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December 2020 Volume 14 / Number 12 Start CRC screening INSIDE GI ONCOLOGY at age 45, USPSTF Task force report Best practices noted for managing malignant now suggests colorectal polyps. • 16 LIVER DISEASE BY ROXANNE NELSON, that all adults aged 45-75 RN, BSN years be screened for CRC. Semaglutide shows

arnes This is an “A” recom- promise in NASH study B creening for colo- mendation for adults aged Phase 2 data show rectal cancer (CRC) 50-75 and a “B” recom- resolution tephanie s Sshould begin at age mendation for adults aged in 60%. • 27 45 years instead of 50 45-49. Dr. Barry explained

ourtesy IBD AND INTESTINAL C years, as recommended that the reason for this Dr. Edward L. Barnes and his associates noted that disparities in care in the current guideline, difference is that the DISORDERS start with later diagnosis of IBD, followed by issues with continuity. the U.S. Preventive Ser- Tool predicted vices Task Force said in 45- to 49-year age group. vedolizumab a draft recommendation “Butbenefit there’s is smaller not much for the nonresponse that is open for public difference between A and Rising IBD rates in comment. B from a practical stand- Point-based scoring “This is the only change point,” he explained. system uses clinical minorities heighten that was made,” said task For adults aged 76-85, variables. • 30 force member Michael PRACTICE Barry, MD, director of of screening need to be need for awareness the Informed Medical weighedthe benefits against and harmsthe indi- MANAGEMENT Decisions Program in the vidual’s overall health and Delay in Stark reform BY AMY KARON wrote Edward L. Barnes, Health Decision Sciences personal circumstances. stunts value-based care MDedge News MD, MPH, of University of Center at Massachusetts This is a “C” recommenda- CMS dragging North Carolina at Chapel General Hospital, Boston. tion. its feet. • 34 - Hill, with his associates. The recommendation is See USPSTF · page 16 ease (IBD) is rapidly in- However, Blacks with IBD Icreasingnflammatory among bowel racial dis and tend to be diagnosed later ethnic minorities, which than Whites, are less likely makes it important to con- to receive recommended Study IDs microbial signature of sider for patients with com- biologics and immunomod- patible symptoms, experts ulators, and are more likely celiac disease in children wrote in Gastroenterology. to receive care at an emer- Crohn’s disease and ul- gency department, to expe- BY AMY KARON healthy children, accord- regardless of whether cerative colitis are “chronic rience delays in colectomy, MDedge News ing to the findings of a children were newly diag- diseases with intermittent and to miss regular visits to study published in Gastro- nosed or had already mod- - IBD specialists because of leven operational tax- enterology. sion, so access to specialists, Eonomic units (OTUs) This microbial signa- Konstantina Zafeiropoulou periodsappropriate of flare therapies, and remis and barriers, they added. of fecal bacteria were andified Ben their Nichols, diet, reported PhD, of frequent follow-up visits financialThese disparities and transportation are less abundant in children approximately four out of - are vital to good outcomes,” See Minorities · page 28 with celiac disease than in ture correctly identified See Celiac · page 9 the Glasgow Royal Infir five cases of celiac disease,

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01_09_to_17_28_31_GIH20_12.indd 1 11/20/2020 3:42:15 PM †NEWS LETTER FROM THE EDITOR Top AGA Community Scientific firepower will save us COVID-19 numbers again are increasing patient cases dramatically. Community infection rates have have next month’s editorial in mind, and I - nearly doubled, and hospitals and health care lookwe publish for useful its officialphrases, newspaper. quotes, ideas, I always and ularly bring their questions to the AGA Com- workers are stretched beyond their limits. It opinions. If you are interested in becoming Pmunityhysicians (https://community.gastro.org) with difficult patient scenarios to reg seek EIC, please email [email protected] for advice from colleagues about therapy and disease this pandemic was managed (mismanaged) more information. management options, is difficult not to feel anger about how poorly best practices, and di- charge and by a large agnoses. The upgraded segmentby so many of ourofficials popu- in As EIC, you will choose the next editorial networking platform lation who still refuse now features a news- protective actions to limit board and forge professional friendships spread. While politics and that are gratifying. You will assume scenarios and regularly scheduled Roundtable dis- ideology continue to cost responsibility for the content, where you feed for difficult patient must balance your own views with those In case you missed it, here are some clinical discus- cussionssions and with Roundtables experts in in the the field. newsfeed this month: ourAmerican saving lives, grace. scientific of both the AGA and our readership. • Practice update: Small intestinal bacteria over- firepowerMy editorial will emergeboard and as Dr. Allen growth (SIBO) (https://community.gastro.org/ posts/22838) year at the helm of GI & Hepatology News. I would be remiss not to acknowledge the • Case: Polypectomy with low neutrophils (https:// AGAI are issuedentering a search our final for the next Editor in contribution that Lora T. McGlade, MS, has community.gastro.org/posts/22844) Chief (EIC), who will take over October 2021. made to GI & Hepatology News. She has been • Case: Esophagus adenocarcinoma after sleeve I urge anyone interested to apply (https:// my partner, as the Frontline Medical Commu- gastrectomy (https://community.gastro.org/ gastro.org/news/prestigious-aga-publica- nications Editor in charge of GI & Hepatology posts/22868) tions-seek-new-editors-in-chief/). As EIC, News. Next month, she will move on to assume • Case: you will choose the next editorial board and a new role. I cannot thank her enough for help- when is it safe? (https://community.gastro.org/ forge professional friendships that are grati- ing make this newspaper work. As the months posts/22890) Restarting infliximab after shingles – fying. You will assume responsibility for the go on, I will highlight the contributions of oth- • Case: Flatulence in Colorado (https://community. content, where you must balance your own ers from the AGA, our Board, and Frontline. gastro.org/posts/22901) views with those of both the AGA and our Please stay safe and do not let your guard • Case: Serrated epithelial change (SEC) in IBD readership. down. COVID-19 is merciless and relentless. (https://community.gastro.org/posts/22948) As EIC, each month I am given space for “If you think research is expensive, try dis- • Case: Multiloculated pancreatic cyst (https:// 300 words to communicate interesting ideas ease.” – Mary Lasker. community.gastro.org/posts/22935) and opinions. The AGA gives the newspaper great editorial freedom, and I hope we have John I. Allen, MD, MBA, AGA View all upcoming Roundtables in the community at supported AGA’s mission and values when Editor in Chief https://community.gastro.org/discussions.

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Editor in ChiEf, Gi & hEpatoloGy nEws Gi & hEpatoloGy nEws is the official newspaper of the American frontlinE mEdiCal CommuniCations soCiEty partnErs John I. Allen, MD, MBA, AGAF Gastroenterological Association (AGA) Institute and provides the Executive Editor Kathy Scarbeck, MA Editor in ChiEf, thE nEw GastroEntEroloGist gastroenterologist with timely and relevant news and commentary about Editor Lora T. McGlade, MS Vijaya L. Rao, MD clinical developments and about the impact of health care policy. Content for Creative Director Louise A. Koenig assoCiatE Editors Gi & hEpatoloGy nEws is developed through a partnership of the newspaper’s Megan A. Adams, MD, JD, MSc medical board of editors (Editor in Chief and Associate Editors), Frontline Director, Production/Manufacturing Rebecca Slebodnik Ziad Gellad, MD, MPH, AGAF Medical Communications Inc. and the AGA Institute Staff. “News from the Kim L. Isaacs, MD, PhD, AGAF AGA” is provided exclusively by the AGA, AGA Institute, and AGA Research Charles J. Kahi, MD, MS, AGAF Foundation. All content is reviewed by the medical board of editors for National Account Manager Joshua Norton 512-375-8202, [email protected] Gyanprakash A. Ketwaroo, MD, MSc accuracy, timeliness, and pertinence. To add clarity and context to important Larry R. Kosinski, MD, MBA, AGAF developments in the field, select content is reviewed by and commented on by Senior Director of Classified Sales Tim LaPella, 484-921-5001, Sonia S. Kupfer, MD external experts selected by the board of editors. [email protected] Wajahat Mehal, MD, PhD The ideas and opinions expressed in Gi & hEpatoloGy nEws do not Advertising Offices 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609 973-206-3434, fax 973-206-9378 Editors EmEritus, Gi & hEpatoloGy nEws necessarily reflect those of the AGA Institute or the Publisher. The AGA Colin W. Howden, MD, AGAF Institute and Frontline Medical Communications Inc. will not assume Editorial Offices 2275 Research Blvd, Suite 400, Rockville, MD 20850, Charles J. Lightdale, MD, AGAF responsibility for damages, loss, or claims of any kind arising from or related 240-221-2400, fax 240-221-2548 Editor EmEritus, thE nEw GastroEntEroloGist to the information contained in this publication, including any claims related Bryson Katona, MD, PhD to the products, drugs, or services mentioned herein. Advertisements do aGa institutE staff not constitute endorsement of products on the part of the AGA Institute or Managing Editor, GI & HepatoloGy News, Jillian L. Schweitzer Frontline Medical Communications Inc. Managing Editor, tHe New GastroeNteroloGIst, Ryan A. Farrell POSTMASTER Send changes of address (with old mailing label) to GI & Senior Publications Manager, Brook A. Simpson Hepatology News, Subscription Service, 10255 W Higgins Road, Suite 280, Director of Publications Lindsey M. Brounstein Rosemont, IL 60018-9914. FRONTLINE MEDICAL COMMUNICATIONS RECIPIENT To change your address, contact Subscription Services at 1-800-430- Vice President of Publications Erin C. Landis Corporate 5450. For paid subscriptions, single issue purchases, and missing issue claims, offiCErs of thE aGa institutE VP, Sales Mike Guire call Customer Service at 1-833-836-2705 or e-mail custsvc.gihep@ President M. Bishr Omary, MD, PhD, AGAF VP, Member Marketing & Digital Production Amy Pfeiffer fulcoinc.com President-Elect John M. Inadomi, MD, AGAF The AGA Institute headquarters is located at 4930 Del Ray Avenue, President, Custom Solutions JoAnn Wahl Vice President John M. Carethers, MD, AGAF Bethesda, MD 20814, [email protected]. Circulation Director Jared Sonners Secretary/Treasurer Lawrence S. Kim, MD, AGAF Gi & hEpatoloGy nEws (ISSN 1934-3450) is published monthly for Director, Custom Programs Patrick Finnegan ©2020 by the AGA Institute. All rights reserved. No part of this publication may be $230.00 per year by Frontline Medical Communications Inc., 7 Century Scan this QR In affiliation with Global Academy for Medical Education, LLC reproduced or transmitted in any form or by any means, electronic or mechanical, Drive, Suite 302, Parsippany, NJ 07054-4609. Code to visit including photocopy, recording, or any information storage and retrieval system, without mdedge.com/ Vice President, Proprietary Conferences, MedscapeLive David J. Small, MBA permission in writing from the publisher. Phone 973-206-3434, fax 973-206-9378 gihepnews

8 December 2020 / GI & Hepatology News

08_18_19_GIH20_12.indd 8 11/20/2020 3:44:21 PM †FROM THE AGA JOURNALS Link between gastroparesis symptoms, constipation?

BY AMY KARON MDedge News constipation (a score of 4 or 5 on a 5-point emptying). In the multivariable analysis, severe medications,ceptor antagonists, and it isor unclearcannabinoids. if these However, induced evere constipation affected 34% of adults constipationmany patients or were if patients taking had combinations primary dis- of with gastroparesis symptoms and showed scale) correlated significantly with a higher S score on the Gastroparesis Cardinal Symptoms anorectal dysfunction, said Adil E. Bharucha, symptom severity in a multicenter prospective patientsIndex (GCSI), with withgastroparesis an odds ratio symptoms of 1.85 were (95% sig- orders, such as abnormal colonic motility or study.a significant positive correlation with confidence interval, 1.30-2.67). In addition, - the gastroenterology and hepatology division Henry P. Parkman, MD, of Temple University MBBS, MD, AGAF, a professor of medicine in in Philadelphia and his associates used a modi- nificantly more likely to report pain in the low - er abdomen (OR, 1.34; 95% CI, 1.06-1.69) and and a medical director in the office of clinical ing scintigraphy, and wireless motility capsule to use medications to manage constipation (OR, withtrials gastroparesis at Mayo Clinic, and Rochester, constipation, Minn., clinicians who fied GI symptoms questionnaire, gastric-empty- and5.09; Hepatology. 95% CI, 2.75-9.41). The findings were shouldwas not consider involved withdrawing in the study. constipatingFor patients published online in Clinical Gastroenterology medications, performing anorectal testing, and enrollsstudies individualsof 338 participants with gastroparesis in the National symp- In the use of individual drug classes, including tomsstitutes (whether of Health or Gastroparesisnot they have Registry,delayed gastric which opiates,Constipation tricyclic was antidepressants, not significantly 5HT3 linked re- with Continued on page 14 referring patients for pelvic floor biofeedback

untreated children, who were test- Question cause or consequence that, after patients started a gluten- Celiac from page 1 said. Gas chromatography showed ed at baseline and then after 6 and and ammonia decreased. of disease processes such as nutri- disease12 months showed on a gluten-freeno evidence diet. of free“Even diet, though fecal levels we identified of butyrate - Children with new-onset celiac mary. “It is not clear whether the celiacmicrobes disease identified or are [in the this result study] of it. resultsent malabsorption, from a gluten-free or whether diet. dys dysbiosis, while a gluten-free diet withdifferences untreated in the celiac abundance disease ofand contribute to the pathogenesis of biosis is present at disease onset or explained up to 2.8% of variation healthya few species controls, between the profound patients mi- performed gas chromatography and ain measure microbiota of species-level between patients diver- and Future research should explore the For the study, the researchers sity,controls. was generallyMicrobial similaralpha diversity, among role of the disease-specific species - crobial dysbiosis noted in Crohn’s identified here,” the researchers 16S ribosomal RNA sequencing of- thedisease investigators was not observed, commented. at least “Al- wrote in Gastroenterology. - fecal samples from 141 children, in groups, but between 3% and 5%- thoughusing crude several diversity alterations indices,” in the neticallyCeliac diseasepredisposed, is multifactorial. only a small cluding 20 with newly biopsy-con of all taxa differed. Irrespective of - proportionWhile up to develop 40% of peopleit, suggesting are ge diagnosedfirmed, previously and on a untreated gluten-free celiac tictreatment, for celiac the disease decreased with abunan error - that environmental factors are key disease; 45 children previously dance of the 11P OTUs was diagnos intestinal microbiota of children with established celiac disease ap have linked celiac disease with ondiet; regular 19 unaffected medications siblings; and hadand no rate of 21.5% ( < .001 vs. random pear to be effects of a gluten-free - to pathogenesis. Recent studies history57 healthy of chronic children gastrointestinal who were not associatedclassification). with Notably, nutrient most or food- of diet, there are specific bacteria symptoms. A single fecal sample these 11 discrepant OTUs were that are distinct biomarkers of ce isalterations pathogenic in orthe a gut secondary microbiome, effect of gluten ingestion, the researchers performingliac disease.” in vitro tests of “can- but it is unclear whether dysbiosis group intake and with biomarkers Future research might involve was tested for all but the previously - t is well known that gluten ingestion in genetically munedidate” cells, bacteria, and studying coculturing whether I - thesedietar bacteriay interventions with human alter theim ac disease, and research over the past decade has that this unique signature is present at diagnosis and- - susceptible individuals does not guarantee celi identifies taxa for further investigation. - A significantly different microbial profile and me researchersrelative abundance said. of these bac natesearched immunity, for environmental which leads totriggers. the adaptive Gut gluten-freetabolites were diet identified are an important in subjects consid- on teria in the gut microbiome, the microbiota play a role in activation of in erationgluten-free when diets. committing The consequences a patient to of this the the Biotechnology and Biological damage that is characteristic of celiac dis- Nutricia Research Foundation, ease.immune The response authors ofand this the study small-bowel sought to may play a role in persistent symptoms identify whether there is a distinct micro- andlife-long the increased therapy. The health microbiome conditions changes we see providedSciences Researchfunding. ThreeCouncil, coinves- and in treated celiac disease. Those on a glu- tigatorsThe Catherine disclosed McEwan ties to Foundation Nutricia, - - ease,bial pattern in comparison among celiac with healthydisease controlspatients, Janssen, Takeda, and several other both those with treated and untreated dis Dr. Adams ten-free diet have other micronutrient defi 4D Pharma, AbbVie, Celltrion, understood.ciencies in addition A gluten-free to microbiome diet focused changes on coinvestigator reported chairing and healthy siblings. - and the health sequelae of this are not fully pharmaceutical companies. One- The authors identified three groups of - - rope. The remaining investigators bacterial taxa: 1) unique to celiac disease indepen restoring the normal gut flora through probiotic or the working group for ISLI Eu dent of treatment, 2) new-onset disease and treat gluten-free prebiotic or fiber supplementation in celi interest. ment responsive, and 3) reflective of diet changes Dawnac disease Wiese patients Adams, could MD, MS, prove is assistant beneficial. professor and reported having no [email protected] of highlyand not predict unique celiac to disease. disease Within regardless the first of treatment. group, 11 medical director, Center for Human Nutrition, depart- distinct operational taxonomic units (OTUs) could- ment of gastroenterology, hepatology, and nutrition, SOURCE: Zafeiropoulou K et al. Gas- - Vanderbilt University Medical Center, Nashville, Tenn. troenterology. 2020 Aug 10;S0016- From these results, we cannot determine if the mi She has no conflicts of interest. 5085(20)35023-X. doi: 10.1053/j. crobial signature is a result of disease or a contrib gastro.2020.08.007. utor to disease development; however, it reinforces MDedge.com/gihepnews / December 2020 9

01_09_to_17_28_31_GIH20_12.indd 9 11/20/2020 3:42:16 PM †FROM THE AGA JOURNALS

Continued from page 9 [based on] physiological measures, medication Therefore, future studies of patients with therapy if anorectal tests are positive, he said use, and detailed symptom questionnaires,” the gastroparesis and constipation should forgo while acknowledging the need for more data study’s method of grouping patients based on grouping patients based on GI motor patterns on these approaches. For patients without evi- continuous variables could mask relevant clin- and instead validate patient-reported symptom dence of anorectal disorders, he recommended ical nuances, Dr. Levinthal said. He emphasized measures by using novel sensory tests with “simple laxatives or, if necessary, prescription stimuli such as eating, drinking, and balloon dis- tension, Dr. Levinthal said. He also recommend- upper gastrointestinal symptoms.” ed studying cognitive and emotional functioning medications,In this study, some constipation of which alsomay did also not benefit cor- ‘These observations highlight that sensory in this patients, given that conditions such as relate with gastric emptying, which suggests mechanisms are very important factors depression and anxiety are known to affect GI that “motility disturbances in the foregut are that are not interrogated by physiological sensation. separable from those in the hindgut,” said David The National Institute of Diabetes and Diges- Levinthal, MD, PhD, director of the neurogastro- motility tests, but that nonetheless may have tive and Kidney Diseases provided funding. The enterology and motility center at the University an outsized impact on how patients feel.’ of Pittsburgh Medical Center, who also was not - involved in the work. Constipation was only entsinvestigators for anorectal reported devices having jointly no withconflicts Minnesota of marginally linked with colonic transit time (OR, Medicalinterest. Technologies,Dr. Bharucha reportedMedspira, having and Medtronic filed pat 1.04; 95% CI, 1.00-1.07), and delayed gastric that individual physiological tests do not reliably and receiving royalties from Medspira. Dr. Levin- emptying did not predict the severity of dys- predict the presence or severity of GI symptoms: thal reported having served on advisory boards pepsia, he noted. “These observations highlight “What would you make of a 50-hour colonic for Takeda Pharmaceuticals and Alexza Pharma- that sensory mechanisms are very important transit time [CTT]? Or a 60-hour CTT? One could ceuticals. factors that are not interrogated by physiological have either no constipation or severe constipa- [email protected] motility tests, but that nonetheless may have an tion with those values. In clinical practice, it is outsized impact on how patients feel.” SOURCE: Parkman HP et al. Clin Gastroenterol Hepatol. Despite “fairly good phenotyping of patients CTT result [when] formulating a treatment plan.” 2020 Oct 28. doi: 10.1016/j.cgh.2020.10.045. less certain how useful it is to know a specific †GI ONCOLOGY FIT unfit for inpatient, emergency settings

BY MICHAEL VLESSIDES 48% of whom were women, who tation than those without (OR, 3.3; essary indications. underwent at least one FIT test. 95% CI, 1.9-5.5; P < .0001). ost fecal immunochemical Mean age of the study cohort was Of the 117 FIT-positive patients in the inpatient and emergency Mtests (FIT) in the hospital set- 54 years. Only three of the tests, or who underwent a GI consultation, settings,“We feel and that measures FIT is unfit should for usebe ting or the ED are performed for in- 0.5%, were performed to screen for upper endoscopy was a more taken to curb its use,” Dr. Bhatti appropriate indications, according common outcome than colonosco- concluded. “We presented our data to new data. interval, 0.09%-1.52%). py (51.3% vs. 23.1%; P < .0001). to our hospital leadership and a de- “This is the largest study that colorectal cancer (95% confidence cision was made to remove the FIT focuses exclusively on the use of ‘Another option – and this has been done in many settings as an orderable test from the EMR.” FIT in the ED, inpatient wards, and These results are “striking,” said with the fecal occult blood test – is just take FIT off the Jennifer Christie, MD, from Emory misuse,” said investigator Umer units or out of the ER, so providers won’t be tempted University, Atlanta. in the ICU, and it shows significant Bhatti, MD, from Indiana University, to use it as an assessment of these patients.’ “We should be educating our ER Indianapolis. providers and inpatient providers The only “validated indication” about the proper use of FIT,” she for FIT is to screen for colorectal Among the indications docu- Of the 34 patients who underwent said in an interview. “Another op- cancer. However, “99.5% of the FIT mented for FIT were anemia in colonoscopy or sigmoidoscopy, tion – and this has been done in tests done in our study were for 242 (44.0%) patients, suspected GI one was diagnosed with colorectal many settings with the fecal occult inappropriate indications,” he re- bleeding in 225 (40.9%), abdominal cancer and one with advanced ad- blood test – is just take FIT off the ported at the annual meeting of the pain in 31 (5.6%), and change in enoma. units or out of the ER, so provid- American College of Gastroenterol- bowel habits in 19 (3.5%). Overt GI bleeding was a better ers won’t be tempted to use it as ogy, where the study was honored The tests were performed most predictor of a GI consultation than an assessment of these patients. with an ACG Presidential Poster often in the ED (45.3%) and on the a positive FIT result. In fact, use of Because often times, as this study Award. FIT for patients with overt GI bleed- showed, it doesn’t really impact And the inappropriate use of FIT also performed in the ICU (10.5%) ing indicates a poor understanding outcomes.” in these settings had no positive andhospital burn floor unit (42.2%),(2.0%). but were of the test’s utility, the investigators In fact, unnecessary FIT could effect on clinical decision-making, Overall, 297 of the tests, or 54%, reported. put patients at risk for unnecessary he added. were negative, and 253, or 46%, “For patients with overt GI bleed- procedures. “We also know that For their study, Dr. Bhatti and were positive. ing, having a positive FIT made no calling for an inpatient or ER con- colleagues looked at all instances of “GI consults were obtained in difference on how often a bleeding sult from a gastroenterologist may FIT use in their hospital’s electronic 46.2% of the FIT-positive group, - increase both length of stay and medical records from November compared with 13.1% of the py, suggesting that FIT should not costs,” she added. 2017 to October 2019 to assess FIT-negative patients” (odds ratio, besource used was to guide identified decisions on endosco about Dr. Bhatti and Dr. Christie dis- how often FIT was being used, the 5.93; 95% CI, 3.88-9.04, P < .0001), endoscopy or hospitalization,” Dr. - indications for which it was being Dr. Bhatti reported. Bhatti said. tionships. used, and the impact of its use on Among FIT-positive patients, closed no relevant financial rela clinical care. those with overt bleeding were urges their peers to consider mea- A version of this article originally more likely to receive a GI consul- suresIn light to reduce of these FIT findings, tests for the unnec- team appeared on Medscape.com.

14They identified 550 patients, December 2020 / GI & Hepatology News

01_09_to_17_28_31_GIH20_12.indd 14 11/20/2020 3:42:17 PM GIHEP_15.indd 1 9/17/2020 11:57:15 AM †GI ONCOLOGY Task force: Best practices for malignant CR polyps

BY AMY KARON Moderate-quality evidence links submucosal The MSTFCC recommends that, when reporting on MDedge News invasion with two types of polyp morphology: a malignant colorectal polyp, pathologists follow the structured template of the College of American or patients with malignant colorectal polyps, type) showing a depression or sessile shape and Pathologists and note the lesion’s histologic type, endoscopists should look for features of deep LST-NGLST-G (laterally (laterally spreading spreading tumor, tumor, granular nongranular type) grade of differentiation, extent of tumor exten- Fsubmucosal invasion and should retrieve, that includes a dominant nodule. According to sion or invasion, stalk and mucosal margin, and handle, and submit specimens in ways that sup- low-quality evidence, these lesions should be man- presence or absence of lymphovascular invasion. port thorough and accurate pathologic assessment, Specimen integrity, polyp size and morphology, and according to new recommendations from the U.S. For both pedunculated and nonpedunculated tumor budding are also useful. To reduce miscom- Multi-Society Task Force on Colorectal Cancer. polyps, features denoting a high risk for munication and facilitate appropriate management, “In nonpedunculated lesions with features of pathologists should avoid using the terms carcino- deep submucosal invasion, endoscopic biopsy is residual or recurrent malignancy are poor ma and cancer when describing malignant colorec- followed by surgical resection. In cases without tumor differentiation, lymphovascular invasion, tal polyps, according to the MSTFCC. features of deep submucosal invasion, en bloc re- The decision to recommend adjuvant surgery section and proper specimen handling should be or more than 1 mm of submucosal invasion. “is based on polyp shape, whether there was en considered (if feasible) for lesions with a high risk bloc resection and adequate histologic assessment, Aasma aged with en bloc rather than piecemeal resection. the presence or absence of unfavorable histologic Shaukat, MD, MPH, AGAF, of the Minneapolis Vet- features, the patient’s risk for surgical mortality eransof superficial Affairs Healthsubmucosal Care Systeminvasion,” and wrote her fellow polyps (even if large) and should be considered for - experts. The recommendations were published in LST-GEn bloc lesions resection with is a important dominant fornodule. all pedunculated Resected Gastroenterology. pedunculated polyps should be retrieved through managementand morbidity, can and optimize patient clinicalpreferences,” outcomes the rec for Malignant colorectal polyps invade the submu- the suction channel – if doing so does not require patientsommendations with malignant state. Because polyps, multidisciplinary gastroenterol- cosa but do not extend into the muscularis propria. them to be cut – or with a net or snare during ogists, pathologists, oncologists, and surgeons Pedunculated and nonpedunculated polyps should should identify best ways to communicate with be considered to invade the deep submucosa if suspected submucosal invasion that are removed each other and share decision-making conjointly enscope bloc withdrawal. should be pinned Nonpedunculated peripherally lesions around with the and with patients. “Patient values are important in cases where the risk of residual cancer and the (neoplasticthey are classified and invasive, as NICE with (NBI an International irregular arrange- 10% formalin. This practice helps pathologists ori- Colorectal Endoscopic) type 3, Kudo type VN ententire specimens circumference to correctly to a hard assess surface depth and of invasionfixed in notes. “In these latter cases, shared decision-mak- - and margin involvement. risk of surgical mortality are similar,” the MSTFCC edment), lesions or Kudo with thesetype VI features (an amorphous should be structure, biopsied For both pedunculated and nonpedunculated pol- The authors of the task force recommendations (inwith the a lossarea of of or surface decrease feature in pits). disruption), “Nonpedunculat tattooed yps, features denoting a high risk for residual or re- ing is emphasized.” (unless in or near the cecum), and referred to sur- current malignancy are poor tumor differentiation, since 2016. gery. Pedunculated polyps with features of deep lymphovascular invasion, or more than 1 mm of reported having no relevant [email protected] of interest submucosal invasion should undergo endoscopic submucosal invasion. For nonpedunculated polyps, - additional high-risk features include tumor bud- SOURCE: Shaukat A et al. Gastroenterology. 2020 Nov 4. mendations. ding and tumor involvement of the cautery margin. doi: 10.1053/j.gastro.2020.08.050. polypectomy,” according to the MSTFCC recom

The rest of the new draft recom- Defining populations CRC rates up in younger adults mendation is similar to the 2016 CRC in young adults made the news USPSTF from page 1 guidelines, in which the task force in August 2020 when Chadwick says there is convincing evidence Increasing the pressure for “Right now it is very confusing that CRC screening substantially change reduces disease-related mortality. Boseman,died of colon known cancer. for Diagnosedhis role as Kingin The move comes after mounting ev- Dr. Yee said in an interview at that However, it does not recommend T’Challa in Marvel’s “Black Panther,” idence of an increase in CRC among time.to physicians “The USPSTF and to and the the public,” ACS dif- any one screening approach over “The recent passing of Chadwick younger adults and mounting pres- fer as far as the age to begin screen- 2016, he was only 43 years old. sure to lower the starting age. ing, and insurers may not cover the ‘The risk now for age 45-49 are with his loved ones during this Two years ago, the American Can- cost of colorectal cancer screening is pretty similar to the risk Boseman is tragic, and our thoughts cer Society revised its own screening guidelines and lowered the starting for people in their early 50s. Chadwickdifficult time,” was saidat higher Dr. Barry. risk for“As de- age to 45 years. Soon afterward, a tookbefore notice age 50.” of recent data showing So in some ways, today’s a Black man, the data show that coalition of 22 public health and pa- anDr. increase Barry saidin the that incidence the Task of Force CRC Unfortunately, there is currently tient advocacy groups joined the ACS among younger adults. late 40-year-olds are like notveloping enough colorectal evidence cancer.” that screening in submitting a letter to the USPSTF “The risk now for age 45-49 is yesterday’s 50-year-olds.’ asking that the task force reconsider pretty similar to the risk for people help prevent tragic deaths such as its 2016 guidance (which recom- in their early 50s. So in some ways, another. It recommends both direct Chadwick’s,Black men younger he commented. than 45 could“The mends starting at age 50 years). today’s late 40-year-olds are like visualization, such as colonoscopy, task force is calling for more re- The starting age for screening - as well as noninvasive stool-based search on colorectal cancer screen- is an important issue, commented mented. tests. It does not recommend se- Judy Yee, MD, chair of radiology at yesterday’sThe task force 50-year-olds,” used simulation he com rum tests, urine tests, or capsule - - endoscopy because there is not yet Limitinging in Black screening adults,” he toadded. demiologic data suggested and “that enough evidence about the bene- those at higher risk the Albert Einstein College of Med modelswe could that prevent confirmed some whatadditional the epi In contrast to the USPSTF and ACS theicine Colon and theCancer Montefiore Committee Health of the colorectal cancer deaths by starting “The right test is the one a patient guidelines, which recommend AmericanSystem in CollegeNew York of andRadiology. chair of fits and harms of these tests. Continued on following page

16 screening at age 45,” he said. will do,” Dr. Barry commented.December 2020 / GI & Hepatology News

01_09_to_17_28_31_GIH20_12.indd 16 11/20/2020 3:42:18 PM †GI ONCOLOGY Statins may lower risk of colorectal cancer

BY WILL PASS associated with a 60% CRC risk reduction (pooled MDedge News OR, 0.40; 95% CI, 0.19-0.86; P = .019).

both analyses (I2 greater than 75), most promi- of colorectal cancer (CRC) in patients with nentlyDr. Singh in the noted IBD populations,“significant heterogeneity” which he ascribed in Statin use may significantly lower the risk to “differences in demographic features, ethnic (IBD), based on a meta-analysis and systematic groups, and risk factors for CRC.” review.or without inflammatory bowel disease While publication bias was absent from the In more than 15,000 patients with IBD, statin non-IBD analysis, it was detected in the IBD ock use was associated with a 60% reduced risk of t portion of the study. Dr. Singh said that selection

CRC, reported lead author Kevin N. Singh, MD, of hinks bias due to exclusive use of observational studies NYU Langone Medical Center in New York, and /T may also have been present in the IBD analysis. colleagues. “Statin use has been linked with a risk re- risk reduction of CRC in the IBD population,

duction for cancers including hepatocellular rogerashford including“Prospective whether trials the are effects needed of statinsto confirm differ the carcinoma, breast, gastric, pancreatic, and bil- between ulcerative colitis and Crohn’s disease iary tract cancers, but data supporting the use patients,” Dr. Singh said. of statins for chemoprevention against CRC is Additional analyses are underway, he added, - ‘Prospective trials are needed to confirm including one that will account for the potential- sentation at the annual meeting of the American the risk reduction of CRC in the IBD ly confounding effect of aspirin use. Collegeconflicting,” of Gastroenterology. Dr. Singh said during a virtual pre population, including whether the effects According to David E. Kaplan, MD, AGAF, of He noted a 2014 meta-analysis by Lytras and the University of Pennsylvania, Philadelphia, colleagues that reported a 9% CRC risk reduc- of statins differ between ulcerative - tion in statin users who did not have IBD (World colitis and Crohn’s disease patients.’ duced CRC in IBD provides additional support J Gastroenterol. 2014 Feb 21. doi: 10.3748/ for“The the finding clinical that importance statins are of associated the antineoplastic with re wjg.v20.i7.1858). In patients with IBD, data are effects of statins. This effect has been strongly scarce, according to Dr. Singh. observed in liver cancer, and is pending pro- To further explore the relationship between meta-analysis involving 15,342 patients from spective validation.” statin use and CRC in patients without IBD, the in- Dr. Kaplan also offered some mechanistic in- vestigators analyzed data from 52 studies, includ- an unpublished abstract. In the four published sight into why statins have an anticancer effect, ing 8 randomized clinical trials, 17 cohort studies, studies,five observational 1,161 patients studies, used one statins of which while was 12,145 pointing to “the centrality of cholesterol biosyn- and 27 case-control studies. Of the 11,459,306 did not. thesis for development and/or progression of patients involved, approximately 2 million used In the non-IBD population, statin use was associ- malignancy.” statins and roughly 9 million did not. ated with a 20% reduced risk of CRC (pooled odds The investigators and Dr. Kaplan reported no To evaluate the same relationship in patients P with IBD, the investigators conducted a separate less than .001). In patients with IBD, statin use was [email protected] ratio, 0.80; 95% confidence interval, 0.73-0.88; relevant conflicts of interest.

Continued from previous page PERSPECTIVE screening for CRC for everyone over a certain age, a set of recommenda- Moving the goal posts for colorectal cancer screening tions developed by an international panel of experts suggests screen- linicians and researchers have actively rising incidence curve of EOCRC. And we must ing only for individuals who are at Cdebated the pros and cons of lowering do so without direct evidence to guide us as higher risk for CRC. the screening age to 45 years since 2018, As previously reported, these when the American Cancer Society released this younger group, the best modality to use, guidelines suggest restricting its colorectal cancer (CRC) screening guide- to the magnitude of the benefit of screening screening to adults whose cumu- lines. The most compelling argument in from screening in this group. We must also be lative cancer risk is 3% or more support of lowering the screening age is that carefulor tools not to risk to worsen stratify racial who isand likely geographic to benefit in the next 15 years, the point at recent data from Surveillance Epidemiology disparities in CRC screening, which already and End Results (SEER) show that the CRC exist for African Americans, Native Americans, and harms favors screening. incidence rates in 45- to 50-year-olds are Dr. Shaukat and other minorities and rural residents. Final- whichThe authors,the balance led betweenby Lise Hel- benefits similar to rates seen in 50- to 54-year-olds ly, even though the goal posts are changing, our singen, MD, Clinical Effectiveness - target remains to get to 80% screening rates for all age Research Group, University of tiate screening at age 50 were widely established. groups, and not neglect the currently underscreened Oslo, said “the optimal choice for Termedabout 20 early-onset years ago, whenCRC (EOCRC), the first theguidelines underlying to ini 50- to 75-year-olds, who are at a much higher risk of each person requires shared deci- reasons for this increase are not completely under- CRC than their younger counterparts. sion-making.” stood, and while the absolute numbers of EOCRC Such a risk-based approach is cases are smaller than in older-age groups, modeling Aasma Shaukat, MD, MPH, AGAF, is an investigator, “increasingly regarded as the most studies show that screening this age group is both Center for Care Delivery and Outcomes Research, appropriate way to discuss can- section chief and staff physician, GI section, Minneap- cer screening.” That approach is Over the last 20 years we have made major strides in olis VA Health Care System; staff physician, Fairview already used in prostate and lung efficientreducing andthe incidenceeffective. and mortality from CRC in ages University of Minnesota Medical Center, Minneapolis; cancer screening, they noted. 50 years and older, and now we must rise to the chal- and professor, University of Minnesota department of lenge of delivering CRC screening to this younger group medicine, division of gastroenterology, Minneapolis. A version of this article originally in order to see similar dividends over time and curb the She has no conflicts of interest. appeared on Medscape.com.

MDedge.com/gihepnews / December 2020 17

01_09_to_17_28_31_GIH20_12.indd 17 11/20/2020 3:42:20 PM NEWS FROM THE AGA CGH releases its first GI cancer–themed issue rticles include guidance levels of sex hormones and risk of tors associated with early-onset polyunsaturated fats is associated on cancer progression in esophageal adenocarcinoma and colorectal cancer), and hepatocel- with reduced risk of hepatocellular ABarrett’s esophagus pa- Barrett’s esophagus), colorectal lular carcinoma incidence (e.g., carcinoma) and risk. tients (e.g., Association between cancer surveillance (e.g., Risk fac- High dietary intake of vegetable or Clinical Gastroenterology and Hepatology (CGH) is proud to re- - troenterological cancers. This “issue withinlease its an first issue” themed includes issue a oncollec- gas tion of articles, selected by Editor in Chief Fasiha Kanwal, MD, MSHS, that will provide you with practical research to help guide cancer pre- vention, surveillance, and treatment decisions for your patients. View the themed issue on CGH’s website and access other curated collections on cghjournal.org. Learn where you want [email protected]

Learn what you want Quick Quiz Q1. You perform a colonoscopy for a patient who underwent sigmoid resection for stage 2 colorectal cancer 1 year ago. The colonoscopy reveals one diminu- tive adenoma in the cecum, which Learn how you want you remove with a cold snare. When should you recommend the next colonoscopy? A. 10 years B. 5 years C. 3 years D. 1 year E. 6 months DDSEP Digestive Diseases Self-Education Program Customized by you

Whether preparing for a GI board exam or keeping current All at your fingertips. Q2. Patients with celiac disease subscribing to a strict gluten-free on advances in the field, DDSEP 9 allows you to customize Also available on diet are at particular risk for learning where you want, what you want and how you want. AGA University and A. Fiber Complete versions are available in digital and print formats ddsep.gastro.org B.which Protein nutrient deficiency? C. Folate as well as by chapter, Q&A modules and/or mock exams. D. Thiamine E. Iron EDU19-45 Answers on following page

18 December 2020 / GI & Hepatology News

08_18_19_GIH20_12.indd 18 11/20/2020 3:44:24 PM NEWS FROM THE AGA Congrats to these five AGA members

- We’re proud to share the news of two insights defined the role of gut hormones on Medicine, for “pioneering the study of the gut - AGA members elected to the presti normal physiology and metabolism, pioneering microbiome in IBD, publishing seminal research gious National Academy of Medicine innovative understanding of neuroendocrine cell- on the relationship between diet and the micro and three honored with the 2020 Sherman biology and the role of neurohormonal pathways biomeJessica — enablingAllegretti, multiple MD, MPH areas of research Prize. in the development and progression of neuroen into dietary interventions for IBD.“ Congratulations to AGA members Judy H. Cho, docrine tumors.” , director of clinical- MD,Judy and H. B.Cho, Mark MD Evers, MD, who were recently Being selected to the Academy is one of trials at Brigham and Women’s Hospital, as a elected to the National Academy of Medicine. the highest honors in the fields of health and - “highly regarded expert in the field of fecal mi- , professor of medicine at Icahn medicine and recognizes individuals who have crobiota transplantation (FMT) and microbiome School of Medicine at Mount Sinai, New York, for demonstrated outstanding professional achieve C.therapeutics, difficile establishing the therapy as an ef “establishing that uncommon, loss-of-function ment and commitment to service. fective treatment in IBD patients with recurrent variants in the microbial-sensing domain of NOD2 DavidIn addition, Rubin, MD,the 2020AGAF Sherman Prize was - .” confer risk for Crohn’s disease, and identifying a awarded to the following three AGA members: Presented by the Bruce and Cynthia Sherman- loss-of-function allele in the IL-23 receptor that , chief, section of gastroen- Charitable Foundation, the Sherman Prize is protectsB. Mark against Evers, Crohn’sMD disease and ulcerative - terology, hepatology and nutrition at University of awarded to experts in the field of Crohn’s dis colitis, leading to new, approved therapies.” Chicago Medicine, for his “renown in the IBD com ease and ulcerative colitis who have exhibited - , physician in chief of oncolo munityGary Wu,as a MDbrilliant clinician, creative researcher,- their commitment to advancing inflammatory gy service at University of Kentucky Healthcare, tireless advocate, and trailblazing educator.” bowel disease care and have [email protected] their ca for “his expertise on intestinal hormones and , professor of medicine at Uni reers to overcome these diseases. hormonal arcades in oncogenesis. His seminal versity of Pennsylvania, Perelman School of Experts release new management strategies for malignant colorectal polyps Quick Quiz E - arly identification and removal 1. Management of malignant - there was en bloc resection and - Answers of cancerous colorectal pol polyps must begin with a thorough- adequate histologic assessment, Q1. yps is critical to preventing the and knowledgeable endoscopic as the presence or absence of unfa- progression of colorectal cancer sessment designed to identify fea vorable histologic features, the RationaleCorrect answer: C and improving survival rates. The tures of deep submucosal invasion. patient’s risk for surgical mor U.S. Multisociety Task Force (U.S. - 2. In nonpedunculated lesions tality and morbidity, and patient MSTF) on Colorectal Cancer has with features of deep submucosal preferences. According to the Multi-Society released new guidance for endos invasion, endoscopic biopsy and For more information, review Task Force on Colorectal Cancer, copists on how to assess colorectal tattooing should be followed by the full publication: Endoscopic - colonoscopy should be performed lesions for features associated with surgical resection. Recognition and Management 1 year after resection, and again - cancer, discuss how these factors- 3. Nonpedunculated lesions with Strategies for Malignant Colorec 3 years later, in order to decrease guide management and outline high risk of superficial submucosal tal Polyps: Recommendations of the risk of metachronous colorec - Reference when to advise surgery after ma invasion should be considered for the US Multi-Society Task Force - tal cancer. lignant polyp removal. en bloc resection and proper spec- on Colorectal Cancer. The U.S. Kahi CJ, Boland CR, Dominitz JA. Gastroenterology. Key recommendations from imen handling. - MSTF recommendations are pub- 2016. 150(3):758-68.e11. the U.S. Multisociety Task Force 4. When pathology reports can lished jointly in Gastroenterology, Q2. on Colorectal Cancer, which is cer in a lesion that was complete The American Journal of Gastro RationaleCorrect answer: D comprised of leading experts ly resected endoscopically, the enterology, and [email protected] representing AGA, ACG and ASGE, decision to recommend surgery Endoscopy. include: is based on polyp shape, whether Deficient intake of fiber and folate- may originate in the food choice of AGA Giving Day: Our fight to eradicate the individual, whereas some defi ciencies of intake, such as thiamine, disparities in digestive diseases appear to be celiac specific. The provider should encourage intake - of nutrient-dense foods including O wholegrain foods, enriched if possi n Dec. 3, AGA brought together understand health disparities and tive health care delivery. - ble, legumes, fruits, vegetables, lean- the GI community in an effort create strategies for overcoming - The AGA Research Foundation’s meat, fish, chicken, and eggs. It is - to fund health disparity research them. AGA Giving Day effort help sup - not necessary to prioritize micro with the goal of improving care for AGA Giving Day was the oppor- port state-of-the-art research that- nutrient supplements over achiev the patients who rely on us. tunity to do something about this aligns with the realities of the cur ing nutritional adequacy through We’re so proud of how AGA important societal issue as it di rent multicultural patient popula dietary intake. Iron deficiency is an members stepped up to make this rectly relates to our field. We all- tion and disease states to achieve- effectReference of untreated celiac disease. campaign a success. With money have a role to play in creating a health equity for all. raised through AGA Giving Day, just world free of health dispari- Learn more at gastro.org/[email protected] Shepherd SJ, Gibson PR. J Human Nutr Dietet. the AGA Research Foundation will ties in digestive diseases and free givingday. 2012;26:349-58. fundMDedge.com/gihepnews research projects that help / December of inequities 2020 in access and effec 19

08_18_19_GIH20_12.indd 19 11/20/2020 3:44:25 PM GIHEP_24.indd 1 11/13/2020 8:23:45 AM †LIVER DISEASE Cirrhosis, Child-Pugh score predict ERCP complications

BY WILL PASS caused by ERCP, and mortality from other caus- other while evaluating outcomes of any surgery MDedge News es. Patients with cirrhosis were further analyzed in patients with cirrhosis.” based on etiology of cirrhosis, Child-Pugh class, In 2017, Udayakumar Navaneethan, MD, a gas- irrhosis may increase the risk of compli- and MELD score. troenterologist at AdventHealth Orlando’s Center cations from endoscopic retrograde chol- The analysis revealed that complications were for Interventional Endoscopy, and an assistant Cangiopancreatography (ERCP), according - professor at the University of Central Florida, to a retrospective study involving almost 700 rhosis than in those without cirrhosis (21.30% Orlando, and colleagues published a national patients. significantlyvs. 13.51%; P more common in patients with cir database study concerning the safety of ERCP in The study also showed that Child-Pugh class patients with liver cirrhosis (Endosc Int Open. was a better predictor of risk than Model for with cirrhosis =than .015). in thoseNo specific without complications cirrhosis. 2017 Apr;5[4]:E303-14). End-Stage Liver Disease (MELD) score, reported wereIn patients significantly with morecirrhosis, common 41.18% in patients of Child- “[The present] study is important as it high- lead author Michelle Bernshteyn, MD, a third- Pugh class C patients had complications, com- lights the fact that ERCP is associated with year internal medicine resident at State Univer- pared with 15.15% of class B patients and sity of New York, Syracuse, and colleagues. 19.30% of class A patients (P = .010). In con- compared to those without cirrhosis,” Dr. Na- “There remains a scarcity in the literature - vaneethansignificant saidcomplications when asked in cirrhoticto comment. patients “Also, regarding complications and adverse effects ated with adverse events. Child-Pugh score appeared to be more reliable after ERCP in cirrhotic patients, particularly trast,Further MELD analysis scores showed were not that, significantly in patients associ with- than MELD score in predicting complications of those incorporating Child-Pugh class and MELD out cirrhosis, diagnostic-only ERCP and underly- ERCP in cirrhotic patients.” score or type of intervention as predictors,” Dr. ing chronic obstructive pulmonary disease were He went on to explain relevance for practicing Bernshteyn said during a virtual presentation associated with high rates of complications (P = clinicians. “The clinical implications of the study at the American College of Gastroenterology .039 and P = .003, respectively). In patients with annual meeting. “Furthermore, literature review cirrhosis, underlying chronic obstructive pulmo- to be done with patients with liver cirrhosis, demonstrates inconsistency among results.” nary disease and hypertension predicted adverse particularlyare that a detailed with advanced risk-benefit liver discussion disease Child- needs To gain clarity, Dr. Bernshteyn and colleagues events (P = .009 and P = .003, respectively). Pugh class C, irrespective of the etiology,” Dr. reviewed electronic medical records from 692 Navaneethan said. “ERCP should be performed patients who underwent ERCP, of whom 174 had cirrhosis has an impact on the occurrence of cirrhosis and 518 did not. For all patients, the complications“The results duringof our studyERCP,” reaffirm Dr. Bernshteyn that liver said. outweigh the risks.” investigators analyzed demographics, comor- “Child-Pugh class seems to be more reliable as whenThe thereinvestigators is clear evidenceand Dr. Navaneethan that the benefits report- bidities, indications for ERCP, type of sedation, compared to MELD score in predicting compli- type of intervention, and complications within a cations of ERCP in cirrhosis patients,” she added. [email protected] 30-day period. Complications included bleeding, “However, we are also aware that Child-Pugh ed no conflicts of interest. pancreatitis, cholangitis, perforation, mortality and MELD scores are complementary to each SOURCE: Bernshteyn M et al. ACG 2020, Abstract S0982. Lipid profiles distinguish obese and nonobese NAFLD patients

BY HEIDI SPLETE - MDedge News cantly decreased in NASH versus NAFLhigh degree in the ofobese desaturation group, which signifi oth obese and nonobese individ- was not observed in the nonobese Buals can develop nonalcoholic group,” they noted. fatty liver disease (NAFLD), and In addition, saturated sphingo- - - tors in both groups, based on data cantly associated with visceral se n e

fromlipid profilesa cross-sectional were effective study predic of 361 c adipositymyelin (SM) in nonobesespecies were NAFLD signifi i L

individuals. s patients, but not in obese NAFLD n Given the strong association be- patients, and SM levels were sig- tween obesity and NAFLD, previous ommo C systemic and adipose tissue insulin

focused on obese White patients, reative resistance.nificantly associated with both wroteresearch Youngae on lipidomic Jung, MD, profiles of the have Ko- /C rea Basic Science Institute, Seoul, potential lipid metabolites for non- ikimedia

and colleagues. /W obeseThe subjectsresearchers and identified seven potential five n lipids for obese subjects that in- ephro

data on circulating lipidomics of N cluded DAGs, TAGs, and SMs that nonobese“However, NAFLD there patients,” are insufficient they were distinct between NAFL and added. holic steatohepatitis (NASH), and 48 obese patients with increases from NASH patients in order to predict In a study published in Alimentary controls; the obese group included NAFL to NASH, the researchers the histologic severity of NAFLD. Pharmacology and Therapeutics, the 106 patients with NAFLD, 107 with noted. Overall, these metabolite combi- NASH, and 18 controls. “Levels of DAGs with relatively nations were effective predictors with NAFLD and 66 controls. Over- short chains and a low degree of of NAFLD/NASH in nonobese and all,researchers 130 participants identified were 295 nonobese adults Lipid profiles show obese patients. The areas under (body mass index <25 kg/m2) and predictive promise in NAFL versus no NAFLD, regard- the receiver operator characteristic 231 were obese (BMI, 25 or higher). Overall, changes in diacylglycerol lessdesaturation of obesity,” significantly the researchers increased curve were 0.916 versus 0.813 for The nonobese group included 51 pa- (DAG) and triacylglycerol (TAG) said. “In contrast, levels of DAGs NAFLD versus non-NAFLD in non- tients with NAFLD, 31 with nonalco- appeared in both obese and non- with relatively long chains and a Continued on following page

MDedge.com/gihepnews / December 2020 25

25_26_27_GIH20_12.indd 25 11/20/2020 3:47:55 PM Continued from previous page patients, who were included with obese NAFLD, which are relevant to Zachary Henry, MD, of the Univer- obese patients, and 0.967 versus overweight patients in the non- precision medicine and personal- sity of Virginia, Charlottesville, said 0.812 for NAFLD versus non-NAFLD obese group. ized therapy based on various phe- in an interview. “Imaging methods in the obese patients. However, the results were notypes of NAFLD,” they concluded. such as transient elastography strengthened by the large amount and MR-elastography have been More BMI groups may - Validation needed in introduced and many biochemical yield more information - other populations markers have been evaluated, yet The key study limitation was the pertof data liver and pathologist, the confirmed they diagno added. “Liver biopsy remains the gold stan- all have their limitations. In the cross-sectional study design, the re- ses of NASH and fibrosis by an ex dard for diagnosing NAFLD/NASH current study, the authors report searchers noted. In addition, divid- new insights that aid in the un- but has its own limitations and a high diagnostic accuracy for ing patients into only two groups derstanding“Therefore, of our pathophysiological findings provide risks, so many researchers in this evaluating NAFLD using lipidomic based on BMI may not reveal any mechanisms responsible for the distinct biology among lean NAFLD development and severity of non- alternative to help with diagnosis,” new noninvasive measurement of field are looking for a noninvasive NAFLD.”profiles, which could introduce a Dr. Henry said that he was not

However, “I believe they are im- surprised by the study findings. that shows differences between Apply to be the next patientsportant as with they NASH define versus a lipid patients profile with NAFLD versus patients with- out NAFLD,” he said. “NAFLD is a disease of disordered lipid metab- Editor-in-Chief olism in hepatocytes, and although it stands to reason there would be AGA’s premier publications — Gastroenterology, Clinical Gastroenterology and Hepatology and GI & Hepatology News — interesting to see the changes be- tweendifferences DAGs in and lipid TAGs profiles, especially it is as are seeking new leadership! disease progresses from NAFLD to NASH. Learn more and “Clinically, I do not think this real- mdedge.com/gihepnews apply at gastro.org. September 2019 ly changes practice right now since DAAs reduce Volume 13 / Number 9 it needs to be validated in other mortality, cancer I N S I D E IBD AND INTESTINAL DISORDERS risk in HCV study AGA Clinical Practice populations of NAFLD. However, it Update Large study with significant results. Recommendations for switching between

maGes i BY ANDREW D. BOWSER biologics and biosimilars

etty MDedge News hepatitis C virus (HCV) in IBD. • 21 /G certainly adds to a growing arma- GI ONCOLOGY A group of internists is alleging that the board is monopolizing the irect-acting antivirals MOC market. infection treated at 1 of CRC diagnosis ompilation France (

C delayed or missed in Drisk of hepatocellular 32There hepatology were no centers signs ofin). significantly decrease - patients under 50 in persons with hepatitis NCT01953458 mentarium of noninvasive testing. Class-action suit filed According to survey, carcinoma and mortality treatmentincreased withrisk ofDAAs, hepato pro- young patients were - cellular carcinoma during- often misdiagnosed. against ABIM over MOC C, according to results of futing earlier, single-center • 22 the first prospective, lon viding more evidence re LIVER DISEASE BY ALICIA GALLEGOS gitudinal study to evaluate Women with cirrhosis Hopefully, we are able to combine thethe infection. effect of the drugs on MDedge News reports that had suggested survive hospitalization complications related to an increased incidence - more often than men group of internists is tiff-physicians are asking- a terbalanceearly after atreatment. recent Co- Studying reasons will suing the American judge to find ABIM in viola cutCompared risk of hepatocellu- with no These findings also coun help treatment. treatment, DAA therapy • A tion of federal antitrust law - 23 some of these noninvasive tests in PRACTICE and to bar the board from chrane review that could lar carcinoma by about MANAGEMENT Board of Internal- tioncontinuing on behalf its of MOC all internistsprocess. not confirm or reject a po - one-third and all-cause Why Pharma can’t Medicine over its main The suit is filed as a class ac tential benefit of drugs on tenance of certification mortality by about half -in long-term morbidity and lower prices the study, which includ Report from the Senate (MOC) process, alleging - and subspecialists required patients with chronic mortality. the future to better predict NAFLD that the board is monopo ed about 10,000 adult Lancet, Finance Committee cations.by ABIM The to purchaseplaintiffs seekMOC- to Results of the study, lizing the MOC market. See DAAs hearing. maintain their ABIM certifi published in the · page 23 • The lawsuit, filed Dec. 6, 25 - Distinct features found in young-onset CRC PUB20-020 2018, in Pennsylvania district damages and injunctive re pricescourt, forclaims maintaining that ABIM cer- is lief, plus lawsuit and attorney BY ANDREW D. BOWSER charging inflated monopoly and NASH as well as outcomes such costs statementarising from ABIM’s MDedge News - alleged antitrust violations. tification, that the organi In a oung-onset colorectal review that included more zation is forcing physicians , ABIM expressed disappointment Y than 36,000 patients. Conversely, those younger to purchase MOC, and that at the lawsuit and said the - CRC patients younger ABIM is inducing employers cancer (CRC) has dis patients were less likely to as cirrhosis and hepatocellular car- organization will vigorously than 50 years of age were and others to require ABIM tinct clinical and molecular have BRAF V600 mutations - defend itself, adding that more likely to have distal - certification. The four plain See - features, compared with than were patients 50 years - doing so will “consumeABIMe ·31 pag re primary tumors, synchro disease diagnosed later in- Cancer.old and older, the investiga nous metastatic disease, - tors reported in the journal life, according to investi and microsatellite instabil gators who conducted a ity (MSI) than were older cinoma,” he said. Very youngSee patients were

patients, investigators said. more likely toDistinct havee signet- ·22 pag

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10255 W Higgins Road, Higgins W 10255 May 18 & 19, 2019 / San Diego, California GI & Hepatology News Hepatology & GI Register now at pgcourse.gastro.org. need to be validated in non-Korean EDU9-14 populations“I think these of patients lipidomic with profiles NAFLD to determine if these changes are ubiquitous to everyone or if a dif- - ferent genetics and environment,” Dr.ferent Henry profile added. exists “As based the authors upon dif note in their paper, there have been previously published differences Finding the right between populations of NAFLD in Asia as compared to Western coun- Job Alerts

Gastroenterology Physician tries and it is unclear how, if at all, San Francisco, California Full Time job or candidate is those differences.” Nurse Practitioner theseThe lipidomicstudy was profiles funded relateby the to Washington, D.C. Part Time at your fingertips Korea Basic Science Institute, the Korea Health Industry Department Pediatric Gastroenterologist Billings, Montana Institute, and the National Research Full Time New Grad Your career hub across all Foundation of Korea. The research- disciplines and specialties in GI. ers had no financial conflicts to Start your search today at disclose. Dr. Henry [email protected] no financial conflicts to disclose. GICareerSearch.com. SOURCE: Jung Y et al. Aliment Pharma- COM19-024 col Ther. 2020 Sep 6. doi: 10.1111/ apt.16066.

26 December 2020 / GI & Hepatology News

25_26_27_GIH20_12.indd 26 11/20/2020 3:47:57 PM †LIVER DISEASE Semaglutide shows promise in NASH phase 2 study

BY KATE JOHNSON P MDedge News - 6.87; < .001 for the highest semaglutide dose). - served in patients with type 2 diabetes in other lmost 60% of patients with biopsy-con- However, the treatment did not lead to significant trials and with the known effects of GLP-1 re between-group differences in the secondary end ceptor agonists,” with gastrointestinal disorders- A point, which occurred in 43%P of patients on the being the most commonly reported. firmed nonalcoholic steatohepatitis and highest semaglutide dose compared to 33% in the Nausea, constipation, and vomiting were re liver fibrosis showed resolution of NASH - placebo group (OR, 1.42; = .48). ported more often in the 0.4-mg semaglutide - after treatment with semaglutide, according to a Treatment with semaglutide also resulted in - group than in the placebo group (nausea, 42% phase 2, double-blind,. randomized, placebo-con dose-dependent reductions in body weight, as vs. 11%; constipation, 22% vs. 12%; and vomit trolled trial published in the New England Journal- well as in glycated hemoglo ing, 15% vs. 2%). - of Medicine - bin levels. Body weight was The overall incidence of benign, malignant, or “This bodes well for further study of sema reduced by a mean of 5% unspecified neoplasms was 15% in the treat glutide and is supported further by marked im in the 0.1-mg semaglutide ment groups versus 8% in the placebo group. provements in weight, glycemic control, and lipid group, followed by mean Rowen K. Zetterman, MD, who was not involved profile,” commented the study’s senior author reductions of 9% and 13% with the study, noted that “treatment of NASH is Philip N. Newsome, PhD, FRCPE, of the University- in the 0.2-mg and 0.4-mg - currently limited, and no therapies have yet been- of Birmingham (England), in an interview. groups, respectively. This approved by the Food and Drug Administration.” The highest daily dose (0.4 mg) of the glu - Dr. Zetterman compared to a mean reduc The findings are “important but not yet ex cagonlike peptide-1 (GLP-1) receptor agonist, tion of 1% in the placebo - citing,” added Dr. Zetterman, who is professor - semaglutide, which is approved for the treat group. emeritus of internal medicine and associate vice ment of type 2 diabetes, led to levels of NASH Similarly, glycated hemo chancellor for strategic planning for the Univer resolution “which are higher than any previously- globin levels among patients with type 2 diabetes sity of Nebraska Medical Center, Omaha. demonstrated,” noted Dr. Newsome. “This was - dropped by 0.63, 1.07, and 1.15 percentage points “Though reversal of liver fibrosis was not noted, also accompanied by improvement in noninva in the 0.1-mg, 0.2-mg, and 0.4-mg semaglutide the resolution of hepatic inflammation and liver cell- sive markers of liver fibrosis and also less fibro groups, respectively, compared with a drop of injury by semaglutide suggests it may be slowing sis progression, compared to placebo.” 0.01 percentage point in the placebo group. - disease progression,” said Dr. Zetterman. This “war The multicenter study, conducted at 143 sites “The fact that the percentage of patients who - rants additional studies where longer treatment in 16 countries, included 320 patients, aged 18- had an improvement in fibrosis stage was not sig with semaglutide may prove reversal of fibrosis 75 years, with or without type 2 diabetes, who nificantly higher with semaglutide than with place and/or prevention of progression to cirrhosis.” had histologic evidence of NASH and stage 1-3 bo – despite a greater benefit with respect to NASH- The study was sponsored by Novo Nordisk. Dr. liver fibrosis. resolution and dose-dependent weight loss – was Newsome reported disclosures related to Novo - They were randomized in a 3:3:3:1:1:1 ratio to unexpected, given that previous studies have sug- Nordisk during the conduct of the study, and to receive once-daily subcutaneous semaglutide at a gested that resolution of NASH and improvements- Boehringer Ingelheim, Bristol-Myers Squibb, Echo dose of 0.1, 0.2, or 0.4 mg, or placebo for 72 weeks. in activity scores for the components of nonal sens, Gilead, Pfizer, Pharmaxis, and Poxel. Several- The primary endpoint was resolution of NASH coholic fatty liver disease are associated with re of the other study authors reported receiving fees and no worsening of fibrosis, with a secondary gression of fibrosis,” wrote the authors. “However, and grants from various pharmaceutical compa endpoint being improvement of fibrosis by at the temporal association among NASH resolution, nies, including Novo Nordisk One author reported least one stage without worsening of NASH. weight loss, and improvement in fibrosis stage- is pending patents for the use of [email protected] Dr. The study found 40% of patients in the 0.1-mg not fully understood. It is possible that the current Zetterman had no relevant disclosures. semaglutide group, 36% in the 0.2-mg group, - trial was not of sufficient duration for improve SOURCE: Newsome PN et al. N Engl J Med. 2020 Nov 13. and 59% in the 0.4-mg group achieved NASH ments in fibrosis stage to become apparent.” - doi: 10.1056/NEJMoa2028395. resolution with no worsening of fibrosis, com The authors also noted that the safety profile pared with 17% of the placebo group (odds ratio, of semaglutide was “consistent with that ob GLIMMER of hope for itch in primary biliary cholangitis

BY EMILY WILLINGHAM - social and emotional quality of life, determine the mean worst daily itch. During the subsequent 4 weeks of P Dr. Levy reported at the Liver Meet. The primary study endpoint was- placebo, after treatment ended, the atients with primary biliary ing, where she presented findings- the change in worst daily itch from itch relief faded in all groups. cholangitis (PBC) experienced from the phase 2 GLIMMER trial baseline after 12 weeks of treat Scores on the PBC-40 itch domain rapid improvements in itch and- After a single-blind 4-week pla ment. Participants whose self-rated improved significantly in every quality of life after treatment with cebo run-in period for patients itch improved by 2 points on the group, including placebo. However,- linerixibat in a randomized, pla with itch scores of at least 4 on a 10-point scale were considered to only those in the twice-dailyP 40-mg cebo-controlled trial of the safety, 10-point rating scale, those with have had a response to the drug. group saw significantP improve efficacy, and tolerability of the - itch scores of at least 3 were then Participants also completed the ments on the social ( = .0016) and- small-molecule drug. randomly assigned to one of five PBC-40, an instrument to measure emotional ( = .0025) domains. - Moderate to severe pruritus “af- treatment regimens – once-daily quality of life in patients with PBC, Linerixibat is an ileal sodium-de fects patients’ quality of life and is linerixibat at doses of 20 mg, 90 answering questions about itch and pendent bile acid transporter in a huge burden for them,” said in mg, or 180 mg, or twice-daily doses social and emotional status. hibitor, so the gut has to deal with vestigator Cynthia Levy, MD, AGAF of 40 mg or 90 mg – or to placebo. Reductions in worst daily itch the excess bile acid fallout, but the from the University of Miami Health After 12 weeks of treatment, all - from baseline to 12 weeks were diarrhea is likely manageable with System. 147 participants once again received steepest in the 40-mg twice-daily antidiarrheals, said Dr. Levy. With a twice-daily mid-range dose- placebo for 4 weeks. During the tri group, at 2.86 points, and in the A versionDr. Levy of disclosed this article support originally from of the drug for 12 weeks, patients al, participants recorded itch levels 90-mg twice-daily group, at 2.25 appearedGlaxoSmithKline. on Medscape.com. with moderate to severe itch report twice daily. The worst of these daily points. In the placebo group, the edMDedge.com/gihepnews significantly less itch and better / December scores 2020 was averaged every 7 days to mean decrease was 1.73 points. 27

25_26_27_GIH20_12.indd 27 11/20/2020 3:47:58 PM †IBD AND INTESTINAL DISORDERS Black patients found less likely to undergo eradication testing after H. pylori treatment

BY WILL PASS said. “There remains a disappointingly low num- hanges

MDedge News c

o

N Across the entire study period, patients were

3.0/ ber of patients who are tested for cure.”

to receive eradication testing after treatment SA testing if they were treated in the gastroenterology

lackfor Helicobacter patients may pylori be significantly infection than less patients likely BY- significantly more likely to undergo eradication

B /CC of other races/ethnic groups, based on a retrospec- tive analysis of more than 1,700 individuals. medicine,department and (52.4%), other departments compared with (P < rates .001). ranging ommons

This disparity may exacerbate the already in- C fromAcross 33% all to departments, 34.6% for internal Black medicine, patients under- family creased burden of H. pylori infection and gastric

cancer among Black individuals, according to ikimedia than patients of other races/ethnicities, at a rate principal author David A. Leiman, MD, MSHP, of /W ofwent 30.5% eradication versus 32.2% testing for significantly White patients, less often 35.1% atho

Duke University Medical Center in Durham, N.C. P for Asian patients, and 36.7% for patients who “H. pylori infection disproportionately affects ra- were of other backgrounds (P < .001). Compared cial/ethnic minorities and those of lower socioeco- System between June 2016 and June 2018, most with White patients, Black patients were 38% less often (71%) via serum antibody test. Approximate- likely to undergo eradication testing (odds ratio, MD, PhD, of Duke University, and colleagues wrote ly two-thirds of those diagnosed were non-White innomic their status,” abstract Dr. presented Leiman, coauthor at the annual Julius meeting Wilder, (66%) and female (63%). Out of 1,711 patients, of the American College of Gastroenterology. “ACG 622 (36%) underwent eradication testing, of with0.62; a95% study confidence by Shria Kumar, interval, MD, 0.48-0.79). and colleagues guidelines recommend treatment for H. pylori whom 559 (90%) were cured. fromDr. Leimanearlier this noted year, that which these found findings no racial contrast dis- - Despite publication of the ACG H. pylori guideline parity in eradication testing within a Veterans herence to these recommendations varies and its midway through the study (February 2017), test- Health Affairs cohort. infectionimpact on followed practice by patterns confirmation is unclear. of cure. This Adstudy - characterizes the management of H. pylori infection P < dergo testing for eradication than [patients of oth- .0001).ing rates dropped significantly from 43.1% in 2016 “Black patients are significantly less likely to un The investigators analyzed electronic medical to 35.9% in 2017, and finally 25.5% in 2018 ( is needed to understand the mechanisms driving andrecords predictors from 1,711 of guideline patients adherence.” diagnosed with H. py- er races/ethnicities],” Dr. Leiman said. “More work lori infection through the Duke University Health cure“These in patients findings treated are consistent for H. pylori with other work Continued on page 30 that has shown low rates of testing to confirm this disparity.” He suggested a number of possible ,” Dr. Leiman rare adopt the United States’ sed- Address disparities in care entary lifestyle and Western diet AGA Resource Minorities from page 1 (low in fruits and vegetables; high in AGA applauds researchers who - are working to raise our aware- known to worsen outcomes. Com- other studies, race and ethnicity did ars, and processed foods), their gut ness of health disparities in pared with Whites, for example, not affect patterns of medication use, microbiomeproinflammatory shifts saturated and their fats, IBD sugrisk digestive diseases. AGA is com- Black patients with Crohn’s disease surgery, or surgical outcomes if pa- increases markedly. Studies in other mitted to addressing this import- have higher rates of stricture and tients had similar access to care. Such countries have produced similar ant societal issue head on. Learn penetrating lesions and are at greater more about AGA’s commitment risk for postsurgical complications of minority races and ethnicities have not help write the review article. through the AGA Equity Project. and death, even after potential con- accessfindings to “indicate appropriate that specialty when patients care findings,She also said noted Dr. Charabaty,that patients who from did founders such as age, sex, smoking and IBD-related therapy, many pre- communities with a historically status, time to operation, and obesity - low prevalence of IBD may not un- and their symptoms tend to be min- are controlled for. To help close these derstand its chronicity or the need imized. There is a lot of unconscious gaps, Dr. Barnes and his associates viouslyHowever, identified race and disparities ethnicity are do re for long-term treatment. However, bias among providers that factors recommended enhanced recovery affectsolved some or reduced,” aspects theof IBD experts disease said. treatment adherence is a common into this. The barriers are multiple, after surgery (ERAS) protocols, which activity, genetics, and treatment safe- issue for patients of all backgrounds “streamline [the] multidisciplinary with IBD, she said. “What is unique management of patients with IBD have made up the vast majority of re- is barriers to continuity of care – not atand the it levelis important of the patient, to define the them clini- before surgery, incorporating evi- searchty and efficacy.participants, Since studies White patientsof racial being able to get to the treatment and find strategies to overcome them dence-based practices focused on and ethnic minorities are needed to center, not being able to afford treat- The Crohn’s and Colitis Founda- nutrition, prevention of postoperative improve their IBD diagnosis, preven- ment or take time off work if you tioncian, supportedand the health the system.”work. Dr. Barnes ileus, and use of nonopioid analgesia tion, and treatment. Such research live paycheck to paycheck, not being disclosed ties to AbbVie, Gilead, is particularly vital because IBD able to pay someone to care for your Takeda, and Target Pharmasolu- Similar approaches also might incidence is rising three times faster tions. Two coauthors also disclosed improveand goal-directed nonsurgical fluid outcomes therapy.” in in racial and ethnic minorities than Other potential barriers to seeking relevant ties to pharmaceutical minorities with IBD, the experts said. Whites, said Aline Charabaty, MD, IBDkids treatmentwhile you includesee the culturaldoctor.” taboos companies. Dr. Charabaty disclosed In the Sinai-Helmsley Alliance for AGAF, clinical director of the gastro- against discussing lower GI symp- Research Excellence (SHARE) study, enterology division at Johns Hopkins toms or concerns that chronic dis- Janssen, Takeda, and UCB. Black patients had more complicated University in Baltimore, and director ease will harm marriage prospects, relationships with AbbVie,[email protected] Pfizer, IBD at baseline but similar clinical of the IBD Center at Sibley Memorial Dr. Charabaty said. Such challenges outcomes and patterns of medica- Hospital in Washington. only heighten the need to ascertain SOURCE: Barnes EL et al. Gastroenter- tion use as Whites when they were She explained that, when immi- IBD symptoms: “Studies show that ology. 2020 Oct 20. doi: 10.1053/j.gas- treated at academic IBD centers. In grants from countries where IBD is minorities have less follow-up care tro.2020.08.064.

28 December 2020 / GI & Hepatology News

01_09_to_17_28_31_GIH20_12.indd 28 11/20/2020 3:42:21 PM GIHEP_29.indd 1 10/21/2020 1:26:42 PM †IBD AND INTESTINAL DISORDERS Tool predicted vedolizumab nonresponse in practice

BY AMY KARON a recent study. Noting the lack of zumab during the blinded phase 3 tis who had received vedolizumab MDedge News real-world data on predictors of GEMINI 1 trial. They used this model (199 patients) or TNF antagonists response, the researchers modeled to create the clinical scoring tool, (123 patients) in routine practice mong patients with ul- data from 620 patients who received which they validated in a cohort of during the Vedolizumab for Health cerative colitis who were induction and maintenance vedoli- 322 patients with ulcerative coli- Continued on following page Atreated in routine practice, a point-based clinical scoring tool PERSPECTIVE predicted nonresponse to vedoli- zumab therapy, according to study Clinical Tool includes variables found in clinical record Gastroenterology and Hepatology. he management of moderate to severe ulcerative requires no additional tests or studies to calculate. findingsA cutoff published of 26 points online or less in was Tcolitis has become more complex because of the The value in these types of tools is to assist in early greater number of Food and Drug Adminis- biologic decision-making by providing a interval, 79%-98%) for identifying tration–approved biologic and small-mole- numeric cutoff that can be used to recom- patients93% sensitive who did (95% not confidencereach corti- cule agents currently available. With more mend one agent versus the other. Another costeroid-free remission during 26 options, practitioners are faced with the noted feature of this tool is the potential weeks of treatment and was 88% challenge of choosing the most appropriate sensitive (95% CI, 83%-92%) for agent based on disease- and patient-specif- from dose optimization because lower or identifying patients who required ic risk factors. The goals of early interven- intermediateto identify which scores patients tended may to respondbenefit colectomy, reported Parambir S. tion are to achieve steroid-free remission to dose escalation in vedolizumab partial Dulai, MBBS, of the University of Cal- with mucosal healing and the associated responders. However, because this tool ifornia, San Diego, and his associates. improvements in quality of life, reduced predominantly assists with the choice of The tool was less reliable for predict- colectomy, and lower colon cancer risks. Dr. Ha anti-TNF vs. vedolizumab, one may not be ing response to tumor necrosis factor Rather than randomly choosing among able to extrapolate these results to usteki- (TNF) antagonists, indicating that it treatment options, this study by Dulai and colleagues numab and tofacitinib positioning in ulcerative coli- offers a clinical prediction tool that helps clarify tis. Further studies are needed to determine if these Vedolizumab, an alpha-4- which option, vedolizumab versus anti–tumor necro- variables similarly affect steroid-free remission for beta-7is treatment anti-integrin specific, that they restricts noted. these agents. agent, to achieve the desired steroid-free clinical lymphocytes to the gut, can induce remissionsis factor (TNF), outcome. would In this be more tool, theylikely, included as a first-line known Christina Ha, MD, FACG, AGAF, is an associate professor corticosteroid-freethe migration of proinflammatory remissions and high-risk factors for colectomy, severe endoscopic of medicine, Inflammatory Bowel Disease Center, Ce- mucosal healing in patients with activity, and hypoalbuminemia with other vari- dars-Sinai, Los Angeles. She is on the advisory board of ulcerative colitis. In clinical practice, ables, such as prior anti-TNF exposure and disease AbbVie, Janssen, Takeda, Pfizer, Salix, and InDex Phar- 22-week rates of clinical response duration. Importantly, this information is readily maceuticals; has received grant support from Pfizer; and remission were approximate- accessible in a routine clinical record and, therefore, and has received research support from Pfizer and Lilly. ly 51% and 30%, respectively, in

Continued from page 28 Rotonya Carr, MD, of the Hospital of the Universi- contributing factors, including provider knowledge AGA Resource ty of Pennsylvania, Philadelphia, and lead author of gaps, fragmented care, and social determinants of AGA applauds researchers who are working a recent publication addressing racism and health health. to raise our awareness of health disparities “It is clear that a greater emphasis on charac- in digestive diseases. AGA is committed to of the present study add weight to a known equity terizing and addressing the social determinants of addressing this important societal issue gap.disparities Dr. Carr in is gastroenterology, also an advisory saidmember the findings for the health, including poverty, education, and location, head on. Learn more about AGA’s commit- American Gastroenterological Association Equity are needed,” Dr. Leiman said. “Although health ment through the AGA Equity Project. Project. systems are not solely responsible for the known “These data are concerning in view of the two- and ongoing observations of disparities in care, fold higher prevalence of H. pylori seropositivity - search, Atlanta, the higher rate of H. pylori infection and twofold higher incidence of gastric cancer in ed to mitigate these issues.” Such interventions in Black individuals may stem partly from genetic Black patients, compared with White patients,” wouldinterventions likely require must be broad identified participation, and implement he said, factors. “Studies have shown that African Ameri- Dr. Carr said. “These and other data support a including policy makers, health systems, and indi- cans with a higher proportion of African ancestry comprehensive approach to reduce GI dispari- vidual practitioners. have higher rates of H. pylori, suggesting a genetic ties that includes targeted education of both GI “We plan to perform a prospective mixed meth- component to this increased risk,” he said. specialists and referring providers.” ods study to contextualize which social determi- Still, Dr. Hall, who is the author of the book “Clinicians should consider H. pylori therapy an nants are associated with a decreased likelihood Patient-Centered Clinical Care for African Ameri- episode of care that spans diagnosis, treatment, of receiving appropriate eradication testing by cans, went on to emphasize appropriate H. pylori exploring barriers at patient, practitioner, and management and recognition of racial disparities the loop in that episode by ensuring eradication is health-system levels,” Dr. Leiman said. “Ultimately, in medicine. vitaland confirmation to conforming of with cure,” best Dr. practices,Leiman said. and “Closing to re- - duce patients’ long-term risks.” evidence-based intervention to circumnavigate ication of H. pylori infections represents a great The investigators disclosed relationships with we aim to leverage these findings to develop an opportunity“The ability to to improve test for, quality treat, and of life confirm through erad Exact Sciences, Guardant Health, and Phathom observed disparities in H. pylori care.” decreased gastritis, gastric ulcers, and gastric Pharmaceuticals. Dr. Hall and Dr. Carr reported no thoseAccording identified to Gregory barriers, L. therebyHall, MD, eliminating of Northeast the Ohio Medical University, Rootstown, and Case yet another disparity in our clinical care of Afri- [email protected] Western Reserve University, Cleveland, and co- cancancer,” Americans he said. that “[The needs present increased findings] awareness show relevant conflicts of interest. director of the Partnership for Urban Health Re- among providers to these communities.” SOURCE: Reichstein J et al. ACG 2020, Abstract S1332.

30 December 2020 / GI & Hepatology News

01_09_to_17_28_31_GIH20_12.indd 30 11/20/2020 3:42:23 PM Continued from previous page

they had higher vedolizumab trough Outcomes in Inflammatory Bowel concentrations to begin with, the re- Diseases (VICTORY) study. searchers said. They called for pro- In the final multivariable model, spective validation of this finding, predictors of steroid-free remission “ideally in a randomized, controlled were TNF-antagonist naivety, at trial setting.” least a 2-year history of ulcerative The derivation and validation co- colitis, moderate rather than severe horts differed in several important endoscopy activity, and baseline al- ways. The validation cohort included bumin concentration. The resulting significantly more females, smokers, Principles clinical scoring tool included these patients with moderate endoscopic four variables and multiplied them disease, and patients who had failed by factors ranging from 0.0647 (for prior TNF-antagonist therapy. These baseline albumin concentration) to patients also had a significantly of GI for the 0.2820 (for no prior TNF-antagonist higher median albumin level and exposure). In the validation cohort, a longer history of disease. “The patients were categorized as “high lower bound of the confidence in- probability” (of response) if they terval for the [model’s] performance NP and PA scored 33 points or more on the tool reached 0.5, suggesting that model and “low probability” if they scored discrimination may not be ideal,” the 26 points or fewer. Rates of cortico- researchers said. “Further validation steroid-free remissions were sub- will therefore be needed to under- On-Demand stantially different at 32% and 12%, stand external validity on additional respectively. The tool also predicted cohorts.” responses to vedolizumab more ac- An American Gastroenterological curately than it predicted responses Association Research Scholar Award to TNF antagonists, indicating that it supported the work. Dr. Dulai report- was drug specific. ed holding a provisional patent for In the validation cohort, 46% (10 the prediction model and consulting of 22) of low- or intermediate-prob- relationships and other ties to Take- ability patients showed least a 50% da, Janssen, Pfizer, and AbbVie. His decrease in symptom activity after coinvestigators [email protected] ties to nu- their vedolizumab infusion interval merous pharmaceutical companies. was shortened to address an insuf- SOURCE: Dulai PS et al. Clin Gastroenterol ficient initial response. “However, Hepatol. 2020 Feb 13. doi: 10.1016/j. none of the high-probability patients cgh.2020.02.010. showed a clinical response to inter- val shortening,” probably because Life expectancy gap persists for IBD patients BY HEIDI SPLETE MDedge News people without IBD in 2011. Expert guidance on GI care: Overall, life expectancy for IBD L patients increased from 75.5 years to ife expectancy increased for adults 78.4 years for women and from 72.2 Become empowered with stronger with inflammatory bowel disease years to 75.5 years for men between diagnostic and therapeutic skills. (IBD) over recent decades, but still 1996 and 2011. However, health-ad- remained lower than that for individ- justed life expectancy, defined as the Learn the latest techniques from GIs uals without IBD, according to data number of years a person is expected from a retrospective cohort study us- to live in full health, decreased by and APPs leading patient care teams. ing Canadian health databases. 3.9 years for men with IBD between M. Ellen Kuenzig, PhD, of the Chil- 1996 and 2008, but did not change Enhance your value to your team dren’s Hospital of Eastern Ontario significantly for women with IBD. and patients. and colleagues said, “Most studies The study was supported by the In- evaluating mortality were con- stitute for Clinical Evaluative Services Earn 15.25 CME where you want and ducted before the biologic era, and (Canada). Lead author Dr. Kuenzig none evaluated life expectancy or received a Post-Doctoral Fellowship when you want. health-adjusted life expectancy.” Award from the Canadian Institutes In a study published in the Cana- of Health Research, Canadian As- Purchase today at dian Medical Association Journal, sociation of Gastroenterology, and the researchers used Canadian data- Crohn’s and Colitis [email protected] The re- nppa.gastro.org. bases to identify a study population searchers had no conflicts.

of 32,818 people with IBD matched SOURCE: Kuenzig ME et al. CMAJ. 2020 Nov EDU20-080 to 163,284 people without IBD in 9. doi: 10.1503/cmaj.190976. 1996 that increased to 83,672 peo- pleMDedge.com/gihepnews with IBD matched to 418,360 / December 2020 31

01_09_to_17_28_31_GIH20_12.indd 31 11/20/2020 3:42:32 PM †OBESITY ‘Disordered eating’ drops after bariatric surgery in teens

BY MARLENE BUSKO sistent severe obesity are at high al takeaway for clinicians is that unplanned and repetitious way be- risk for poor health and well-being,” “disordered eating is associated tween meals and snacks), objective mong young patients with Dr. Decker said in an interview. with other mental health problems overeating (eating a “large” amount severe obesity and disor- “This means disordered eating and self-worth. Clinicians treating of food without loss of control), Adered eating behaviors – behaviors should be closely mon- obesity must address problems re- and objective binge eating (eating a continuous eating, overeating, and itored” in all such patients, both lated to eating disorders to improve “large” amount of food with loss of binge eating – those who had bar- those who undergo surgery and outcomes and well-being,” she control). iatric surgery saw an improvement those who don’t, she stressed. stressed. At baseline, rates of continuous in the eating behaviors. eating, overeating, and binge eating Kristina M. Decker, PhD, a post- Robust findings are due to Effects of bariatric surgery were higher in the surgical group doctoral fellow at Cincinnati Chil- long follow-up and controls impact on overeating, binge (50%, 40%, and 30%, respectively) dren’s Hospital Medical Center, eating, in teens questioned than the nonsurgical group (40%, based on adult bariatric literature, “For teens with severe obesity, 22%, and 11%, respectively). virtual ObesityWeek 2020. butThe arefindings “novel are because not unexpected, of the age metabolic and bariatric surgery is Six years later, when participants presentedDr. Decker these and findings associates during exam- the of the patients,” senior author the most effective treatment for were aged 19-24 years, rates of ined rates of disordered eating in Margaret H. Zeller, PhD, Cincinnati improved cardiometabolic function- continuous eating, overeating, and more than 200 adolescents (aged Children’s Hospital Medical Center binge eating had declined in the 13-18 years) who were severely and professor at the University of surgical group (to 17%, 5%, and obese, of whom 141 underwent Cincinnati, added. However, an important additional 1%, respectively). In the nonsurgi- bariatric surgery and the remainder In a comment, psychologist Kajsa takeaway for clinicians is that cal group, only continuous eating did not. Järvholm, PhD, of the Childhood and overeating declined (to 24% At baseline (presurgery), the teens Obesity Unit at Skåne University ‘disordered eating is associated and 7%, respectively), and binge in both groups had rates of disor- with other mental health eating increased slightly (to 13%). dered eating ranging from 11% to published related work, said that 50%, with higher rates in those who thisHospital, is “a neededMalmö̈, study.”Sweden, who has problems and self-worth.’ Disordered eating associated went on to have bariatric surgery. Notably, it had “long-term fol- with low self-worth, Six years later, rates of disordered low-up and a control group,” and it anxiety, and depression eating were much lower in those ing, weight loss, and improved qual- In young adulthood in both groups, who had bariatric surgery. better control of their eating after ity of life,” Dr. Decker stressed. disordered eating was associated The data nevertheless “under- surgery.”“confirms that adolescents are in However, pre- and postsurgical with lower self-worth. In the sur- score that young adults with per- However, an important addition- disordered eating behaviors have gical group, it was also associated been associated with a lower per- with lower weight-related quality centage change in body mass index, of life, and in the nonsurgical group, although this has not been well it was also associated with anxiety studied. and/or depression. To investigate how disordered eat- ing is affected by bariatric surgery us whether disordered eating is a in adolescents with severe obesity, direct“The result current or findingscaused by cannot anxiety, tell ® researchers used data from Teen- depression, low self-worth, or poor CROHN’S & COLITIS CONGRESS LABS, which enrolled 242 partici- quality of life,” Dr. Decker said. Connecting Virtually | January 21–24, 2021 pants aged 19 years and under who mainly underwent Roux-en-Y gastric about what other areas of clinical bypass (67%) or sleeve gastrectomy concern“These might findings present do give together us insight [in] - young adults (e.g., disordered eat- olescent bariatric surgery centers. ing, low self-esteem).” (28%)The currentfrom 2007 analysis to 2012 examined at five ad Bariatric surgery affects the TRANSFORMING IBD CARE data from 141 participants in Teen- amount of food people can eat at LABS who underwent bariatric one time, she noted in reply to Get inspired to transform IBD care at the premier surgery at a mean age of 16.8 years. a question from the audience. If conference for IBD clinicians and researchers. Mean BMI was 51.5, most were girls people eat too much at a time they In 2021, the Crohn’s & Colitis Congress® goes virtual. You’ll (80%), and they had diverse race/ can experience vomiting, dump- get all the benefits and quality programming you have ethnicity (66% were White). ing syndrome (where certain food come to expect from the Crohn’s & Colitis Foundation and is “dumped” into the small intestine AGA — all from the safety of your home or office. There will control group of 83 adolescents of without being digested, causing also be new and exciting ways to network with fellow IBD a similarResearchers age and also gender identified who ahad nausea and vomiting), and plugging leaders, learn best practices, hear what’s on the horizon in diverse race/ethnicity (54% White) (a sense of food becoming stuck). potential treatments and receive practical takeaways you’ll and a mean BMI of 46.9. The home environment and tran- be able to implement immediately. At year 6, data were available for sition to adulthood might impact 123 young adults in the surgery disordered eating in young adults, group (who by then had a mean she said in reply to another ques- #CCCongress21 BMI of 39.7) and 63 young adults in tion, but these issues were not ex- the nonsurgery group (who had a amined in this study. REGISTER TODAY. mean BMI of 52.6). www.crohnscolitiscongress.org At baseline and year 6, partici- disclosures for Dr. Decker or Dr. pants replied to questionnaires that Järvholm.There are no relevant financial A version of this article originally continuous eating (eating in an appeared on Medscape.com. identified three eating disorders: 32 December 2020 / GI & Hepatology News

32_to_35_GIH20_12.indd 32 11/24/2020 9:24:14 AM †UPPER GI TRACT Antibody promising in eosinophilic gastritis/duodenitis

BY JIM KLING somewhat of a disconnect between with active, uncontrolled eosinophilic age change in total symptom score MDedge News symptom reduction and reduction gastritis or duodenitis, or both, to re- was –48 versus –22 in the placebo of the eosinophil counts. Sometimes ceive four monthly low- (0.3, 1, 1, and group (P = .004). In the per-protocol n a phase 2 trial in eosinophilic 1 mg/kg) or high-dose lirentelimab analysis, 69% responded versus 5% gastritis and duodenitis, an anti– enough]. Maybe there is other dam- (0.3, 1, 3, and 3 mg/kg), or placebo. A (P < .001). The mean percentage ISiglec-8 antibody greatly reduced agejust toblocking the bowel.” the inflammation [isn’t total of 10 patients had gastritis, 25 change in total symptom score was numbers of eosinophilic cells and led The research, led by Evan S. Dellon, had duodenitis, and 30 had both. –53 versus –24 (P = .001). to improved symptoms. The spon- MD, MPH, of the University of North In the intention-to-treat analysis, About 60% in the treatment group soring company, Alkalos, is currently Carolina at Chapel Hill, and Ikuo Hi- there was a mean 86% reduction in had an infusion-related reaction ver- conducting a phase 3 trial in eosino- rano, MD, of Northwestern University, eosinophil count in patients in the sus 23% who received placebo; 93% philic gastritis or duodenitis. Chicago, appeared in the New En- treatment groups, compared with a of reactions were mild to moderate. The news is welcome to clinicians gland Journal of Medicine. 9% increase in controls (P < .001). In Serious adverse events occurred in who treat these rare conditions, since The antibody (lirentelimab) targets the per-protocol analysis, there was a 9% of the treatment group and 14% the only current treatment is ste- sialic acid–binding immunoglobulin-­ 95% reduction vs. a 10% increase (P of patients on placebo: 86% of pa- roids. This is particularly challenging like lectin 8 (Siglec-8), which is an < .001). Of treated patients, 95% had tients in the treatment group experi- because most patients with these inhibitory receptor found on mature a gastrointestinal eosinophil count enced transient lymphopenia, as did conditions present in their 30s and eosinophils and mast cells, and ex- 47% of the placebo group, but there 40s, according to Carol Semrad, MD, pressed at low levels on basophils. compared with 0% with placebo. were no clinical consequences. professor of medicine at the Universi- The antibody reduces eosinophil cells of In6 orthe fewer intention-to-treat per high-powered analysis, field, The study was funded by Alkalos. ty of Chicago, who was asked to com- through natural killer cell–mediated 63% of treated patients had a treat- ment on the study. She noted that the cellular cytotoxicity and apoptosis, disclosures. study’s results were impressive, but and other antibodies against the same a 30% reduction in total symptom Dr. Semrad has no [email protected] financial it will take a phase 3 trial to convince. target have been shown to inhibit scorement response,and at least defined a 75% as reduction at least mast cell activation. in eosinophil count. About 5% of pa- SOURCE: Dellon ES et al. N Engl J tracks with the impressive reduction At 22 sites across the United States, tients had a response in the placebo Med. 2020 Oct 22. doi: 10.1056/NEJ- seenIt’s also in eosinophilunclear if the count. clinical “There’s benefit researchers randomized 65 adults group (P < .001). The mean percent- Moa2012047. CLASSIFIEDS Also available at MedJobNetwork.com

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32_to_35_GIH20_12.indd 33 11/20/2020 3:50:28 PM †PRACTICE MANAGEMENT TOOLBOX Value-based care stunted from delayed Stark, anti-kickback reform BY JOSEPH LOSURDO, MD, AGAF pany model frameworks necessarily violate the implement MACRA law as Congress intended. AKSs and the OIG’s Advisor Opinions FAQ states AGA and the physician community have nti-kickback statutes (AKSs) were orig- no person or entity can rely on an advisory opin- long sought to update Stark self-referral and inally enacted in 1931 to stop Great ion issued to someone else. However, Advisory AKSs. Last year, Centers for Medicare & Med- ADepression–era employers from circum- Opinion No. 12-06 has been cited in AKS investi- icaid Services proposed exceptions directed venting wage provisions in federal contracts. gations ever since. at value-based arrangements that would have Since its enactment, AKSs’ main focus has When Congress passed the Medicare Access allowed providers to participate in value-based changed and is currently aimed at the health and CHIP Reauthorization Act (MACRA) in 2015, arrangements while still protecting the Medicare care industry. In addition to AKSs, Stark laws it changed how physicians would be paid under program from potential abuses. Many of the were enacted over 30 years ago to address Medicare and sought to transition physicians to changes that CMS proposed would have allowed physician self-referral of physician practices to engage in value-based ar- Medicare patients. Both laws S. 2051/H.R. 4206, the Medicare Care rangements that would improve patient care and comprise the government’s AGA provided comments on both the Stark and Coordination Improvement Act, would AKS proposed rules. However, CMS has not yet waste, and abuse. However, allow innovative payment models AKSsmain toolsand Stark for fighting laws have fraud, not developed by gastroenterologists to be been updated to keep pace opportunityissued the final to improverules and health has indicated care delivery. that they with changes in how medical implemented in the Medicare program. willOn not the issue legislative a final front, rule on AGA Stark supports which S. is a lost practices do business and Unfortunately, this legislation has 2051/H.R. 4206, the Medicare Care Coordina- care for patients. tion Improvement Act, which would provide Over the years, additional Dr. Losurdo received little traction in Congress. CMS with the regulatory authority to create - exceptions under the Stark law for APMs and to cation has been issued by the Department of a more value-based payment system. Physicians remove barriers in the current law to the devel- interpretation and clarifi - were incentivized to develop physician-driven opment and operation of such arrangements. spector General. In HHS’s June 1, 2012, Advisory - OpinionHealth & No. Human 12-06, Services there is and guidance the Office regarding of In tient outcomes. However, existing Stark self-re- Stark laws for physicians seeking to develop and legality of anesthesia services providers’ con- paymentferral laws models prohibit to improvephysicians efficiency from referring and pa operateThe legislation APMs similar would toallow what CMS Congress to waive allowed the tract with physician-owned professional corpo- - rations or limited liability companies to provide cial interest. As a result, physician practices are payment models developed by gastroenterol- unablepatients to to participate an entity in in which many theyadvanced have alterna-a finan ogistsfor ACOs. to be The implemented legislation would in the allowMedicare innovative pro- the “company model” where owners of an am- tive payment models. gram. Unfortunately, this legislation has received bulatoryanesthesia surgery services. center Specifically, (ASC) create it focused a separate on Stark laws, which have not been updated since little traction in Congress. company for anesthesia services which directly their enactment 30 years ago, pose barriers to Until meaningful regulatory and legislative contracts with anesthesia providers and charges care coordination since they prohibit payment reform updating both Stark and AKSs occur, for the anesthesia services while the ASC arrangements that consider volume or value innovative payment models must wait and gas- charges for facility fees. of referrals or other business generated by the troenterologists and other providers will remain vulnerable to these outdated regulations. You an advisory opinion from the OIG about the in delivering care by inhibiting practices from can help us advance these issues by sharing how applicationAnyone with of OIG’s specific fraud questions and abuse may authorities request incentivizingparties. These their prohibitions physicians stifle to deliverinnovations patient and existing or proposed business arrange- value-based arrangements you would participate ments. An OIG advisory opinion is legally bind- cannot use resources from designated health inthey and impact how would your practice. they improve Tell us patient what types care andof servicescare more in efficiently,rewarding because or penalizing the practices adherence to any other governmental department or agency. new clinical care pathways. ing on the requesting party and HHS, but not on- Congress recognized that the Stark law was a Dr.efficacy Losurdo at [email protected]. is the AGA’s Alternate Advisor to the barrier to new health care delivery models. Con- American Medical Association’s CPT Editorial opinionWhile advisory may not opinions be relied are on specific by any personsto the enti gress, therefore, authorized the HHS Secretary to Panel, a member of the AGA Practice Management ty that requested it and specifically states, “This waive Stark self-referral and anti-kickback laws for and Economics Committee’s Coverage and Reim- this opinion. ...” - bursement Subcommittee and is a partner with otherIt captured than [name the attention redacted], of thethe requestormedical com- of er was not extended to physician-driven alterna- Elgin Gastro Endoscopy, who owns an ASC, and tiveaccountable payment care models organizations (APMs), that (ACOs). also need This thesewaiv Managing Partner and Medical Director of Illinois should not be interpreted to mean that all com- exceptions to drive innovation in health care and to Gastroenterology Group/GI Alliance, Elgin, Ill. munity. The AGA has argued that this opinion †COVID-19 ROUNDUP Obesity increases pneumonia risk, mutation ups contagiousness

BY LUCAS FRANKI - younger than 50 years after other Common mutation making MDedge News lation increased in patients with factors were adjusted for. SARS-CoV-2 more contagious obesity,and requiring independent mechanical of age, venti sex, di- However, the study also found While there was a wide variety of After age and male sex, abetes, hypertension, dyslipidemia, an “obesity paradox” for mortality SARS-CoV-2 strains early in the obesity biggest risk for and smoking. after admission to the ICU, where pandemic, 99.9% of circulating COVID-19 pneumonia For each 5-kg/m2 increase in patients with a BMI of 25-39.9 had SARS-CoV-2 strains in the study In a large international study pub- body mass index, there was a 27% a lower risk of death than those feature the D614G mutation on the increased risk of mechanical ven- with a BMI of less than 25, although spike protein, which is associated at ObesityWeek 2020, the likelihood tilation in the overall cohort and patients with a BMI over 40 had the with increased nasopharynx viral oflished developing in The Lancet severe andpneumonia presented a 65% increased risk in women highest mortality rate. Continued on following page

34 December 2020 / GI & Hepatology News

32_to_35_GIH20_12.indd 34 11/20/2020 3:50:29 PM Continued from previous page not patient care according to a AGA Resource The authors recognize that HCPs, loads at diagnosis. study conducted by the Minnesota For the latest clinical guidance, like the rest of the community, are The mutation likely dominates Department of Health. Nonwork education, research and experiencing COVID fatigue and because it increases the spike pro- exposures were more likely to lead physician resources about that facilities have to constantly tein’s ability to open cells for the to infection. coronavirus, visit the AGA be innovative and vigilant to help virus to enter, but the mutation is Between March and July 2020, COVID-19 Resource Center at HCPs maintain rigorous safety pre- not associated with worse clinical researchers evaluated 21,406 cas- www.gastro.org/COVID. cautions. COVID-19 severity and will likely Frontline associate editor Lucas COVID-19 cases. Franki compiled this column from any current treatment or vaccine in es“Since of HCP the exposure time period to confirmed covered in outside of work due to household reports first published on MDedge. development.not interfere with the efficacy of or social contacts,” said lead author com, Medscape.com, and Kaiser “As bad as SARS-CoV-2 is, we may increase in the proportion of HCPs Ashley Fell, MD, MPH, from the Min- Health News. have dodged a bullet in terms of whothis report, have had we’ve higher-risk seen a significant exposures nesota Department of Health. [email protected] how quickly it mutates,” said Ilya Finkelstein, PhD, of the Finkelstein Lab at the University of Texas, Aus- tin, adding that the slower mutation rate will give researchers a greater chance to stay one step ahead.

VA joins Pentagon in recruiting volunteers for COVID-19 vaccine trials Renew your - partment of Veterans Affairs and OperationAccording Warpto officials Speed, from the theVA willDe membership recruit 8,000 volunteers for phase 3 clinical trials of at least four Continue learning. COVID-19 vaccine candidates at 20 U.S. federal medical facilities. Continue growing. This announcement follows a September announcement by the Continue improving digestive Department of Defense that it has health with AGA membership to partnered with AstraZeneca to re- support your needs. facilities. Since active troops are essentialcruit volunteers to national at five security, of its medical and Renew by Dec. 1 at veterans are extremely vulnerable to COVID-19, both departments www.gastro.org/renew have a vested interest in supporting MEM20-028 the development of safe, effective vaccines, said J. Stephen Morrison, senior vice president and director of global health policy at the Center for Strategic and International Studies, a bipartisan think tank in Washington.

COVID exposure risk outside of work increasing for clinicians One-third of COVID-19 exposures With the right planning and care, women with among health care providers inflammatory bowel disease (IBD) can have (HCPs) in Minnnesota are caused healthy pregnancies and healthy babies. by family or community exposure, We help GIs provide care for them.

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