic modalities. The membership of the AGA is ideally suited to translate these findings from the bench to the bedside,” says Gary Wu, MD, chair of the scientific advisory board.

Scientific advisory board members:

  • Gary D. Wu, MD, chair
    Professor of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • Martin J. Blaser, MD
    George and Muriel Singer Professor of Medicine, Professor of Microbiology and Director, Human Microbiome Program at the New York University Langone Medical Center, New York
  • Jeffrey I. Gordon, MD, AGAF
    Dr. Robert J. Glaser Distinguished University Professor and Director of the Center for Genome Sciences & Systems Biology at Washington University, St. Louis, MO
  • Gail Hecht, MD, MS, AGAF
    Professor of Medicine; Microbiology/Immunology and Chief, Gastroenterology and Nutrition at Loyola University Medical Center, Maywood, IL
  • Lee M. Kaplan, MD, PhD, AGAF
    Director, Obesity, Metabolism & Nutrition Institute, Gastrointestinal Unit at Massachusetts General Hospital, Boston
  • Rob Knight, PhD
    Associate Professor, University of Colorado, Boulder
  • Mary Ellen Sanders, PhD
    Executive Director of the International Scientific Association for Probiotics and Prebiotics, Centennial, CO
  • Ryan Balfour Sartor, MD
    Distinguished Professor, Medicine, Microbiology and Immunology at the University of North Carolina - Chapel Hill
  • Richard M. Peek, Jr., MD, AGAF, ex-officio
    Chairman, Division of Gastroenterology, Hepatology & Nutrition at Vanderbilt University School of Medicine, Nashville
  • Vincent W. Yang, MD, PhD, ex-officio
    Professor and Chair of Medicine, Stony Brook University School of Medicine, NY

The AGA will fund the center’s activities and will seek funds from private, non-profit and governmental sources to help support the center.

The AGA Center for Gut Microbiome Research and Education is online at www.gastro.org/Microbiome.

NEWS FROM THE LITERATURE

Automated Intervention Increases Uptake of CRC Screening

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals. Beverly Green and colleagues determined whether interventions using electronic health records (EHR), automated mailings and stepped increases in support improve CRC screening adherence over two years. Compared with those in the usual care group, participants in the intervention groups were more likely to be current for colorectal cancer screening for both years with significant increases by intensity, automated, assisted and navigated. Increases in screening were primarily due to increased uptake of fecal occult blood test being completed in both years. Publishing in Annals of Internal Medicine, Dr. Green's team concludes that compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over two years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

Annals of Internal Medicine 2013: 158(5_Part_1): 301-311

View the AGA CRC Clinical Service Line

The AGA has developed a clinical service line for colorectal cancer in order to optimize care for patients and health-care practitioners. It offers unique and relevant information and tools that health-care professionals can easily access and incorporate into their workflow.

Novel Classification System for Endoscopic Assessment of Eosinophilic Esophagitis

Abnormalities are commonly identified during endoscopy in eosinophilic esophagitis. There is no standardized classification to describe these features. Ikuo Hirano and colleagues evaluated the interobserver agreement of a grading system for the esophageal features of esophageal esophagitis. The proposed system incorporated the grading of four major esophageal features and the presence of additional features of narrow caliber esophagus, feline esophagus, stricture and crepe paper esophagus. Endoscopic videos from 25 patients with eosinophilic esophagitis and controls were reviewed by 21 gastroenterologists. Publishing in Gut, Dr. Hirano's team concluded that the proposed system for endoscopically-identified esophageal features of eosinophilic esophagitis defines common nomenclature and severity scores for the assessment of eosinophilic esophagitis disease activity. The system has good interobserver agreement among practicing and academic gastroenterologists.

Gut 2013; 62: 489-495

MCH Controls Hepatic and Adipocyte Metabolism

Specific neuronal circuits modulate autonomic outflow to liver and white adipose tissue. Melanin-concentrating hormone (MCH)-deficient mice are hypophagic, lean and do not develop hepatosteatosis when fed a high-fat diet. Monica Imbernon and colleagues investigated the role of MCH, an orexigenic neuropeptide specifically expressed in the lateral hypothalamic area, on hepatic and adipocyte metabolism. Chronic central administration of MCH and adenoviral vectors increasing MCH signaling were performed in rats and mice. Vagal denervation was performed to assess its effect on liver metabolism. The peripheral effects on lipid metabolism were assessed by real-time polymerase chain reaction and Western blot. Publishing in Gastroenterology, the researchers reported that their findings show that central MCH directly controls hepatic and adipocyte metabolism through different pathways.

Gastroenterology 2013: 144(3): 636-649

Patient Attitudes to Colonoscopy and the Importance of Endoscopist Interaction

A study published in the Scandinavian Journal of Gastroenterology concludes that understanding patients' attitudes to their medical experience is essential for identifying value in the patient pathway, optimizing care and use of resources. Jude McEntire and colleagues determined patients' preferences and expectations for day-case colonoscopy, a common gastrointestinal procedure for which there is limited such data. The team invited patients attending for elective colonoscopy to complete a composite, validated dedicated endoscopy questionnaire, with Likert-scale questions and a 15-point preference scale of domains of endoscopy care that were considered most important to least important as contributing to a satisfactory experience. The doctors found that the median values for ranked preference scores consistent with greatest importance for satisfaction were technical skill of the endoscopist, discomfort during the procedure and manner of the endoscopist. Factors considered of relatively low importance included the single-sex environment, noise levels and explanation of delay. 

Scandinavian Journal of Gastroenterology 2013: (48)3: 366-373

PRACTICE

AGA Lays Groundwork for Expanding Choosing Wisely® Quality Program

One year ago, AGA and eight influential specialty societies committed to quality care launched the Choosing Wisely® campaign by releasing lists of “Five Things Physicians and Patients Should Question.” Since launch, more than 55 peer-reviewed journal articles have been published about the campaign’s quality recommendations and media stories have reached millions of patients. AGA is proud that we helped the ABIM Foundation launch this important campaign, which has recently grown as 16 additional specialty societies released their Choosing Wisely lists.

AGA continues to build resources to support your work: 

“We recognize that patients often ask for tests and treatments that are not necessarily in their best interest, and physicians often struggle with decisions about prescribing tests and procedures as a way of covering all possible bases. However, in many cases, more care is not always higher quality care,” says Lawrence Kosinski, MD, chair of the AGA Institute Practice Management and Economics Committee. “The evidence is overwhelming that our extraordinary level of health-care spending is not delivering on either quality or value, and we are committed to playing a constructive role in addressing health-care costs.”

AGA is interested in hearing from you. Has the campaign affected the way you practice? Are you having more conversations with your patients about avoiding unnecessary care? What is working well, and what — if anything — is proving to be more challenging? Please share your story.

AGA Introduces a New Process for Clinical Practice Guideline Development

By John M. Inadomi, MD, AGAF

As reimbursement shifts from fee-for-service to value-based, it is essential for physicians to focus on the quality — rather than quantity — of services provided. Given that physician reimbursement will increasingly hinge on achieving high-quality health outcomes, it is essential to address how health-care “quality” is defined. AGA is committed to leading efforts to define the metrics by which clinical services and health outcomes are judged. As a result, AGA has recently introduced a new process for clinical practice guideline development, utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. A complete review of the revised process was published in the April issue of Clinical Gastroenterology and Hepatology in the “Practice Management: The Road Ahead” column (log in required).

Employed by more than 70 organizations and accepted by the National Quality Forum, GRADE is an internationally recognized method to determine the strength of current clinical evidence. The GRADE framework allows for comparison between published studies that vary in methods, comparison populations and statistical strength, allowing clinicians to judge strength of evidence and provide clinical recommendations. A “strong recommendation” means that most patients should receive the recommended course of action, whereas a conditional or “weak recommendation” means that different choices may be appropriate for different patients. Importantly, GRADE provides clear and actionable direction to patients, clinicians and policymakers.

In addition to utilizing GRADE, the AGA’s new process for clinical practice guideline development fundamentally reshapes how topics are solicited. Beginning this year — and annually every March — AGA will make a “call for topics” to all members. By completing an online form, members may submit topics to be developed within the coming year. The current deadline is April 15.

The AGA Institute Council will review guideline topics in May, prioritizing and ranking topics based on the following criteria: prevalence of disease, resource utilization, variation in care, other existing guidelines, new data/changes in diagnosis or treatment, and potential for measure/quality development. Once vetted, four new guidelines will be recommended for development across the year.

We encourage you to take part in this important process and submit your topic recommendations. AGA believes that gastroenterologists should define the quality metrics upon which they will be judged and reimbursed. In taking an active role, we can improve patient outcomes and be appropriately rewarded for performing high-quality care.

Review all current AGA guidelines online.

Protect Your Practice and Personal Assets

Insure with Great Divide Insurance Company’s gastroenterologist professional liability policy and save 5 percent. As an AGA member, you can also qualify for claims-free, group size and other discounts that will help you protect your practice and personal assets.

Policy features include:

  • Competitive premiums.
  • Defense against proceedings brought by licensing boards, governmental bodies or hospital peer-review committees.
  • Reimbursement for your expenses and loss of income while you are away from your practice assisting in your defense of a malpractice suit.
  • Limit of up to $1 million for each incident and $3 million annual aggregate (higher limits may be available nationwide).
  • Portable protection — coverage travels with you to all of your work settings and covers lawsuits brought anywhere in the U.S.
  • Free tails for death, disability or permanent retirement from practice.
  • Defense for HIPAA Wrongful Acts.

To learn more about this program, view the brochure, visit www.cisinsurance.com/aga or call CIS at 301-933-3373 and ask for Israel or Aton Teitelbaum.

This program is endorsed by the AGA Institute.

RESEARCH

Salix Commits $1.125M to AGA Research Foundation

The AGA Research Foundation is pleased to welcome Salix Pharmaceuticals as a supporter of the foundation’s endowment.

The AGA Research Foundation provides research funding grants to young investigators in gastroenterology and hepatology. The foundation’s grants transform young researchers’ lives by encouraging them to embark on and continue careers in research. Many ultimately make discoveries that improve patient care.

Salix Pharmaceuticals’ $1.125 million, five-year commitment to the AGA Research Foundation endowment will help ensure that researchers have the tools they need to discover ways to better diagnose, treat and cure digestive diseases.

Read more.

Student Abstract Prize Brings University of Arizona Student to DDW®

Alexandra CeeYour AGA Research Foundation gifts support Farhan Anwar for work at the University of Arizona, who received the 2012 AGA - Horizon Pharma Student Abstract Prize.

“I am honored to receive the AGA Horizon Pharma Student Abstract Prize. I am excited to witness and listen to the various lectures at DDW®, particularly to those that are related to my research. This conference will expose me to a whole range of research and will allow me to expand my research further into new avenues of research. Along with new directions, I am curious to see collaborative results of other researchers. Ultimately, the criticism I will receive at this conference on my poster will help me grow as a researcher in terms of presenting research, and understanding other’s research.”

To make a donation, visit www.gastro.org/contribute.

Memorial and Honorary Gifts: A Special Tribute

Did you know that you can honor a family member, friend or colleague whose life has been touched by GI research through a gift to the AGA Research Foundation? Your gift will honor a loved one and support the AGA Research Awards Program while giving you a tax benefit; any charitable gift can be made in honor or memory of someone. 

A Gift Today
An outright gift will help fund the AGA Research Awards Program. Your gift will assist in furthering basic digestive disease research, which can ultimately advance research into all digestive diseases. The financial benefits include an income tax deduction and possible elimination of capital gains tax. A cash gift of $25,000 or more qualifies for membership in the AGA Legacy Society, which recognizes the foundation’s most generous individual donors. 

A Gift Through Your Will or Living Trust
You can include a bequest in your will or living trust stating that a specific asset, certain dollar amount or — more commonly — a percentage of your estate will pass to the AGA Research Foundation at your death in honor of your loved one. A bequest gift of $50,000 or more qualifies for membership in the AGA Legacy Society. 

For more information on how to give and recognize your loved one, visit www.gastro.org/contribute or contact Stacey Hinton Tuneski at 301-222-4005 or stuneski@gastro.org.

POLICY

Take Action on the Colonoscopy Co-Insurance Medicare Issue

The GI community recently received great news that a government guidance clarified its policy related to cost sharing for colonoscopy for privately insured patients. However, patients with Medicare are still subject to colonoscopy co-insurance when a screening turns therapeutic, which affects a large portion of patients who need to be screened.

We urge you to contact your legislators to tell them to fix the co-insurance issue for your Medicare patients. While the AGA will continue to advocate that legislators correct the colonoscopy coinsurance issue for Medicare patients as well, we need your help. Legislators need to hear from their constituents that this loophole needs to be fixed.

On Wednesday, March 20, join AGA, Fight Colorectal Cancer and a number of other GI societies and patient advocacy groups to reach out to Congress for the “United Behind a Cure Congressional Call In.” Call 1-866-615-3375 to tell your legislator that you support a bill in Congress that ensures that screening colonoscopy is free to all Medicare beneficiaries, regardless of whether a polyp or other tissue is removed.

Read the AGA issue brief on Medicare beneficiary cost sharing.

We continue to make great strides in our knowledge about the detection, prevention and treatment of colorectal cancer, but more work needs to be done to ensure this research translates to improved patient care. By working together, we can help increase colorectal cancer screening rates to reduce the morbidity and mortality associated with the disease.

As Sequestration Sinks In, Old Budget Battles Resume

On March 1, President Obama signed an order officially implementing the sequester, which cut $85.3 billion from government agencies, half of which was taken from defense programs ($42.7 billion). The other half of the sequestered amount comes from non-defense programs — $16.9 billion from mandatory programs like Medicare, and $25.8 billion from discretionary programs, like NIH.

GI will experience the effects as early as April 1 when the 2 percent Medicare cuts and 5 percent NIH cuts are scheduled to begin. Read more on the AGA Washington Insider, a policy blog for GIs.

JOURNALS & PUBLICATIONS

A Rare Pancreatic Tumor in a 52-Year-Old Chinese Woman

Question: A 52-year-old Chinese woman without any significant past medical history presented with one month of postmenopausal bleeding without abdominal pain, fever, jaundice, weight loss or other symptoms. General physical examination did not reveal any abnormality. Abdominal examination showed a large (10 cm), firm, fixed mass with well-defined borders in the suprapubic area. Routine laboratory tests and tumor markers including CA 19-9 and CA-125 were within normal range.

Computed tomography (CT) showed an approximately 10 × 10 cm hysteromyoma arising from the anterior wall of uterus and the other mass of 4 cm in diameter within the endometrial cavity (Figure A). The latter one was proved to be grade I endometrial carcinoma by endometrial biopsy. Simultaneously, a 2.9 × 3.4 cm heterogeneous enhanced mass in the pancreatic head was accidentally discovered in the preoperative CT examination (Figure B). Exploratory laparotomy was performed. Intraoperatively, the tumor in the pancreatic head was found to directly invade the superior mesenteric vein and could not be resected. Hysterectomy and bilateral adnexectomy were performed after pancreatic tumor biopsy with prostatic trocar.

What is the most likely diagnosis of the pancreatic mass? Is it a primary or a secondary tumor?

Find the answer in Gastroenterology.

View This Month's Journal Highlights, All in One Place

The editors of Gastroenterology and Clinical Gastroenterology and Hepatology (CGH) would like to bring to your attention highlighted articles from the March issues of the journals.

Gastroenterology

Long-term Outcomes After Resection for Submucosal Invasive Colorectal Cancers; By Hiroaki Ikematsu, et al

Sex and Age Are Determinants of the Clinical Phenotype of Primary Biliary Cirrhosis and Response to Ursodeoxycholic Acid; By Marco Carbone, et al.  

Increased Risk of Advanced Neoplasms Among Asymptomatic Siblings of Patients With Colorectal Cancer; By Siew C. Ng, et al.  

Weight-Independent Effects of Roux-en-Y Gastric Bypass on Glucose Homeostasis via Melanocortin-4 Receptors in Mice and Humans; By Juliet F. Zechner, et al.  

Central Melanin-Concentrating Hormone Influences Liver and Adipose Metabolism Via Specific Hypothalamic Nuclei and Efferent Autonomic/JNK1 Pathways; By Monica Imbernon, et al

CGH

Psychological Treatments in Functional Gastrointestinal Disorders: A Primer for the Gastroenterologist; By Olafur S. Palsson, et al

Discordance Among Transient Elastography, Aspartate Aminotransferase to Platelet Ratio Index, and Histologic Assessments of Liver Fibrosis in Patients With Chronic Hepatitis C; By Naveen Gara, et al

Intractable Nausea and Vomiting From Autoantibodies Against a Brain Water Channel; By Raffaele Iorio, et al

Bisphosphonates Are Associated With Reduced Risk of Colorectal Cancer: A Systematic Review and Meta-Analysis; By Siddharth Singh, et al.  

Ferric Carboxymaltose Prevents Recurrence of Anemia in Patients With Inflammatory Bowel Disease; By Rayko Evstatiev, et al

EDUCATION & MEETINGS

2013 Spring Postgraduate Course Resources Now Available for Pre-Order

Pre-order resources from the 2013 AGA Spring Postgraduate Course, Putting Patients First: Actionable Evidence for Clinical Practice and receive unlimited, on-demand access to the latest science behind recent clinical advances, current diagnostic methods and the best approaches for handling controversial management issues. With the course at your fingertips, you can earn CME, review topics and listen to lectures anytime or anywhere.

The online sessions contain the complete audio track with presentation slides. The general session and select breakout sessions are included, and are fully searchable by topic or author. The DVD offers the same features, but does not offer CME credit.

Save by ordering both: purchase the DVD, and receive the online sessions for only $10 more. The combo deal is available through the AGA Store.

The course syllabus, now available on a USB thumb drive as well as in book format, contains comprehensive details of all sessions, including abstracts, key points, references, slides, graphs, charts and tables. Also included are the learning objectives and reference lists by chapter.

While supplies last, the syllabus, DVD and online sessions from the 2012 Spring Postgraduate Course, Emerging Concepts and Their Practical Applications, are also available.

To order, visit www.gilearn.org/pgresources. You may also order the course recordings as part of DDW on Demand. The course is included in both the full set and the AGA library. Place your order when you register for DDW.

DDW® Sessions Offer Fellows Career Help, Networking

Fellows attending DDW® 2013 will have the opportunity to broaden their professional network, review board material and get tips on starting a career at the AGA Trainee and Young GI Track. With the exception of the Spring Postgraduate Course, all of the sessions are free, but you must be registered for DDW to attend. Registration is free for trainees through April 10.

Trainee Track sessions include:

  • AGA Spring Postgraduate Course: Putting Patients First: Actionable Evidence for Clinical Practice — Saturday, May 18 and Sunday, May 19
    This clinically focused course offers you immediately applicable information. Trainees may register at a reduced registration fee. 
  • Sorcerers and Apprentices: An Evening Reception with AGA Mentors — Saturday, May 18
    Meet your peers and more established colleagues who serve as mentors, while enjoying refreshments.
  • Board Review Session — Monday, May 20 
    Designed around content from the new Digestive Diseases Self-Education Program® (DDSEP) 7, this session serves as a primer for third-year fellows preparing for the board exam, and as a review course for others. Discount coupons for DDSEP 7 will be available to attendees. 
  • Career and Professional Related Issues — Monday, May 20
    Get advice on common career issues such as choosing a practice type and location, developing your CV, interviewing, negotiating contracts, and work-life balance.
  • Maximizing Opportunities Within Fellowship Training: Advice from Fellows and Faculty — Monday, May 20
    Learn how to create a niche within GI, discuss career options and explore advanced clinical training opportunities. 
Register now to take advantage of reduced rates. Registration fees will increase for both DDW and the Spring Postgraduate Course after April 10.

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Classifieds

Place GI Position Listings and Activity Announcements

For as little as $82.50, you can place a classified ad of 100 words or less in AGA's weekly email newsletter, AGA eDigest, or AGA's bimonthly magazine, AGA Perspectives. If you place ads in both AGA Perspectives and AGA eDigest, you will receive a 10 percent discount. Advertising in either includes a free online classified listing. Learn more.

Washington, D.C.

Gastroenterologist BC/BE to join suburban Washington, D.C. busy 100 percent outpatient consultative GI group practice with adjacent accredited endoscopy center. Practice includes on-site capsule endoscopy small-bowel studies. We have state-of-the-art EMR. Applicant must be experienced in all endoscopic procedures. Early pathway to partnership. Email resume to drdbd@aol.com or FAX (301) 897-5290.