ACG MAGAZINE | Vol. 3, No. 1 | Spring 2019

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ACG MAGAZINE Spring 2019

MEMBERS. MEDICINE. MEANING.

Profiles in Courage IN The Fight Against Colorectal Cancer


Attend an upcoming

ACG POSTGRADUATE COURSE 2019 ACG’s Hepatology School & Eastern Regional Postgraduate Course  Marriott Marquis | Washington, DC  June 7–9, 2019

ACG’s IBD School & Midwest Regional Postgraduate Course  Hyatt Regency Bloomington | Minneapolis, MN  August 16–18, 2019

ACG’s Functional GI School & ACG/VGS/ODSGNA Regional Postgraduate Course  The Williamsburg Lodge | Williamsburg, VA

NEW!

Functional GI School

 September 6–8, 2019

ACG 2019 Annual Scientific Meeting and Postgraduate Course  Henry B. Gonzalez Convention Center | San Antonio, TX  October 25–30, 2019 • • • • •

Practice Management | October 25 GI Pharmacology | October 25 GI Pathophysiology | October 25 Postgraduate Course | October 26–27 Annual Scientific Meeting | October 28–30

ACG’s Hepatology School & Southern Regional Postgraduate Course  Omni Louisville | Louisville, KY  December 6-8, 2019

2020 ACG’s Functional GI School & Women in GI Course  Marriott Marquis | San Diego, CA  Jan 10-12, 2020

ACG’s IBD School & Board of Governors / ASGE Best Practices Course  The Bellagio | Las Vegas, NV  January 24-26, 2020

FOR MORE INFO, VISIT: GI.ORG/ACG-COURSE-CALENDAR


SPRING 2019 // VOLUME 3, NUMBER 1

FEATURED CONTENTS COVER STORY

PROFILES IN COURAGE IN THE FIGHT AGAINST COLORECTAL CANCER A LEAP OF FAITH How Dr. Victor Colon rebuilt in the wake of Hurricane Maria. PAGE 24

DO I INVEST?

Ann Bittinger, Esquire, on legal issues in considering endoscopy center investment. PAGE 22

MOST READ IN RED

The eye of Hurricane Maria as it descends on Puerto Rico.

The top 10 most-viewed AJG articles in 2018. PAGE 42

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A M E R I C A N

C O L L E G E

O F

G A S T R O E N T E R O L O G Y

Annual Scientific Meeting & Postgraduate Course Henry B. Gonzalez Convention Center, San Antonio, TX OCTOBER 25–30, 2019

Submit Your Abstract! The American College of Gastroenterology invites you to submit abstracts for presentation at the 2019 Annual Scientific Meeting and Postgraduate Course. Abstracts must be clinical or researchoriented, with a focus on gastroenterology or hepatology.

 SUBMISSION DATES: MARCH 11 – JUNE 10, 2019  SUBMIT YOUR ABSTRACT: CONFERENCEABSTRACTS.COM/ACG2019.HTML Visit the site to download complete instructions and start your submission.


SPRING 2019 // VOLUME 3, NUMBER 1

CONTENTS

“It was a leap of faith,” says Colon, who was uncertain patients would return to the practice. “But, somehow, I had a gut feeling that this is the way to go.” — Victor J. Colon, MD, FACG, "A Leap of Faith: Rebuilding After Hurricane Maria" PG 24

6 // MESSAGE FROM THE PRESIDENT

24 // COVER STORY

41 // INSIDE THE JOURNALS 42 AJG The top 10 most-viewed AJG articles in 2018.

Authors and awardees, in memoriams, a crosscountry walk for CRC awareness, and more.

PROFILES IN COURAGE IN THE FIGHT AGAINST COLORECTAL CANCER By Brian C. Davis The story of Dr. Victor Colon is told in "A Leap of Faith: Rebuilding After Hurricane Maria," and is followed by Blue Notes: Colorectal Cancer Awareness Highlights.

15 // PUBLIC POLICY

35 // ACG PERSPECTIVES

GOVERNORS’ VANTAGE POINT Five questions to introduce new leaders— Board of Governors Chair Dr. Neil Stollman and Vice Chair Dr. Patrick Young.

MINDFULNESS AND MEDICINE What is mindful listening? How can it help you and your patients? Scott Rogers, JD, and ACG Past President Dr. Arvey Rogers address these questions.

Dr. Sunanda Kane on what keeps her excited and gets her out of bed in the morning— knowing her why.

7 // NOVEL & NOTEWORTHY

19 // GETTING IT RIGHT 19 BUILDING SUCCESS How to set up an ambulatory infusion center in your practice by Dr. David Limauro. 22 LAW MIND Do I invest? Legal considerations in endoscopy center investment by attorney Ann Bittinger.

37 // EDUCATION

43 CTG Diagnostic and Therapeutic Long-Term EoE Management—Current Concepts and Perspectives for Steroid Use. 43 ACGCRJ Gastric Angiomyolipoma Masquerading as Gastric Malignancy.

44 // REACHING THE CECUM A LOOK BACK: PNEUMATIC DILATOR FOR ACHALASIA The evolution of pneumatic dilators since Mosher described the original version in 1923.

EDGAR ACHKAR VISITING PROFESSORS Dr. Nicholas Shaheen on the impact of the Edgar Achkar Visiting Professorship Program.

Photo Top: Dr. Victor Colon and the team at Instituto Digestivo De Puerto Rico, PSC, celebrating Dress in Blue Day on March 2, 2018. Photo courtesy of Dr. Victor Colon.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG

Executive Director Bradley C. Stillman, JD

youtube.com/ACGastroenterology

Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant Managing Editor; Senior Writer Brian C. Davis

facebook.com/AmCollegeGastro

twitter.com/amcollegegastro

instagram.com/amcollegegastro Copy Editors; Staff Writers Sarah Richman Lindsey Topp

bit.ly/ACG-Linked-In

Art Director Emily Garel Graphic Designer Antonella Iseas

BOARD OF TRUSTEES President: Sunanda V. Kane, MD, MSPH, FACG President-Elect: Mark B. Pochapin, MD, FACG Vice President: David A. Greenwald, MD, FACG Secretary: Daniel J. Pambianco, MD, FACG Treasurer: Samir A. Shah, MD, FACG Immediate Past President: Irving M. Pike, MD, FACG

CONTACT IDEAS & FEEDBACK We'd love to hear from you. Send us your ideas, stories and comments.

ACGMag@gi.org

CONTACT ACG American College of Gastroenterology 6400 Goldsboro Rd., Suite 200 Bethesda, MD 20817 (301) 263-9000 | gi.org

Past President: Carol A. Burke, MD, FACG Director, ACG Institute: Nicholas J. Shaheen, MD, MPH, FACG Co-Editors, The American Journal of Gastroenterology: Brian E. Lacy, MD, PhD, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Brennan M. R. Spiegel, MD, MSHS, FACG Chair, Board of Governors: Neil H. Stollman, MD, FACG Vice Chair, Board of Governors: Patrick E. Young, MD, FACG Trustee for Administrative Affairs: Delbert L. Chumley, MD, FACG

TRUSTEES Jean-Paul Achkar, MD, FACG William D. Chey, MD, FACG Immanuel K. H. Ho, MD, FACG Caroll D. Koscheski, MD, FACG Paul Y. Kwo, MD, FACG Jonathan A. Leighton, MD, FACG Amy S. Oxentenko, MD, FACG David T. Rubin, MD, FACG John R. Saltzman, MD, FACG Renee L. Williams, MD, MHPE, FACG

4 | GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 14,000 physician members representing some 85 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.


CONTRIBUTING WRITERS

Ann M. Bittinger, Esquire

Nicholas J. Shaheen, MD, MPH, FACG

Ms. Bittinger is health law expert at Bittinger Law Firm in Jacksonville, FL. She regularly contributes to ACG's publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups (bittingerlaw.com).

Dr. Shaheen, of the University of North Carolina, Chapel Hill, is Director of the ACG Institute for Clinical Research & Education.

Robert E. Kravetz, MD, MACG Dr. Kravetz is passionate about the history of medicine and the history of the College. He is Past Chair, ACG Archives Committee, and was instrumental in publishing the ACG 75th Anniversary history in 2007. Read about ACG’s History: gi.org/ about-acg/#Anniversary

David L. Limauro, MD, FACG

Neil H. Stollman, MD, FACG Dr. Stollman, of the East Bay Center For Digestive Health and the University of California, San Francisco, serves as Chair of the ACG Board of Governors.

Patrick E. Young, MD, FACG Dr. Young is the Director of the Division of Digestive Diseases at the Uniformed Services University of Health Sciences in Bethesda, MD. He currently serves as Vice Chair, ACG Board of Governors and chairs the ACG Membership Committee and the ACG Credentials Committee.

Dr. Limauro, of Pittsburgh Gastroenterology Associates, is a member of the ACG Practice Management Committee.

Arvey I. Rogers, MD, MACG Dr. Rogers is Past President, ACG (1991–1992) and Professor Emeritus of Internal Medicine and Gastroenterology at the University of Miami Miller School of Medicine.

Scott Rogers, JD, MA Scott Rogers directs the University of Miami School of Law’s Mindfulness in Law Program and co-directs the University’s Mindfulness Research and Practice Initiative. For more than 10 years, Professor Rogers has addressed members of the medical profession, including physicians, nurses and medical students, sharing insights and practices for integrating mindfulness practices into their lives in memorable, accessible and practical ways. He has authored numerous books, articles, chapters and peerreviewed research on mindfulness.

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MESSAGE FROM THE PRESIDEN

KNOWING MY WHY WHEN YOU KNOW YOUR WHY, YOU WILL KNOW YOUR WAY MOC, EMR and CMS, oh my! Abbreviations that have come to bring shivers to our spines and make some of us leave medicine altogether. We are living in an age where the physician burnout rate rivals the national obesity rate, both of which are directly impacting health in the United States. On top of that, there is direct patient access to medical records, now filled with subjective terms where everyone is “pleasant” and never “obese,” which in the long run is not doing any favors for the health of our patients. Speaking of patients, they have become “clients,” “customers” or “consumers,” which in my mind changes the dynamic of the relationship and makes my job harder. I need to be their doctor—not their friend—and sometimes it means saying things that are not going to sit well. Did you also know that the scoring system used by U.S. News and World Report is dropping the Safety measure and replacing it with Patient Satisfaction? So, apparently you can let your patients fall or get a line infection or C. diff, but as long as they are happy you are going to be rated highly. What is going on? No wonder we are burning out. With so much of our field in turmoil and out of our control, who can we turn to for support and guidance? Considering how the field of medicine has changed over the last 20 years, I think about what has kept me buoyant and excited and gets me out of bed in the morning. It is knowing my Why. When you know your Why, you will know your way. If you have a Why, it gives you the courage and energy you need to succeed and be happy, or at least some resilience to prevent burnout. But how did I find my Why? It wasn’t until I reflected on my professional home—the ACG— that I realized there was an entity, a resource to help me define my Why. For every step of my career and training, ACG was there for me, and continues to be to this day. It was literally in the last century when, as a fellow attending the North American Conference of Gastroenterology Fellows, I realized how impactful the ACG could be. At that meeting, I

6 | GI.ORG/ACGMAGAZINE

“Considering how the field of medicine has changed over the last 20 years, I think about what has kept me buoyant and excited and gets me out of bed in the morning. It is knowing my Why. When you know your Why, you will know your way.”

made long-lasting friends and had the chance to meet true thought leaders and experts in gastroenterology and hepatology in a small, non-threatening setting. From there I never looked back. I aligned with a society that wanted me, as a clinician interested in clinical research, to excel in the field. My first research support was a pilot grant from the ACG Institute, an entity whose existence is to help educate and promote growth in the field through funding of research proposals both large and small. As a new graduate after fellowship, I reached out and asked to be on a committee and volunteered for projects. It was through that committee work that I began to understand the importance of the structure of the ACG, which includes its Board of Governors, comprised of local gastroenterologists who at the grassroots level make changes to our everyday practice. So, I ran for Governor in a two-man race, and came in second. After licking my wounds, I figured I was meant for other tasks on behalf of the College. Being Course Co-Director of the annual Postgraduate Course gave me new insight into how it really is impactful to help our colleagues deliver the best care possible. Being on the Board of Trustees gave me a deeper appreciation for all that the College does for us, and I am grateful I had the chance to learn that. From advocacy on Capitol Hill, support of international society meetings, and selection of editorial staff for the Red Journal, the ACG is ever thoughtful in how to improve the practice and delivery of care in gastroenterology. And don’t forget, getting to go to an Annual Scientific Meeting that has NO registration fee—how rare is that? So when I am asked, “What does the ACG mean to me?” it is an easy answer. ACG for me is a place where I am welcome and is a source for all of my needs, whether professional—in terms of education, research funding or a voice on my behalf at the national level—or personal—in terms of leadership training or help with burnout. From ACG, I have received more than I could ever give.

­­—Sunanda V. Kane, MD, MSPH, FACG


Note thy wor ACG MAGAZINE is a forum for College news—a place to showcase the interests and accomplishments of ACG members, as well as notable GI news and innovation. This issue of ACG MAGAZINE includes in memoriams, recognizes authors and awardees, salutes a crosscountry walk for CRC awareness, and more. Email your professional news and any ideas for future issues of ACG MAGAZINE to ACGMag@gi.org

Novel & Noteworthy | 7


// N&N

[QUALITY]

CMS APPROVES GIQUIC AS A QCDR FOR THE 2019 REPORTING YEAR The GI Quality Improvement Consortium, Ltd. (GIQuIC) Registry has been approved as a Qualified Clinical Data Registry (QCDR) for reporting to the Merit-based Incentive Payment System (MIPS) for the 2019 reporting year. “GIQuIC’s continued ability to offer quality reporting to CMS as a benefit of participation in the registry is a strategic imperative. We have maintained QCDR status since its inception in 2014, as it is critical for

8 | GI.ORG/ACGMAGAZINE

providers to report on measures that are meaningful to their specialty practice. GIQuIC’s QCDR status allows gastroenterologists to concurrently foster improvement in the quality of care provided to patients with gastrointestinal disorders, while being in compliance with reporting requirements,” said Glenn M. Eisen, MD, MPH, President of the GIQuIC Board of Directors. The 2019 GIQuIC QCDR is approved to report for individual eligible providers, groups and virtual groups to the Quality, Promoting Interoperability and Improvement Activities performance categories. GIQuIC will host an informational webinar on reporting via the GIQuIC 2019 QCDR in Spring 2019. A recording of this webinar will be available on the GIQuIC website.

READ the press release: bit.ly/GIQUIC19QCDR, and visit the GIQuIC website: giquic.org

[AUTHORSHIP]

AMY S. OXENTENKO, MD, FACG, ACG BOARD OF TRUSTEES Dr. Oxentenko contributed to a piece for Doximity entitled, “5 Female Leaders Share Lessons They Wish They Learned in Med School.” While the co-authors mentor and sponsor many physicians, they submit that “…often our advice to them is not what we did ourselves. Why? Because when we were younger, we didn’t know what we do now.” The article offers advice in five areas— such as asking for what you deserve and strategically expanding your professional networks—and provides concrete steps to take action in these areas.

READ the article: bit.ly/Oxentenko18


[AWARENESS]

CHAD SCHRACK A walk that began on May 6, 2018, at Arlington National Cemetery in Arlington, VA, ended in late August and 2,600 miles away—in Venice Beach, CA. Chad Schrack, a FedEx freight driver and Fight Colorectal Cancer advocate, walked across the country to raise awareness for colorectal cancer and veterans suicide. Schrack derives his passion for both causes from two life experiences. His wife, Sheila, who is now cancer free, was diagnosed with colon cancer in 2006, at age 38, according to a FedEx blog post about Schrack’s “Cancer Stroll.” Additionally, a man who served in Schrack’s squad in Iraq in the early 2000s took his own life after returning from war. Along the cross-country walk, Schrack met with Congressional offices, stopped at the Fight Colorectal Cancer headquarters in Springfield, MO, raised awareness with singer Harry Connick Jr., and found common ground with a man he coincidentally met riding his bike the full length of Route 66. The common ground? The man is a bowel cancer survivor.

READ the FedEx blog post about Schrack: bit.ly/Schrack18

FOLLOW Schrack on Twitter @cancerstroll

[AWARDEES]

AYSE AYTAMAN, MD, FACG The American Liver Foundation recognized Dr. Aytaman with its Physician of the Year award at its annual ALF Honors Gala, November 27 in New York, NY. Aytaman, who is Chief of Gastroenterology & Hepatology at the VA New York Harbor Health Care System, is the first VA physician and the first woman to win the award. “I am truly humbled to be chosen as an honoree by the ALF,” Aytaman told ACG. The gala was “unbelievably touching,” she said.

The award is given annually to a physician who supports ALF’s mission, either directly or indirectly. “We are always on the lookout for individuals who go above and beyond for the treatments, care, support and education of their patients,” ALF Executive Director Veronica Perez said in an email to ACG. Perez advised that Aytaman’s peers nominated her for the award.

“Dr. Aytaman is beyond deserving of this prestigious honor,” she said. During the gala, ALF played a video which told the powerful story of the relationship between Aytaman and Harvey Lee Ware, a Vietnam veteran and a patient of hers.

WATCH the video: bit.ly/Aytaman

Novel & Noteworthy | 9


// N&N  Photo right: At the ACG Annual Scientific Meeting in 2000 in New York City, Dr. Balart presents ACG’s Distinguished Service Award to Virginia Senator Emily Couric.

[IN MEMORIAM] [IN MEMORIAM]

LUIS A. BALART, MD, MACG, NEW ORLEANS, LA ACG Past President Luis A. Balart, MD, MACG, a transplant hepatologist, died of leukemia on January 14, 2019. He was Professor of Medicine and Section Chief of Gastroenterology and Hepatology at Tulane University Health Sciences Center. During his long and distinguished career in New Orleans, LA, Dr. Balart served as chief of GI at both Louisiana State University and Tulane University medical schools, in addition to time at Ochsner Medical Center and Southern Baptist Hospital. Dr. Balart was ACG President from 1999 to 2000 and rose to leadership in the College through the Board of Governors, starting with his election in 1990 and culminating in service as Chair from 1994 to 1995. One of his most important roles in ACG leadership was his tenure as Chair of ACG’s National Affairs Committee from 1995 to 1997. Dr. Balart provided important leadership and personal connections with legislators and was energetic and committed to advancing the interests of clinical gastroenterologists during his many visits to Washington, DC. One of the highlights of his ACG presidency came in 2000, when he awarded the ACG Distinguished Service Award to Emily Couric, a state senator from Virginia. Before her death from pancreas cancer, Senator Couric had been instrumental in passing the first state legislation requiring private insurers to cover preventive colorectal cancer screening. Senator Couric was the sister of journalist Katie Couric. ACG Past President Seymour Katz, MD, MACG, who served with Dr. Balart on the ACG

10 | GI.ORG/ACGMAGAZINE

Board of Trustees, remembers his colleague and friend: “Luis was the quintessential physician educator and ACG President. His buoyant personality and ever-present smile, coupled with competence and concern for patients and colleagues, created and indelible memory of a physician who always seemed to know ‘to do the right thing.’ I shall miss him.” Dr. Balart’s year as ACG President was immediately preceded by Christina M. Surawicz, MD, MACG, who reflects on what he meant to her: “Luis was an amazing person, the definition of a true gentleman— always honest, insightful, smart and reliable. I could always count on him for wise counsel. With his death, we have lost a truly wonderful man, but we have not lost his legacy.” Dr. Balart was born in Havana on October 20, 1948, emigrated with his family to the United States in 1961, and settled in New Orleans. Dr. Balart received his medical degree from Louisiana State University in New Orleans. He completed his internship at Charity Hospital in New Orleans and finished his residency in internal medicine at the Naval Regional Medical Center in Philadelphia, PA. He completed two fellowships: the first in Gastroenterology at Ochsner Medical Institutions, and the second in Hepatology at the University of Southern California. While in medical school, Dr. Balart enlisted in the Navy and served 20 years in the Navy Reserve, rising to the rank of lieutenant commander. Dr. Balart was one of the authors of The New York Times best-selling diet book, “Sugar Busters! Cut Sugar to Trim Fat.” Dr. Balart is from a family of gastroenterologists. Both his father, Louis A. Balart, MD, FACG, who died in 2013, and his son, J. Carter Balart, MD, of Baton Rouge, LA, have been members of the College.

ACG REMEMBERS G. RICHARD LOCKE, III, MD, FACG The College is saddened by the death of G. Richard Locke, MD, FACG, of the Mayo Clinic, Rochester, MN. Dr. Locke died January 10, 2019, at age 57 from complications of progressive supranuclear palsy. Dr. Locke was known for his work in the epidemiology of functional gastrointestinal disorders and gastroesophageal reflux disease. He was a consultant in the Division of Gastroenterology and Hepatology at Mayo with a joint appointment in the Division of Health Care Policy and Research. He was also a professor of medicine at the Mayo Medical School. Yuri A. Saito-Loftus, MD, MPH, FACG, a Mayo colleague of Dr. Locke, paid him this tribute: “He was the consummate clinician and clinical researcher.

His energy and enthusiasm were boundless, even on the busiest of days. His former patients still inquire about him, reflecting the kindness and care he afforded them. The GI community has lost a wonderful gastroenterologist.” Dr. Locke served as an associate editor of The American Journal of Gastroenterology from 2003 to 2009. He served as the ACG Governor for Minnesota from 2009 to 2013 and was a member of the ACG Educational Affairs Committee. Born September 21, 1961, in Cleveland, OH, Dr. Locke graduated from DePauw University in 1983 and was elected Phi Beta Kappa. He went on to study medicine at Harvard Medical School, from which he graduated in 1987 and where he met his wife, Jean. He completed his residency in Internal Medicine at the University of Minnesota, where he served as chief resident, and completed his fellowship in gastroenterology at the Mayo Clinic School of Graduate Medical Education. At the time of his death, Dr. Locke was also a member of the Board of Trustees of DePauw University, his alma mater. The G. Richard Locke, III Endowed Prize for Pre-Medical Excellence is awarded each spring to the DePauw University student with the highest grade point average of those attending medical school.

“He was the consummate clinician and clinical researcher. His energy and enthusiasm were boundless, even on the busiest of days. His former patients still inquire about him, reflecting the kindness and care he afforded them. The GI community has lost a wonderful gastroenterologist.” —Yuri A. Saito-Loftus, MD, MPH, FACG


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2018 Braintree Laboratories, Inc. All rights reserved.

HH27314B

September 2018

Novel & Noteworthy | 11


THE ORIGINAL 1 LITER PRESCRIPTION BOWEL PREP SOLUTION

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1 WITH MORE THAN 15 MILLION KITS DISPENSED SINCE 20101

A CLEAN SWEEP

EFFECTIVE RESULTS IN ALL COLON SEGMENTS2 · SUPREP® Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 · >90% of patients had no residual stool in all colon segments2* †

These cleansing results for the cecum included 91% of patients2*

SUPREP Bowel Prep Kit also achieved ≥64% no residual fluid in 4 out of 5 colon segments (ascending, transverse, descending, and sigmoid/rectum)2* †

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4

*This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IQVIA. National Prescription Audit Report. September 2018. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2017. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2018 Braintree Laboratories, Inc. All rights reserved.

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September 2018


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NORTH AMERICAN INTERNATIONAL GI TRAINING GRANT AWARDS DEADLINE Learn More: gi.org/na-intl-training-grant

ENTER TO WIN A SCOPY Sumbit your Entry: gi.org/scopy

MARCH 29 INTERNATIONAL GI TRAINING GRANT AWARDS DEADLINE

JUNE

JUNE

7

8–9

HEPATOLOGY SCHOOL AT EASTERN REGIONAL

EASTERN REGIONAL POSTGRADUATE COURSE

 Washington, DC

 Washington, DC

Register: gi.org/regional-meetings

Register: gi.org/regional-meetingsv

Learn More: gi.org/intl-training-grant

APRIL 15 AWARD NOMINATIONS DEADLINE Learn More: gi.org/awardees-and-special-lecturers

IBD SCHOOL AT MIDWEST REGIONAL

AUGUST

JUNE

16

10

ACG 2019 CALL FOR ABSTRACTS DEADLINE Submit Your Abstract: conferenceabstracts.com/ACG2019.html

AUGUST

17–18

SEPTEMBER

SEPTEMBER

FUNCTIONAL GI SCHOOL AT ACG/VGS/ODSGNA REGIONAL

ACG/VGS/ODSGNA REGIONAL POSTGRADUATE COURSE

 Williamsburg, VA

 Williamsburg, VA

Learn More: gi.org/regional-meetings

Learn More: gi.org/regional-meetings

6

 Minneapolis, MN Learn More: gi.org/regional-meetings

MIDWEST REGIONAL POSTGRADUATE COURSE

 Minneapolis, MN Learn More: gi.org/regional-meetings

7–8

Learn More: acgmeetings.gi.org

Novel & Noteworthy | 13

ACG CALENDAR

MAY

MARCH 29


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PUBLIC

POLICY // GOVERNORS' VANTAGE POINT

INTRODUCING

NEW LEADERS ACG’S BOARD OF GOVERNORS ELECTED NEIL H. STOLLMAN, MD, FACG, AS CHAIR AND PATRICK E. YOUNG, MD, FACG, AS VICE CHAIR. The pair took the reins from

Costas H. Kefalas, MD, MMM, FACG, Chair, and Douglas G. Adler, MD, FACG, Vice Chair. The ACG Governors are state and regional elected representatives whose role in the College is in part to serve as a conduit at a grassroots level for ACG members to share their needs and insights for clinical matters and other issues affecting the practice of medicine. ACG MAGAZINE invited Dr. Stollman and Dr. Young to introduce themselves and to share their vision for the work of the Governors going forward.

DR. NEIL H. STOLLMAN, CHAIR, ACG BOARD OF GOVERNORS

Tell us about your practice and clinical interests. My GI career has been a bit, well, non-linear! After my GI Fellowship, my first job was at the Miami VA Medical Center. I loved working at the VA and still miss those Vets. I then came out to California to join the faculty at the University of California, San Francisco (UCSF) and to run the GI Division at San Francisco General, our county/teaching hospital. I’ve subsequently joined a single-specialty GI practice in Oakland where I now have a fulltime private practice. In addition, however, I still teach at UCSF and elsewhere, still take shifts and night call at our county facility, and have also maintained my academic interests and continue to do clinical research and 

Public Policy | 15


// PUBLIC POLICY: GOVERNORS' VANTAGE POINT

writing in the C. difficile, fecal microbiota transplantation and diverticular disease spaces. Nothing unique or interesting about any one of those aspects of my work-life, really, although I think I’m somewhat of an outlier in that I’m still trying to do all three of those things full time despite the day apparently remaining only 24 hours long! On the plus side, I believe it allows me to have insight into many of the issues facing ACG members, in that I’m an active clinical practitioner, as well as an active teacher and researcher. My (now grown) teenage littleleaguer would say I’d make a good “utility infielder”—not an expert at any one thing, but able to fake it at most positions! And I can live with that…

How did you get involved in ACG? My GI training was at the University of Miami, where I was fortunate enough to work with Jamie S. Barkin, MD, MACG, and my primary mentor, Arvey I. Rogers, MD, MACG, both of whom are ACG Past Presidents. They were both very kind and supportive at helping me to get involved, including a stint on the Educational Affairs Committee, among others. That experience cemented my connection to the College, and it has remained a main focus of my professional life since.

What’s your perspective on the role the Governors play in the life of the College? Why are the Governors relevant right now? We’re all aware of the uniqueness of the Board of Governors, with elected colleagues providing a critical conduit from “the trenches” to the Board of Trustees and College officers. That’s always been of tremendous value to the College, but I believe more recently, as legislation and public policy issues have become far more important, having an “army” of Governors to work locally and nationally has been a key strength of the College’s efforts. To me, the maintenance of certification (MOC) issue is one illustrative example of the effectiveness of the Governors. While the bigwigs were working with the other societies and the American Board of Internal Medicine (ABIM), the Governors were quietly working state by state on local initiatives. I firmly believe that the success of these local efforts was a major factor in bringing the ABIM folks to the negotiating table. That kind of effort would be impossible without our 70+ Governors working hard at the local level. 16 | GI.ORG/ACGMAGAZINE

What is your vision for the year ahead for the Governors? In the simplest sense, more of the same. Continue strong traditions established by the Governors of working with our local and national legislators on ACG priorities, including the colonoscopy “polypectomy” surprise, the increasing bureaucratic burdens of prior authorizations, mandatory “step care” with forced failure, and ongoing efforts to address widespread concerns with MOC in its current form. Two efforts that Immediate Past Chair Dr. Costas Kefalas started that I’d like to see us run with would be increased input from the Governors to assist with issues facing private practice GI clinicians—something we hear repeatedly— as well as increasing the representation of women on our Board of Governors.

The Governors host a fly-in to Washington DC each spring to visit legislators. What tips do you have for the Governors on effective advocacy on the Hill? First off, comfy walking shoes and an umbrella! More seriously, lobbying and talking with legislators and their staff is not a skill set many physicians naturally possess or have been trained in. Some things I’ve learned from my six plus years of doing this include working to “know your audience.” Most of us are pretty good at reading people, but I try to think of how the best (i.e., most effective? least annoying?) pharma reps work, and I’ve realized that the good ones have excellent “radar” and a sense of their audience. Does this person have two minutes or 20? Are they interested in small talk and

pleasantries, or are they all business? Don’t be focused on saying every talking point in every single meeting; it’s not possible, and we need to get good at picking out the highlights, the “two-minute elevator pitch.” I also try to personalize things when I feel that’s appropriate. Most of our contacts are young, but they have parents, many of whom have had colonoscopies, for example (and some of whom have had family members with colon cancer.) Often I simply refer to their constituents, but as people. Bills are boring…people are not! Finally, when I leave a congressional office, I jot down literally one “note” on each contact, something personalized that I’ve noticed or we discussed (they’re a Warriors fan, their Mom had cancer, they just moved to DC, etc.), then I do follow-up emails to all, and make reference to that one “factoid” to remind them of who I am so the messages seems less like a copy-and-paste job.

PATRICK E. YOUNG, MD, FACG, VICE CHAIR, ACG BOARD OF GOVERNORS Tell us about your practice and clinical interests. I practice at Walter Reed Military Medical Center, a tertiary care teaching hospital for the Defense Health Agency. Clinically, I spend 40% of my time performing therapeutic endoscopy and 40% in general gastroenterology. Most of this time is also spent teaching fellows, which is one of the highlights of my work! The remainder of my

Photos: Dr. Patrick Young in his office. Dr. Neil Stollman during a past ACG Board of Governors Washington, DC Fly-in.


time is divided between formal teaching, administration and research. My research and professional interests include Barrett’s esophagus, colorectal cancer screening and prevention, therapeutic endoscopy, emotional intelligence in leadership, and ergonomics. I am also the Director of the Digestive Diseases Division at the Uniformed Services University of the Health Sciences.

How did you get involved in ACG? I had the great fortune to have wonderful mentors early on, especially Brooks D. Cash, MD, FACG, Brian P. Mulhall, MD, and Roy K. Wong, MD, MACG. Seeing my passion for academic gastroenterology, they encouraged me to serve with the ACG. I started with the Educational Affairs Committee. There, I had the chance to work shoulder to shoulder with people I consider luminaries in the field. They treated me with collegiality and respect despite my junior status. The ACG staff was incredibly professional and helpful. The energy and enthusiasm of that group were fantastic, and I have been hooked ever since! Since then, I have had the privilege of serving on a number of committees including Training, Public Policy, Credentials, National Affairs and Membership. While each has a unique mission, I have learned much from each experience. I would highly encourage our members to get involved in the life of the ACG in this way. When I began, I had no particular vision for where things would lead. I simply knew that I believed in the College and its mission, and that I wanted to play some part in helping it to thrive in service of our patients and ourselves.

You have served as ACG’s Military Governor and now are making a transition to civilian life. What are the unique challenges facing GI physicians serving on active duty in the U.S. military? (Full disclosure, since the incredibly capable Dr. Joseph Cheatham has succeeded me as the ACG Military Region Governor, he and I collaborated on this answer.) While some of the challenges—scope disinfection, documentation of quality assurance, etc. are the same, there are indeed unique aspects to military practice. Some challenges, such as the unexpected loss of personnel to deployment in support of our troops, are longstanding with time-tested management strategies. Others, such as the transition from service-specific medical centers to a single entity—the Defense Health Agency—are new. Like any widespread change in a large organization, many unknowns exist. How will career progression and assignments differ from the previous model? How will the roles and responsibilities of clinicians and clinical leaders change? Now more than ever, leaders in military GI must become facile in the management of both change and expectations. With folks like Dr. Cheatham at the helm, I have no doubt that they will successfully navigate these challenges.

The Young Physician Leadership Scholars will join the ACG Board of Governors at their Washington, DC Fly-In this spring. What are the goals for this collaboration?

“When I began, I had no particular vision for where things would lead. I simply knew that I believed in the College and its mission, and that I wanted to play some part in helping it to thrive in service of our patients and ourselves.” —Patrick E. Young, MD, FACG, Vice Chair, ACG Board of Governors

Many of us have dedicated our careers to excellence in clinical care, research, etc. and have only come to advocacy relatively late in the game. Though earnest in intent and knowledgeable about the practice of gastroenterology, we often lack the fundamental skills necessary to be successful advocates before legislators and policymakers. By developing an interested cohort of young leaders, we can ensure that they have both the training and experience necessary to clearly elaborate the needs of gastroenterologists and their patients to our nation's congressional leaders and the key federal agencies. The Young Physician Leadership Scholars will benefit the ACG Governors as well. These young leaders will provide a fresh perspective to the meetings on the Hill, and legislators are often interested in hearing from younger individuals. The seasoned ACG leader and the young scholar will exchange stories and ideas from their different experiences and thus learn from each other.

How can ACG members get involved in supporting the College’s public policy priorities and the work of the Board of Governors? ACG members should become familiar with the ACG’s Legislative Action Center. Through our Action Center, ACG maintains active track of both state and federal legislation relevant to your practice and patients, along with action alerts that allow you to reach out directly to your congressional leaders on important and urgent issues. Members are also encouraged to reach out to their respective ACG Governors for any state-specific questions you may have, if you wish to help introduce legislation in your state, or if there are any specific issues you feel that ACG should be advocating for on your behalf. The ACG Governor has been elected to be your voice and is eager to hear from you. ACG also keeps a list of the contact information for the state GI and medical societies for those who wish to become more directly involved at the local level.

RESOURCES  ACG Legislative Action Center: bit.ly/ACGActionCenter  State and Federal Legislative Tracker on gi.org: bit.ly/ACGLegTracker  ACG “Action Alerts”: bit.ly/ACGActionCenter  Reach Your ACG Governor: gi.org/governors  List of State GI Societies: bit.ly/StateGISocieties

Public Policy | 17


Accessible. Relevant. Practical.

The information you need to improve your practice. The ACG Practice Management Committee’s mission is to equip College members with accessible tools to overcome management challenges, improve operations, enhance productivity, and support physician leadership in their private and physician-lead clinical practices. Learn from practicing colleagues through monthly articles on topics important to you. Articles include a topic overview, suggestions, examples, and a list of resources or references.

Explore the 2018

PRACTICE MANAGEMENT TOOLBOX and LAW MIND insights! Download the e-Book: bit.ly/PM18EBOOK

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"Pressures are high as gastroenterologists make important management decisions that profoundly affect their business future, their private lives, and their ability to provide care to patients." —Louis J. Wilson, MD, FACG

Start Building Success Today. GI.ORG/TOOLBOX


GETTING IT Ambulatory

GETTING it Right // BUILDING SUCCESS

Setting Up an

Infusion Center in Your Practice This article is part of a series sponsored by the ACG Practice Management Committee. See more: gi.org/toolbox David L. Limauro, MD, FACG, Pittsburgh Gastroenterology Associates, Pittsburgh, PA

 PRIVATE PRACTICES IN GASTROENTEROLOGY ARE FACING INCREASING PRESSURE on many fronts. At a minimum, these pressures include decreasing reimbursements, higher practice personnel and equipment expenses, and increasing regulatory burdens. Many successful independent practices have found the revenue from ancillary service lines to be critical for financial success. Ancillary services which align best with gastroenterology are those which provide commonly necessary billable services while allowing practices to improve convenience for patients and improve care while adding supplemental revenue to the practice. Practices caring for a population of patients with inflammatory bowel disease should seriously consider the addition of outpatient infusion services. Ambulatory infusion centers can be beneficial to patients and providers. Patients can expect to receive care in a familiar setting under the care of their usual physicians. Physicians might expect better compliance with therapy administered in office, and this also allows further opportunities to see patients and improve the therapeutic relationship. There is reason to expect that ambulatory infusion centers can continue to be a source of expanded revenue and value added for GI practices. Insurers that have to pay higher rates for hospital-based medical infusions services will likely continue to encourage outpatient infusion center utilization. This paper will briefly review the Centers for Medicare and Medicaid Services (CMS) rules and guidelines in the area of outpatient infusion. It will discuss practice and physical plan needs and requirements. It will review coding and billing, and lastly touch on reimbursement and financial risk. 

Getting it Right | 19


// GETTING IT RIGHT: BUILDING SUCCESS

CMS REGULATIONS The owners and operators of ambulatory infusion centers must be prepared to understand and follow CMS rules in this area. The rules for physician supervision of infusion are more stringent in the freestanding centers and physician offices than for hospital outpatient departments in this area. Ambulatory infusion centers must strictly adhere to CMS supervisor requirements. CMS requires direct supervision by physicians, and this explicitly means that the physician—and not an advanced provider—must be “immediately available” and “interruptible” to provide assistance and direction throughout performance of the infusion. However, the physician does not need to be in the infusion room when the infusion is given. Stated another way, the supervising physician must be present in the office suite or center during the entire infusion.

SETTING UP THE INFUSION SUITE

Equipment and staffing needs and costs will need to be carefully considered and budgeted for by each group prior to starting the infusion center within their GI practice. The physical space for the center is a fixed cost, and ideally the physician group would have the space available in their office and thus be “renting from themselves.” Infusion centers can, of course, vary considerably in their size and comfort structure. One center might be as simple as a single infusion chair with an IV pole compared with other units decked out with 20 high-tech leather recliners, each with its own TV and massage unit. A minimum financial outlay might likely include the costs of two infusion chairs, infusion pumps, blood pressure monitor(s), patient entertainment equipment, and general supplies (locking refrigerator, IV tubing, needles, gloves and medications to handle complications). An estimate of the costs for this equipment is modest and can be found elsewhere.

20 | GI.ORG/ACGMAGAZINE

HIRING THE RIGHT STAFF

Hiring the correct infusion nurse(s) or training an existing staff member(s) will likely be one of the most important determinants of the success of the infusion center. Centers should make every effort to hire a skilled, competent and knowledgeable nurse early in the process.

BUYING AND BILLING MEDICATIONS

This will likely spare many headaches which could arise later if the wrong person is selected. Owners must consider the expected total time spent giving infusions as well as whether this nurse will be involved in helping to obtain authorizations for the biologics, which can be a considerable time outlay. Salary, medical insurance and benefits for this provider need to be considered

Obtaining and billing for biologic medications is usually done by ambulatory infusion centers in one of two ways. There may be a “pass through”type arrangement or “buy and bill.” In a pass-through situation, a specialty pharmacy delivers the drug [and possibly infusion equipment] to the ambulatory center, and then the pharmacy bills the insurer directly. The pharmacy would also be responsible for the authorization and collection of copays. Alternatively, in buy and bill, the outpatient infusion center establishes an account with a wholesaler and purchases the drug directly from a specialty pharmacy. The infusion center then bills the patient’s insurance plan or Medicare directly. The buy-and-bill method requires caution and diligence on the infusion center’s part in several areas. It will be the center’s responsibility to comply with insurance company and CMS rules in this area, to obtain the most competitive pricing for drugs, to ensure correction and necessary authorizations, and finally to collect patient co-pays, to name a few. It is important for any practice undertaking an infusion center to understand coding and billing for outpatient infusion services. As busy physicians, we may sometimes have a poor understanding of what appears to be a bizarre and confounding structure when it comes to the details of coding and billing. Having competent coders and billers and a clear understanding of the most recent current procedural terminology (CPT) codes is paramount to receiving the appropriate reimbursements. Each insurer may also have their own policies regarding infusion payment and reference should be made to the insurers' individual websites.

carefully when trying to assess the bottom line. Owners of ambulatory infusion centers need to be aware of the state licensing requirements and verify that these are met by the infusion nurse or other personnel involved with the infusion of medications to patients.

There are specific rules regarding infusion coding that can be complex. It is very important to record the timing of the entire infusion. For example, CPT code 96413 for infusion of infliximab covers the “administration of drug, IV infusion techniques up to 1 hour,” whereas code 96415 covers each additional hour (listed separately in addition to the code for the primary procedure). The Healthcare Common Procedure Coding System (HCPCS) is used to supplement the CPT codes. In the case of infusions, this would be used to cover the drug, IV tubing, syringes and other supplies for the infusion that are not included in the CPT code. For infliximab, the HCPCS code is J1745 for 10 mg, and the code represents 1/10 of a 100 mg vial. Therefore, you would need to bill 10 units of J1745 on the claim form to indicate every 100 mg that was used. Coding coverage may vary by insurer or even between plans with the same insurer. Consult your payers for specific coding policies. Be aware that policies pertaining to reimbursement of biologic medication can be complex and are updated frequently. Adding outpatient infusion services to your physician practice can be a great benefit to your patients and a good opportunity to supplement practice income. As with any new service line, a business plan should be done and reviewed with an administrator or consultant who understands the risks and benefits of the endeavor. Centers will be infusing small amounts of very expensive drugs, and non-payment of even one patient can be detrimental financially, costing literally thousands of dollars. Understanding how to obtain proper authorization and payment is critical. Infusion can be profitable for physician practices if managed properly. There are several companies that provide infusion management services that are experienced in helping practices navigate the process from setup to operations.


PRACTICAL SUGGESTIONS AND EXAMPLES FOR YOUR PRACTICE

Reasons to Consider an Outpatient Infusion Suite for Your Practice 1. Continuity of patient care (better control of their disease). This in turn improves patient compliance, as you can monitor infusion appointments and appropriate dosing.

2. Improved patient care. Patients prefer in-office infusion suites over alternate sites due to lower cost share and time requirements. 3. Adding ancillary services to a GI practice is the best solution to compression of reimbursement.

Practical Suggestions 1. Make your patients aware that by infusing GI-specific biologics (infliximab, vedolizumab, etc.), we are giving drugs with which GI physicians have intimate knowledge and experience. This gives an advantage to us over hospital infusion centers, where a wider variety of medications are being infused but with no such specialized experience.

3. Anticipate time to get insurance contracts and reimbursements in place. Expect to operate in the red in the short run. 4. Consider iron infusions in addition to infusion of biologics for IBD.

1. Create a list of patients currently receiving biologics as well as patients that may require biologics in the near future.

5. Keep a close eye out for advances in biotech and infusion; biosimilars as an example.

3. Investigate contracted fee schedules with all payers for all biologics and CPT codes. 4. Compare purchase prices to contracted fee schedules. This step alone will determine infusion suite viability. 5. Identify appropriate space and purchase necessary equipment (infusion chair, blood pressure monitors, patient entertainment equipment and infusion supplies.) 6. Identify and hire experienced staff for verifications, billing and an infusion nurse. These are critical to the success of your infusion suite. 7. Identify and select a wholesaler medication vendor to begin purchasing. Be sure to compare several wholesalers and to negotiate payment terms. 8. Contact drug manufacturers to enroll in patient access support services, which will assist in verifications of benefits for infusion patients. 9. Begin verifying benefits and scheduling patients.

ACCESS KEY RESOURCES ACCESS at KEY theRESOURCES point of care at the point of care

2. Make your infusion facility patient friendly. Strive for convenience for the patient in both location and setting. Hire great infusion nurse(s) and, when possible, shorten time of patient infusions.

Steps to Adding Outpatient Infusion Services

2. Contact drug manufacturer (Johnson & Johnson, UCB, Takeda) to get information on Contract Purchase programs, rebate programs and co-pay assistance programs.

ACG ACG MOBILE MOBILE

6. Carefully review payer mix and payer contracts, as reimbursement from some may not be adequate to make office infusion worthwhile. 7. Get administrative help from a consultant group or outside agency if you are not able to do it yourself.

STAY ON-THE-GO

RESOURCES  Managing an in-office infusion practice, The Rheumatologist:

bit.ly/InOfficeInfusion

 Infliximab Coding and Billing:

bit.ly/InflixCB

 Versel, N. Build Your Own Infusion Clinic, Biotecnol Healthc 2005 Feb; 2(1), 35-36, 39-14. See bit.ly/VerselN

STAY ON-THE-GO with ACG’S MOBILE APP with ACG’S MOBILE APP An exclusive ACG Member benefit that provides access valuable benefi resources An exclusive ACGtoMember t that for your practice and your patients, all provides access to valuable resources from your mobile device. for your practice and your patients, all

from your mobile device.

 Medicare Supervisory Requirements:

bit.ly/MedSupReqs

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DOWNLOAD THE ACG MOBILE APP Download the app via the Apple or Android Store. Getting it Right | 21


// GETTING IT RIGHT: LAW MIND

DO I INVEST? // LAW MIND

Legal Issues in Considering Endoscopy Center Investment By Ann M. Bittinger, Esq., a health care attorney with physician group clients across the country. Questions? Email ann@bittingerlaw.com

THE FEDERAL ONE-THIRD TESTS

 MOST GASTROENTEROLOGISTS ARE OFFERED AN OPPORTUNITY TO INVEST in an endoscopy

or surgery center at some point in their careers. Along with practical and financial considerations that I touch on below, the federal AntiKickback Statute governs these investments at the time of buy-in and as long as the gastroenterologist owns shares. In today’s evolving health care environment, with less-complex procedures happening more frequently outside of the hospital environment, the time is right to consider investment. But proceed wisely.

22 | GI.ORG/ACGMAGAZINE

The federal AntiKickback Statute makes it illegal for physicians to refer Medicare patients to facilities with which they have an investment interest. There’s a very complicated exception to that prohibition, however, to allow physicians to invest in ambulatory surgery or endoscopy centers where they perform procedures. Generally speaking, to comply with the Statute, the physician’s work at the center has to be an extension of the physician’s office practice. The law intends to disallow passive investment in a center. For example, a primary care physician investor who refers patients

to a gastroenterologist who performs services at the center would have a difficult time meeting the rule. The rule construes the dividends on the primary care physician’s investment as a kickback for a referral of patients to the gastroenterologist, who performed the surgery and helped the center make a profit. Instead, investors have to be actively engaged in the practice. There are two “one-third tests” to meet the Statute safe harbor. At least one third of the investor’s medical practice income must be derived from performance of procedures that are reimbursable by Medicare when performed at a center. That means that the investor has to perform surgeries or endoscopies frequently enough that income therefore makes up one-third of his or her income. There’s another one-third test applicable only to multi-specialty centers; endoscopy centers are typically not multi-specialty, as they are owned exclusively by gastroenterologists and perform only GI procedures. If the center has investors from different specialties, at least one third of the procedures that the investor performs have to be performed in this center. In other words, this center is where the investor has to be taking his or her cases. According to 1999 regulations, the purpose is to ensure that the center is “an extension of the physician’s office space and not a means to profit from referrals.” If you don’t think you can meet these thresholds, don’t invest. Not only could you face prosecution under federal criminal law and have to repay Medicare, the surgery center could kick you out and not return your investment. If the feds get involved, you and the surgery center could be forced to repay three times the amount that Medicare paid for services you performed when you were not in compliance. Also, you could be excluded from Medicare participation.


INVESTMENT AMOUNT Many clients have told me that the centers claim that the law requires the same buy-in price to all physician investors. That’s not entirely correct. While the center can’t loan you the investment amount or require you to pay for investment through work i.e., sweat equity, there’s nothing in the federal regulatory scheme that mandates one price for all. Generally speaking, when a person invests in any company, the price per share is based on the value of the company. A center cannot vary the buy-in price based on the expected or actual volume or value of referrals that the owner brought or would bring to the center. That doesn’t mean, however, that the dollar-per-share or buy-in price has to be the same for everyone for years. In fact, if patient volume or reimbursement is down or debt up, it makes sense from a compliance standpoint to argue that indeed the value of the company has fluctuated so the price to buy in should change.

EBIT—WHAT? Often, the buy-in price is based on a formula called EBITDA. That stands for the company’s Earnings Before Interest, Tax Depreciation and Amortization. The company’s CPA determines that amount, typically each year. The center’s governing documents (usually called an operating agreement) may say that the price per share will be a multiple of EBITDA. The company’s directors may be able to change that multiple. Alternatively, the operating agreement may allow the directors to determine the value of the company, usually based on a definition other than EBITDA in the operating agreement. You should be able to see that document prior to buying in. You will likely be asked to sign a non-disclosure agreement before receiving the operating agreement.

HOW MANY SHARES? Endoscopy centers must pay dividends to their gastroenterologist investors in direct proportion to the gastroenterologist’s ownership percentage. If Dr. Jones owns 5%, and a dividend is issued for

$500,000, Dr. Jones would be paid 5% of $500,000 or $25,000. This amount does not vary based on the number of cases Dr. Jones performs or the profits generated to the center from those cases. When you are offered an investment opportunity, you might be presented with a range of percentage of shares you can buy. Keep in mind that if it is a small percentage (less than a majority), the investment brings with it no real rights to control the company (more on that below). Instead, you’re getting an opportunity to get a share of profits based on the percentage of shares you own—not based on how profitable you are to the center. You may buy in at 10% while other ACG members decide to buy-in at 5%. There’s nothing illegal about that.

DECISION-MAKING One allure to investing in a surgery center is the voice that the physician investors have in how the center is operated (as opposed to having no ownership or control of the hospital’s operating rooms). Be sure to read the fine print in the operating agreement, however, so your expectations are on-point as to just how much control you have, or don’t have. If there’s an outside management company, that management company may be the majority shareholder, thus having control of all decisionmaking—and dividend issuing. In other words, despite your percentage, if the management company can unilaterally decide whether to pay out profits as dividends to shareholders (it’s not automatic), and they decide not to pay, then you get nothing. Keep in mind that the management company is also being paid by the center to manage the center. Likewise, who decides what is important? Even if

there is no management company involved, a select group of investors on the board of directors may be the exclusive decisionmakers. If you invest, do you get a seat on the board? The answer is in the operating agreement.

EXITING Another key consideration is whether you get your money back if you leave, for whatever reason. In many cases, there is little or no return on your investment. Your health care attorney can help you understand your operating agreement terms about exiting. In summary, endoscopy center investment can be quite lucrative and professionally fulfilling. Be sure to evaluate all offers, though, with the help of experienced health law counsel.

KEY ISSUES IN INVESTING IN A CENTER • Is 33% of your practice made up of surgery/endoscopy center procedures? • Is the center single- or multispecialty? • Is there a management company and, if so, what percentage does it own? • What percentage interest would you own? • What decision-making rights come with that percentage? • Who determines if dividends are paid to investors? • Do you get your investment back if you leave?

Getting it Right | 23


// COVER STORY

Profiles in Courage IN THE FIGHT AGAINST COLORECTAL CANCER 24 | GI.ORG/ACGMAGAZINE


Cover Story | 25


// COVER STORY

“It was all destroyed,” says Victor J. Colon, MD, FACG, reflecting on the first time he first saw his gastroenterology office in Caguas, Puerto Rico, after Hurricane Maria struck the island in September 2017. Water dripped from where the ceiling once stood. “It was daylight outside, but it seemed like it was raining inside the office,” says Colon, during an interview with ACG. Hurricane Maria hit Puerto Rico as a high-end Category 4 storm. The island “almost certainly felt” Category 5 intensity winds.1 Caguas endured nearly 38 inches of rainfall—the most on the entire island.2 It is estimated that the storm accounted for 2,975 deaths in Puerto Rico from September 2017 to February 2018.3 There was no quick fix or obvious first E IMAGE OF HURRICANE MARIA NEARING PEAK INTENSITY AT 1942 UTC 19 SEPTEMBER 2017. IMAGE step for the practice. COURTESY OF UW-CIMSS. “So, what’s next? We didn’t have an idea what to do next,” says Itzaira Hernandez, as a very severe Cape Verde Hurricane that ravaged the island of Dominica office manager at Instituto Digestivo De (on the Saffir-Simpson Hurricane Wind Scale) intensity, and later devastated Puerto Rico, PSC, who also visited the as a high-end category 4 hurricane. It also inflicted serious damage on some office shortly after the storm. lands of the northeastern Caribbean Sea. Maria is the third costliest hurricane While uncertainty ruled that day and many that followed, four months later tes history. the practice had recovered from the By Brian C. Davis destruction and despair. Before spring e 5 April 2018. Corrected damage photo of Dominica in Fig. 9. began, the team was hosting a Colorectal Cancer Awareness Month event for its community in the spacious confines of a new office, an event for which Colon and the practice won the 2018 “SCOPY Fighting Colorectal Cancer in the Face of Disaster Award.”

A Leap of Faith Rebuilding After Hurricane Maria THE WIND HAD STRIPPED THE ROOF FROM THE BUILDING. WIRES AND CORDS JUTTED IN PECULIAR, UNNATURAL DIRECTIONS. DEBRIS WAS STREWN ACROSS THE OFFICE AND ON TOP OF EQUIPMENT AND FURNITURE.

26 | GI.ORG/ACGMAGAZINE

THE STORM & THE AFTERMATH Holed up in a closet at home with snacks, water and a few flashlights, Colon waited out the storm with his wife, son and their two dogs. They had lined the closet floor with a couple of twin mattresses. “All we heard was the wind” and “very loud noises of things breaking outside,” Colon says. At around 2:00 am, water crept into the closet. The wind had dislodged a window frame from the wall, ushering water and dirt into the house. You could feel the walls in your home “trembling” if you touched them, Hernandez says. “It was that kind of scary.” Image left: Hurricane Maria as it approached peak intensity the evening of September 19, 2017. This satellite mage can be found in the National Hurricane Center Tropical Cyclone Report: Hurricane Maria. Photo on page 27: Dr. Colon with his wife, two sons and two dogs. Photo courtesy of Dr. Colon.


When they emerged the next morning, the Colons saw downed trees torn from their roots. Solar panels once fastened to neighbors’ roofs now filled the street. The Colons’ house had flooded but did not have much damage. All of the electric polls fell to the ground in a line, remembers Hernandez, who lost power for five months. Some colleagues fared far worse. Two staff members lost their homes and everything in them, according to Colon. Elysha Morales, RN, returned to her home after the storm to find the nearby river had overflowed and packed the home with five feet of mud. More than 13 months after the storm, she was in the process of acquiring a new home. Having lost many trees and leaves, the surrounding mountains were a “bare image” of their former selves, revealing houses “you never knew were there,” Colon says. Gas stations and shopping centers were ruined and there was complete darkness at night. Everything looked “deserted.” “It almost felt like The Walking Dead” says Colon, referring to the postapocalyptic television show. CONFRONTING THE UNEXPECTED Two days after the storm, Colon returned to the office with his wife and the younger of his two sons (his older son is in college). He did not expect the office was severely impacted because it was located in the center of a building, with no exposure to the outside. However, this hope was betrayed by the devastating hurricane winds, which had “ripped off the upper layers of the roof treatments,” Colon explains. “It looked like a carpet,” he says of the roof. Debris clogged the roof drains, allowing water to flow into the office. When Colon went to the roof, the air conditioning unit was not where it had been.

“It was daylight outside, but it seemed like it was raining inside the office.” —Victor J. Colon, MD, FACG

“I didn’t know even where [the unit] was. It went flying.” Communication did not come easy following the storm. Seen as a miracle to some, one AM radio station was still functioning. People called the station to relay messages to family and friends that they hoped were listening. Many gathered and made calls near the highway, the area which offered the best service for customers of the sole cell phone provider that had maintained service. More than one week after the storm, Hernandez started hearing from coworkers who lived farther away from the office. Shortly after, Colon and his team met in the parking lot of the depleted, rubbleladen office. Some staff members were living with neighbors or relatives; some had nothing to go back to at home. “Morale was low,” Colon says. He was unsure when he would find another office, Colon told the team. He realized they had financial needs and understood—even encouraged—them to take another job if one became available. Then Colon handed each staff member a check for about $1,000. He had liquidated vacation time, sick days, holidays and bonuses. “That was a saving factor to all of us,” Hernandez says of the check. The group agreed to remain in touch and parted ways. IN LIMBO Weeks passed, and the future remained unclear. The conveniences of everyday life were on an extended hold. Each night you had to plan what you wanted to do the following day, explains Hernandez, who once spent six hours in a bank line and four hours in a gas line. Nicole Miranda, clinical nurse with the practice, was seven months pregnant when the hurricane struck the island. She was without power and slept in her carport for more than two months due to major damage to her home. Blue tarps were draped around the Cover Story | 27


// COVER STORY Photo left: Members of Dr. Colon's team during a colorectal cancer awareness event. Photos on page 29: A combination of photos captures both the destruction of Dr. Colon's former office and reveals his pristine new office. Photos courtesy of Dr. Colon.

“That’s when we decided we were coming back because...everything kind of came together,” Colon says.

openings in the car port, “as if it was a curtain,” Colon said. As time passed, staff continued to check in about when they would be going back to work. “You know, we were anxious,” not only because of the lack of income, said Hernandez, but “also we were thinking about our patients. There were a lot of procedures that got canceled before the hurricane, so we wanted to get back as soon as possible.” Colon weighed his options. He could find a new office space, although destruction from the storm limited his choices. Friends offered him opportunities, such as working half-days in their offices. “In gastroenterology if you’re seeing patients without doing procedures…you’re not really doing much. It’s kind of half practicing,” Colon said. “I didn’t want to kind of go back to practice until I was able to provide a good service.” Moving to the mainland U.S. was another option. TURNING POINT It was November 2018, and the Colons were considering moving to Florida. The family was living on an emergency fund they had previously set aside. They cashed out some individual retirement arrangements, taking advantage of a window offered to island residents to do so without penalty. They still had no electricity or water. It was unclear when school would reopen, and they did not want their son to miss an entire year of high school. “We went to Florida with plans of perhaps, if we don’t hear anything, we just go ahead and move here,” Colon says. Their son had friends in Miami, and the Colons were prepared to enroll him in a school there. Then, while in Florida and considering moving their entire life there, the Colons began receiving answers to the pressing questions back home. The school in San Juan emailed to announce the date that classes would resume. With uninhibited cell service, Colon made calls more easily and learned about a new office space in Caguas.

28 | GI.ORG/ACGMAGAZINE

“In gastroenterology if you’re seeing patients without doing procedures… you’re not really doing much. It’s kind of half practicing,” Colon said. “I didn’t want to kind of go back to practice until I was able to provide a good service.” —Victor J. Colon, MD, FACG

REBUILDING Ironically, the new office is in the same building, but only suffered minor damage from Hurricane Maria. Unable to find an architect, Colon drew up floor plans with the assistance of graph paper and guidelines on building an endoscopy center. He and his wife measured the space and marked the location of the walls on the floor, to ensure there was sufficient space. “I corrected things that I wish I would’ve done in the other office,” says Colon, particularly “…in terms of space, structure and workflow.” For example, Colon increased the width of the doorways to four feet instead of the previous three feet, which had been a bit uncomfortable when transporting patient beds. The 2,500-square foot office has more waiting and recovery space and a new patient screening area, which allows for some same-day evaluation. After 10 weeks of construction, the new office opened in January 2018. Not one of Colon’s employees left the practice. “…The whole team wanted to work with each other. They just waited,” said Colon, who increased the staff from six to nine and who described the support as “very overwhelming.” The team still faces challenges stemming from Hurricane Maria. While the practice overcame its own phone issues, it is still difficult to reach some patients, as many residents still do not have phone service. Managing the old office is an ongoing challenge, as it remains depleted and continues to flood when it rains. The property value, which had already decreased significantly due to the economic climate in Puerto Rico, after the storm is now worth roughly one-fifth of the original purchase price,


Cover Story | 29


// COVER STORY

Colon says. Hernandez tries to be especially careful and considerate when talking to patients, as many residents now suffer from Post-Traumatic Stress Disorder. She is still scanning records from the old office. “I’m still working with Maria,” she says. The office rennovation and the equipment expenses represented a big investment for Colon. “It was a leap of faith,” says Colon, who was uncertain patients would return to the practice. “But, somehow, I had a gut feeling that this is the way to go.” COLORECTAL CANCER AWARENESS MONTH EVENT When the practice reopened, many residents were still without power and water. “If you can imagine, if you want to do a screening colonoscopy, you wouldn’t have it done” at that time, Colon says. “You have no water in your house, so going to the bathroom, you know 20 times in 24 hours, it’s not the ideal scenario.” To regain old patients, earn new patients, and, plainly, let the community know that they were open for business, Mariely Mercado, RN, suggested that the practice hold a small awareness event for March Colorectal Cancer Awareness Month. “We barely had any savings left,” says Colon, so the practice sought sponsorship. Ten companies provided support. On March 16, 2018, the practice held the event, which featured handouts and goodies, a mini theater, where Dr. Colon gave short presentations about screening, and a colon model on display allowed patients to better understand what takes place 30 | GI.ORG/ACGMAGAZINE

during a colonoscopy. Attendees enjoyed refreshments and different meals, which was particularly helpful as many remained without electricity.

“It was a leap of faith,” says Colon, who was uncertain patients would return to the practice. “But, somehow, I had a gut feeling that this is the way to go.” —Victor J. Colon, MD, FACG

SCOPY AWARD Just over one year after Hurricane Maria hit Puerto Rico, Colon took the podium and addressed a room full of his colleagues at the SCOPY Awards Ceremony & Workshop at ACG 2018 in Philadelphia. He accepted the “SCOPY Fighting Colorectal Cancer in the Face of Disaster Award,” the name of which “…literally applied to us,” he says. As Colon told his story, it became clear how committed he and his team had been to return to work—for themselves, for each other, and, most importantly, for their patients.

1. National Hurricane Center Tropical Cyclone Report: Hurricane Maria, pgs. 1, 4. See www.nhc.noaa.gov/data/tcr/AL152017_Maria.pdf. 2. National Hurricane Center Tropical Cyclone Report: Hurricane Maria, Figure 8. See www.nhc.noaa.gov/data/tcr/AL152017_Maria.pdf. 3. See gwtoday.gwu.edu/gw-researchers-2975-excess-deaths-linkedhurricane-maria.

Photos top: The team at Instituto Digestivo De Puerto Rico, PSC, celebrating Dress in Blue Day on March 2, 2018. A team member prepared to hand out colorectal cancer materials. Dr. Colon poses with his SCOPY Award lucite after accepting the “SCOPY Fighting Colorectal Cancer in the Face of Disaster Award" and addressing his colleagues at ACG 2018 in Philadelphia, PA.


FACES OF CRC AWARENESS AND PREVENTION March after March, ACG members around the country dedicate their time, imagination, brainpower and money to awareness and prevention initiatives during Colorectal Cancer Awareness Month. Since 2015, the College has recognized many of these initiatives, awarding the achievements of members in their community engagement, education and awareness efforts for CRC prevention through the SCOPY—Service Award for Colorectal Cancer Outreach, Prevention & Year-Round Excellence. While ACG shares photos of the initiatives in the SCOPY Awards Booklet, on the ACG Blog, and during the annual SCOPY Awards Ceremony at the Annual Scientific Meeting, there are many more to share. To acknowledge these initiatives, to demonstrate their range and variety, and to inspire your 2019 awareness efforts—here is a curation of photos of GI professionals and their communities hard at work to prevent CRC.

 GET INSPIRED! View the 2018 winners and SCOPY Awards Booklet: bit.ly/SCOPY18 APPLY for a 2019 SCOPY Award by May 31, 2019: gi.org/scopy

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// COVER STORY

Photos, top to bottom: Live from ACG 2018 in Philadelphia, ACG President-Elect Dr. Mark Pochapin hosts SiriusXM’s Doctor Radio. Dr. Pochapin speaks with ACG Vice President Dr. David Greenwald, Dr. Aasma Shaukat, and ACG Past President Dr. Carol Burke. Dr. Pochapin chats with Dr. Nicholas Talley, Dr. Eamonn Quigley, and AJG Co-Editors Dr. Brennan Spiegel and Dr. Brian Lacy. Dr. Greenwald, Fight Colorectal Cancer President Anjelica "Anjee" Davis, and the National Colorectal Cancer Roundtable’s (NCCRT’s) Public Awareness & Social Media Task Group take a selfie at the 2018 NCCRT Annual Meeting, Baltimore, MD.

Blue Notes

Colorectal Cancer Awareness Highlights

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Getting the Signal Loud and Clear: A CRC Screening Connection via SiriusXM ACG’s message about colorectal cancer (CRC) screening clearly resonated with one member of the audience of the SiriusXM Doctor Radio live broadcast at the ACG Annual Scientific Meeting—the technical engineer broadcasting the show. Tom MacDonald, a remote radio engineer working with SiriusXM, was at the controls on October 7 in Philadelphia when Doctor Radio host and ACG President-Elect Mark B. Pochapin, MD, FACG, and guests were discussing CRC screening. After the broadcast, MacDonald, 54, admitted that he had never been screened. Dr. Pochapin immediately made sure Tom could connect with a GI physician in Philadelphia, ACG Trustee Immanuel K. H. Ho, MD, FACG. Tom’s day job is as a news reporter for Philadelphia’s public FM radio station, WHYY. After his colonoscopy, Tom followed up with ACG: “Thanks for convincing me to have my colonoscopy done…all clear and good for 10 years...”


“What kind of steals an being inflatable colon?!” —question shared via Twitter Assessing “80% by 2018” and Moving Forward The American Journal of Gastroenterology dedicated a special issue to taking stock of the state of CRC prevention as the nation reached the end of 2018. The “80% by 2018: Did We Make It?” issue included an overview of this major public awareness campaign written by the American Cancer Society’s Dr. Richard Wender and colleagues, “Creating and Implementing a National Public Health Campaign: The American Cancer Society’s and National Colorectal Cancer Roundtable’s 80% by 2018 Initiative.”

Photo top: ACG Vice President Dr. David Greenwald, Digital Communications and Publications Chair Dr. Jordan Karlitz, and Minority Affairs and Cultural Diversity Committee Chair Dr. Darrell Gray pause for a photo at the NCCRT Annual Meeting.

ACG Offered Reward for Return of the #StolenColon “What kind of steals an inflatable colon?!” was the question being shared via Twitter. Inquiring minds wanted to know how a dastardly criminal stole a large bin containing this 150-pound teaching tool from a vehicle in Kansas City. The colon, which was purchased by the nonprofit Colon Cancer Coalition and had previously been stored at the University of Kansas Cancer Center, was stolen from a pickup truck before it was to be transported to a breast cancer run/walk. A social media maelstrom ensued when Forbes covered the heist. ACG offered a $1,000 reward for information leading to the safe return of the colon and got journalist Katie Couric involved in the search. Couric’s social media clout pushed the story over into mainstream media. People and even The New York Times covered the story. The Late Show with Stephen Colbert did a shoutout as #StolenColon trended on Twitter. Thanks to a tip, Kansas City police recovered the colon in an abandoned house. In the course of one week, #StolenColon garnered an estimated 995,000,000 media impressions. Yes, almost one billion impressions. ACG made donations to four nonprofit CRC advocacy groups: • Colon Cancer Coalition • Colorectal Cancer Alliance • Fight Colorectal Cancer • National Colorectal Cancer Roundtable

Beyond “80% by 2018”— Introducing “80% in Every Community” ACG will support the National Colorectal Cancer Roundtable’s new awareness campaign that aims to continue the fight beyond the “80%

 READ the article: bit.ly/Creating80by18

 READ the Special Issue: bit.ly/AJG80by18

2019 New Year’s Resolution: Get Your Colon Screen in ‘19

will continue to post these graphics in March Colorectal Cancer Awareness Month and beyond. ACG members are encouraged to:

“Get Your Colon Screen in ’19” is the recommendation offered by a CRC screening campaign launched by the ACG Public Relations Committee in late 2018. The campaign is centered on a series of graphics, intended primarily but not exclusively for social media, which create urgency around the public getting screened in 2019. The College began sharing the graphics in the final days of 2018, in hopes of catching people’s attention during the holidays—when they might not be working—or at the start of the new year, when people often reset and refocus efforts on taking care of their health. ACG

 DOWNLOAD the graphics: bit.ly/CRCGraphics  SHARE the graphics on social media using #CRCScreen19

by 2018” national screening goal. ACG Vice President David A. Greenwald, MD, FACG, represents the College on the NCCRT’s Public Awareness & Social Media Task Group. New to NCCRT leadership is Jordan J. Karlitz, MD, FACG, who was appointed to the Roundtable’s

Steering Committee. Dr. Karlitz got involved with the Roundtable during his time as Chair of ACG’s Public Relations Committee.  LEARN MORE about 80% in Every Community: nccrt.org/80-inevery-community

Cover Story | 33


­ ACG AWARD NOMINATIONS

Honor Your Colleague with an£ACG Award Nomination

T ACG A C           ﹒ B/F C A A The intent of the Berk/Fise Clinical Achievement Award is to recognize an individual who has provided distinguished contributions to clinical gastroenterology, which could include: (a) clinical medicine, (b) technology application, (c) health care delivery, and (d) related factors such as humanism and ethical concern. It is not intended that this award be given in honor of one’s laboratory research accomplishments.

C S A The Community Service Award is bestowed upon an ACG Member who has initiated or has been involved in numerous volunteer programs/activities or has provided significant volunteer service post-training. The service must have been performed on a completely voluntary basis and not for the completion of training or position requirements.

I L A The International Leadership Award is given to a Fellow or Master of the ACG in recognition of outstanding and substantial contributions to gastroenterology, to the College, and to the international gastroenterology community.

M   A C  G Masters of the American College of Gastroenterology shall have been Fellows who, because of their recognized stature and achievement in clinical gastroenterology and because of their contribution to the College in service, leadership, and education, have been recommended for designation as Masters.

M D H C A The ACG Minority Digestive Health Care Award is an achievement award that will recognize an ACG Member or Fellow whose work in the areas of clinical investigation or clinical practice has improved the digestive health of minorities or other underserved populations of the United States. These efforts can be shown by community outreach activities through clinical or educational programs, or research in an area of digestive disease that negatively impacts minority populations such as colorectal cancer, hepatitis B and C, cirrhosis and other GI cancers.

S S﹒ W A The Samuel S. Weiss Award is granted in recognition of outstanding service to the American College of Gastroenterology over the course of an individual’s career.

   ﹕ A ﹐

Nominations for all awards must:

Nominations should be sent to:

• • • •

John W. Popp, Jr., MD, MACG Chair, ACG Awards Commi ee 6400 Goldsboro Road, Suite 200 • Bethesda, MD 20817-5842 Email: awards@gi.org

Be accompanied by two le ers of recommendation Include the nominee’s CV Conform to the specific requirements listed Be unsolicited by the nominee

£﹒﹒/--- ££﹒ 34 | GI.ORG/ACGMAGAZINE


ARE YOU LISTENING?

MINDFULNESS AND MEDICINE:

The Healing Capacity of Genuine Listening

Scott L. Rogers, JD, MA, University of Miami School of Law and Arvey I. Rogers, MD, MACG

You’re probably a pretty good listener. One way to assess this is to reflect on how often you interrupt a patient after you have asked, “Tell me what brings you in today?” To be better than average, research on physician communication skills suggests you’d want to let more than 11 seconds pass before interrupting. But if you are genuinely interested in listening to your patient, gathering information, wanting the patient to feel heard, and understanding better why you interrupt in the first place, "mindful listening" may be just what the patient ordered. This article explores mindful listening, an accessible mindfulness practice that may meaningfully improve your quality of life, personally and professionally. Given the robust treatment of mindfulness in popular culture, you’ve most likely heard of mindfulness and of the psychological, cognitive and physical benefits associated with engaging in mindfulness practices. You may even have attended a presentation or been guided in a short mindfulness exercise to help manage stress, reduce burnout or be more at ease amid moments of uncertainty. Here, we offer guidance on how to incorporate a practical mindfulness practice into your day. We decided to address mindful listening because it is a useful tool to improve listening and to help deepen the physician-patient relationship, and it serves as an important mindfulness practice unto itself.

MINDFUL LISTENING

The practice of mindful listening invites you to direct your attention inward to the thoughts, feelings and body sensations that arise when you are engaged in conversation, and to become more skillful at attending to them, rather than impulsively reacting by, for example, interrupting. Beneath the surface, our thoughts readily move into past and future—even while talking with someone—and such mental time travel can adversely influence our beliefs, mood and levels of stress, often without our realizing it. 

ACG Perspectives | 35


// ACG PERSPECTIVES

When listening, attention is usually directed outward. Whether we are aware of it or not, our inner experience often influences our decision-making and conduct, yet we tend not to notice these vital signals or know what to do with them. For example, a patient begins to share his or her fears about a procedure, and we interrupt to reassure them that things will be okay. If we paid closer attention, we might notice the arising of feeling anxious, body sensations of tension in the chest, and thoughts like “they need” to have the procedure or “I don’t have time for this.” But interrupting, no matter how well intended, tends not to be the most effective response. It’s simply the response that is triggered most immediately—and often without our being aware—as a way to quell the agitation we are feeling, be it frustration, anger, worry or even boredom. It is a superpower to be able to truly listen, especially when feeling stressed or when the emotional content of an issue is intense, and still be able to maintain a steady state. Notably, there are certain times when interrupting is appropriate, and it is helpful to be able to discern the difference. Mindful listening facilitates this discernment and establishes a foundation for doing so in a more effective, more empathic, less reactive way.

“DO NOT INTERRUPT”

The following mindful listening exercise can improve your listening skills and, if you pay attention while practicing it, deepen your understanding of mindfulness and help you live a more mindful life. The instruction is to go an entire day without interrupting anyone, be it a colleague, family member or patient. While you likely will find it extremely challenging, it is the very moments of challenge from which you can learn the most. When you catch yourself about to interrupt, turn your attention inward and, rather than interrupt, “observe” your thoughts, feelings and body sensations. This can feel uncomfortable, and you may find it helpful to steady yourself with a few slower, deeper breaths. It is likely that, at first, you will not be able to go a whole day. But as you develop your ability to catch yourself about to interrupt and, informed by that moment of awareness, observe the agitation that is crying out for you to interrupt, you will become better equipped to sustain your attention and engagement, and genuinely listen. Importantly, try not to “white knuckle” it, meaning that the instruction is not to clench your teeth and fight the urge to interrupt until you detect an opening to jump in. Rather, it is an open invitation to practice patience, to genuinely listen, to gather more data, and to demonstrate a show of respect for another human being, as well as yourself. As Sir William Osler reminds us, “Just listen to your patient; she is telling you the diagnosis.”

ARE YOU STILL LISTENING?

As mindfulness carves a deeper niche into medicine, more will be learned about its benefits and the various ways it can be practiced. We believe that mindful listening is a powerful mindfulness practice, often confused with the admonition to “listen” and “pay attention,” skills that are assumed but rarely taught. We hope you find the “Do Not Interrupt” practice helpful for becoming a more effective listener, while at the same time offering you insight into why you may interrupt in the first place. Many articles on mindfulness address the importance of establishing a daily mindfulness practice, which can consist of

36 | GI.ORG/ACGMAGAZINE

 Photo Top: Scott Rogers and his father, ACG Past President Dr. Arvey Rogers. Photo courtesy of Dr. Rogers.

sitting for five to 30 minutes, resting attention on the breath, and when mind wandering is detected, returning attention to the breath. We strongly advocate this practice, which in many ways is a form of mindful listening. For if you pay close attention, you will “listen” to yourself and, as you do, you will be less likely to interrupt what may be the most interesting and important thing you have to say.

RESOURCES  Epstein RM., “Mindful practice.” JAMA. 1999;282(9):833-839.  Jaret, P., “The medicine of the moment,” Mindful (March 19, 2018). See mindful.org/the-medicineof-the-moment.  Joshi, N., Doctor, shut up and listen, New York Times (Jan. 24, 2015). See nytimes.com/2015/01/05/ opinion/doctor-shut-up-and-listen.html.  Krasner, M., et. al., “Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians,” JAMA. 2009;302(12):1284-1293.  Mind Tools, “Developing awareness to listen fully.” See mindtools.com/pages/article/ mindful-listening.htm.  Phillips KA, Ospina NS. “Physicians interrupting patients,” JAMA. 2017;318(1):93–94. doi:10.1001/ jama.2017.6493. See jamanetwork.com/journals/ jama/article-abstract/2635621.  Rogers, A., “The listening art,” The Pharios (Summer 2016).  Rogers, S., “Attending: A physician’s introduction to mindfulness “(Mindful Living Press CD: 2009).  Rogers, S., “The Elements of mindfulness,” (2018).  Singerman, P., “The return on investment from my study and practice of mindfulness,” 90(4) Fla. B. J. 26 (2016)  Yee, B., “How long you can talk before your doctor interrupts you?” Forbes (July 22, 2018). See forbes.com/sites/brucelee/2018/07/22/ how-long-you-can-talk-before-your-doctorinterrupts-you/#3f4a32f31443.  Apps: Insight Timer, Head Space, 10% Happier, Calm, Waking Up.


EDUCATION THE ACG EDGAR ACHKAR VISITING PROFESSORSHIP Photo Top: Corey A. Siegel, MD, MS, during his visit to the National Institutes of Health, Bethesda, MD.

Providing Noteworthy Speakers for Training in Your Communities THE EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM (EAVP) was developed to

address an unmet need in GI training programs. With the shrinking of resources, programs have become largely unable to afford funding visiting professor programs. The ACG Institute for Research & Education recognized the value of these interactions, which allow learning in an informal, small group setting, with a world leader in gastroenterology. The Institute makes it a priority to match EAVP speakers with GI training programs which offer a broader opportunity

49 INSTITUTIONS have hosted

39 SPEAKERS from coast to coast in the

UNITED STATES, as well as in

CANADA.

for community involvement. Inviting ACG members in the local area and encouraging evening events with local gut clubs broadens the audience and adds value to the visits. The first year of the program in 2014 confirmed our impression that the program would address an important need, as more than twice the number of institutions applied than we had the ability to accommodate. Our biggest challenge has been meeting the demand for these speakers. To date, 49 institutions have hosted 39

Nicholas J. Shaheen, MD, MPH, FACG, University of North Carolina, Chapel Hill; Director, ACG Institute for Clinical Research & Education

speakers from coast to coast in the United States, as well as in Canada. Uniformly, the feedback from both the speakers and the attendees has been glowing— speakers find the learners to be bright, engaged, inquisitive and eager. Trainees report the speakers are passionate, inspirational, knowledgeable and approachable. Leaders in gastroenterology have been enthusiastic in serving as visiting professors, despite their busy schedules and many other commitments. Given this feedback, our goal has been to expand this program to service the next generation of gastroenterologists. Education | 37


// EDUCATION

“Not only did we gain a wealth of knowledge, but Dr. Pandolfino reassured us with his practicality when treating his patients. He steered us away from algorithms and absolutes and strongly advised us to be clinicians and treat each patient individually. He proved to us that we can be heavily involved in research and clinical practice simultaneously...This will be an experience we never forget.” —Ramy Mansour DO, GI Fellow, Ascension Genesys

38 | GI.ORG/ACGMAGAZINE


2019

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS

EAMONN M.M. QUIGLEY, MD, MACG Mount Sinai Beth Israel, St. Luke and West FEBRUARY 26–27 DOUGLAS K. REX, MD, MACG Texas Tech University Health Sciences Center El Paso MARCH 28 AMY S. OXENTENKO, MD, FACG NYU School of Medicine APRIL 2 STEPHEN B. HANAUER, MD, FACG Lehigh Valley Health Network APRIL 3–4 DAVID T. RUBIN, MD, FACG Brown University MAY 8–9 BRIAN E. LACY, MD, PHD, FACG New York Presbyterian/Weill Cornell MAY 9

“We especially liked being able to discuss our cases with Dr. Siegel in a small forum setting and appreciate how much thought he put into them! IBD is a very nuanced field, and Dr. Siegel really helped break it down for us with pearls one can only learn from an expert.”­­ —NIH Fellows

NICHOLAS J. SHAHEEN, MD, MPH, FACG Wayne State University/ Detroit Medical Center MAY 9–10 WILLIAM D. CHEY, MD, FACG University of Colorado JUNE 6–7 DAVID J. HASS, MD, FACG Cooper University Hospital JUNE 13 ASHWANI K. SINGAL, MD, MS, FACG University of Iowa Hospitals & Clinics JULY 25 SUNANDA V. KANE, MD, MSPH, FACG Washington University in St. Louis School of Medicine SEPTEMBER 18–19 EDWARD V. LOFTUS, JR., MD, FACG University of California, Davis SEPTEMBER 19 COREY A. SIEGEL, MD, MS Creighton University SEPTEMBER 25

Education | 39


Your Journals,

REINVENTED

ACG’s Journals Are Now Published by Wolters Kluwer ACG

CASE REPORTS JOURN L ACGCASEREPORTS.GI.ORG ACGCASEREPORTS.COM

VOLUME 6

An Online Journal of Case Reports edited by An Online Journal of Case Reports edited by Gastroenterology & Hepatology Fellows Gastroenterology & Hepatology Fellows

acgcasereports.com clintranslgastro.com amjgastro.com

40 | GI.ORG/ACGMAGAZINE


Inside the

JOURNALS

G

AC RTS EPO CASE RO J URN L

an of the Americ Ofcial Journal nterology College of Gastroe January 2019

G OM I.OR TS.C TS.G POR POR ERE ERE CAS CAS ACG ACG

| Volume 114 | Number 1

Volume 114

| Number 1

VOLUME 6

| January 2019

The American OENTEROLOG Journal of GASTR Y

ed by orts edit e Rep ed by nal of CasRep orts edit ne Jour ows An Onli nal of Case atology Fell ne Jour ows An Onli ology & Hep atology Fell Gastroenter ology & Hep Gastroenter

pages xx-xx

EDITORS: Brian

R. Lacy, PhD,

MD, FACG and

Brennan Spiegel,

MD, MSHS, FACG

ACG and Wolters Kluwer Embark on New Publishing Partnership The College is pleased to announce that Wolters Kluwer now publishes all three of ACG’s scientific journals. As of January 11, 2019, the journals’ new websites are live. ACG is confident that in Wolters Kluwer we have a meaningful partner who will help take all three journals to the next level. As a global leader in professional information services and a leading medical and scientific publisher, Wolters Kluwer brings deep experience to foster innovation and excellence in ACG’s scientific publications. The American Journal of Gastroenterology Brian E. Lacy, MD, PhD, FACG, & Brennan M. R. Spiegel, MD, MSHS, FACG, Co-Editors-in-Chief  amjgastro.com: ACG members login to gi.org and

follow prompts

Clinical and Translational Gastroenterology David C. Whitcomb, MD, PhD, FACG, Editor-in-Chief  Open Access: clintranslgastro.com

ACG Case Reports Journal Samuel Y. Han, MD, Editor-in-Chief  Open Access: acgcasereports.com

Inside the Journals | 41


// INSIDE THE JOURNALS

INSIDE THE JOURNALS [THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

“MOST READ IN RED 2018” Brian E. Lacy, MD, PhD, FACG, Brennan M. R. Speigel, MD, MSHS, FACG | Co-Editors-in-Chief, The American Journal of Gastroenterology

“Top Ten Most Viewed Articles in The American Journal of Gastroenterology, 2018” 1. ACG Clinical Guideline: Management of Crohn’s Disease in Adults Lichtenstein G R, Loftus E V, Isaacs K L, Regueiro M D, Gerson L B, Sands B E.  READ the article: bit.ly/CrohnsDGuide

2. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts Elta G H, Enestvedt B K, Sauer B G, Lennon A M.  READ the article: bit.ly/PancCysts

3. Discontinuing Long-Term PPI Therapy: Why, With Whom, and How? Targownik L.  READ the article: bit.ly/DiscPPIs

4. Current Management of Hepatic Encephalopathy Acharya C, Jasmohan S B.

7. American College of Gastroenterology Monograph on Management of Irritable Bowel Syndrome Ford A C, Moayyedi P, Chey W D, Harris L A, Lacy B E, Saito Y A, Quigley E M M.  READ the article: bit.ly/IBSMon

8. Evaluation of Chronic Diarrhea and Irritable Bowel Syndrome with Diarrhea in Adults in the Era of Precision Medicine Schiller L R.  READ the article: bit.ly/DiarrheaIBS

9. Management Options for Patients with GERD and Persistent Symptoms on Proton Pump Inhibitors: Recommendations from an Expert Panel Yadlapati R, Vaezi M F, Vela M F, Spechler S J, Shaheen N J, Richter J, Lacy B E, Katzka D, Katz P O, Kahrilas P J, Gyawali C P, Gerson L, Fass R, Castell D O, Craft J, Hillman L, Pandolfino J E.

 READ the article: bit.ly/ManageHE

 READ the article: bit.ly/GERDMgmt

5. A Systematic Review and Meta-Analysis Evaluating the Efficacy of a Gluten-Free Diet and a Low FODMAPs Diet in Treating Symptoms of Irritable Bowel Syndrome Dionne J, Ford A C, Yuan Y, Chey W D, Lacy B E, Saito Y A, Quigley E M M, Moayyedi P.

10. Treatment of Supragastric Belching with Cognitive Behavioral Therapy Improves Quality of Life and Reduces Acid Gastroesophageal Reflux Glasinovic E, Wynter E, Arguero J, Ooi J, Nakagawa K, Yazaki E, Hajek P, Woodland P, Sifrim D.

 READ the article: bit.ly/GFLFIBS

6. Chronic Nausea and Vomiting: Evaluation and Treatment Lacy B E, Parkman H P, Camilleri M.  READ the article: bit.ly/NauseaVomit

42 | GI.ORG/ACGMAGAZINE

 READ the article: bit.ly/SBelching

 ACG MAGAZINE INVITED THE COEDITORS-INCHIEF of The American Journal of Gastroenterology to reflect on those 2018 articles published in the Red Journal with the highest number of unique page views—the Most Read in Red. Brian E. Lacy, MD, PhD, FACG, and Brennan M. R. Speigel, MD, MSHS, FACG, who were reappointed to a second three-year term in 2018, share their insights and thoughts on the year ahead. Most Read in Red: Major Topics of Broad Clinical Interest “It is gratifying to see that the top cited articles in 2018 represent the breadth and depth of gastroenterology and hepatology, from IBD, to pancreaticobiliary diseases, to hepatic encephalopathy, to dietary interventions for IBS. The list covers major topics of broad clinical interest,” commented Dr. Spiegel. “What I see is a thirst for knowledge,” said Dr. Lacy. “I see an interest in a diverse group of topics. I see that our readers want to continue to educate themselves in order to provide the best possible patient care that they can.” The Bible of Clinical GI “Dr. Lacy and I frequently refer to the Red Journal as the ‘Bible for Clinical Gastroenterologists.’ Our goal is to publish research and timely reviews that support everyday clinical practice and answer burning questions that commonly arise in the clinical trenches,” said Dr. Speigel. He added, “Whenever our editorial board reviews a submission to the Journal, we always ask a simple question: ‘So what?’ By that, we mean will the results of this study be of interest to our largely clinical readership? Will it answer an important question of clinical relevance? Will it help, if even in a small way, to improve the lives of our patients?” This year, Dr. Lacy hopes to see a series of state-of-the-art original research articles and review articles that will enable readers of ACG’s Red Journal to continue their lifelong commitment to education and patient care. Both Co-Editors-in-Chief are proud of the papers they publish and are grateful to the talented GI and liver researchers around the world who are willing to submit their best work to ACG’s clinical journal.


[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

Diagnostic and Therapeutic Long-term Management of Eosinophilic Esophagitis—Current Concepts and Perspectives uter et al. Clinical and Translational for Steroid Use Gastroenterology (2018)9:212 Thomas Greuter, MD, Jeffrey A. Alexander, MD, Alex Straumann, MD, David A. Katzka, MD, FACG

[ACG CASE REPORTS JOURNAL]

Gastric Angiomyolipoma Masquerading as Gastric Malignancy Page 6 of 8 Divya Achutha Ail, MD, Roopa Rachel Paulose, FRCPath, Abhijit Kalitha, MD, Annie Jojo, MD, PDCC, and Unnikrishnan G, MS, DNB GASTRIC ANGIOMYOLIPOMA (AML) IS EXTREMELY RARE, with

only three cases reported in English literature, all Eosinophilic esophagitis (EoE) of which presented with upper gastrointestinal is a chronic inflammatory bleed, either in the form of hematemesis or disease of the– esophagus, –which melena. A 42-year-old man presented with – requires short- and long-term upper gastrointestinal bleed, the source of which treatment. In addition, patients was found to be a large mass in the stomach, – – under long-term treatment for which was shown histologically to be gastric any chronic condition should AML. This is the fourth but largest tumor (9 × 6 × have a structured follow-up. 5 cm) to be reported to date. The mainstays in EoE treatment are drugs (such as swallowed  READ the full case: bit.ly/CRJDec18 topical corticosteroids (STCs) and proton pump inhibitors), – – dietary exclusions, and endoscopic dilations. STCs are the most widely used treatment and have proven efficacy in inducing clinical, endoscopic and histological remission in active EoE. However, data regarding maintaining disease remission and longterm management are limited. Ongoing y (2018)9:212 Page 6 of 8disease activity and relapses despite STC treatment are frequently observed. This 1 Current therapeutic concepts at the Swiss EoE Clinic and at the Mayo Clinic sheds light on the urgent need for adequate maintenance strategies, which have not in terms of long-term EoE management presence of isolated esophageal eosinophilia in an gap been well defined. In terms of mptomatic patient with a– low EREFS– score predicts (NCT02493335 and NCT03245840, clinicaltrials.gov) follow-up concepts, to date ase progression; and (4) It is unclear if a static mea- particularly in the context of very high histological neither guidelines nor consensus ement of esophageal eosinophilia represents absolute response rates ( > 93%) with the budesonide regimen in the recommendations have been – es on a month to month basis or the esophagus as a short-term38. However, the trials are not expected to be published. To summarize the ole given the patchy distribution of esophageal eosi- completed and published within the next two years. Until current knowledge on long-term hilia. Esophagogram is used based on a recent study more data exist, one of the two or a blend of the two diagnostic and therapeutic STC wing higher sensitivity for detecting strictures with strategies might be followed after a successful induction management of EoE, the authors um esophagography compared to endoscopy. Indeed, treatment: (1) switch to a low maintenance dose, which is conducted a literature search sitivity of endoscopy to detect a small caliber eso- associated with significant better outcome than no treatusing PubMed and Embase gus of less than 13 mm is less than– 26% 37. ment and has a well-documented safety profile or (2) treat applying the following key search – ifferences in the long-term management of EoE at our patients with the same dose that brought them into items: Eosinophilic esophagitis, EoE referral centers highlight the lack of clear remission. The fact that a dose reduction appears to be eosinophils, esophagus, with a worse outcome and the findings of lower ommendations. Nonetheless, the two concepts applied associated swallowedrates topical in corticosteroids, the long-term than with high-dose he Swiss EoE Clinic and Mayo Clinic have two remission fluticasone, budesonide, treatment favorlongthe second option. However, the ortant features in common: (1) indefinite treatment is induction term, treatment, and in the published observarates of loss therapy, of follow-up ommended in most if not all EoE patients, and (2) high follow-up. In appear addition, studies tothe be authors an important confounder since ase activity should be monitored in the long-term by tional present empirically developed patients are more likely to show up for e objective measure which goes beyond assessment of non-compliant long-termvisits, management scheduled which concepts might result in falsely elevated ptoms alone (Fig. 1). applied at two large EoE centers, rates of treatment failure. In addition, it is still unclear if withreduction a special focus dose per seonorSTC rather a dose reduction below a pectives on long-term steroid treatment treatments. the authors level Finally, are responsible for an inferior outcome. wo areas of uncertainty been therapeutic identified: (1) opti- specific FIG. have 1: Current highlight research When it areas comesoftofuture the best follow-up strategies, there is doses of STC in the maintenance phase and (2) concepts at the Swiss EoE Clinic perspectives regarding the at theand Mayo Clinic noandconsensus without available data to better guide hod frequency of and diagnostic follow-up. at the Mayo Clinic Two curlong-term management of EoE. However, close follow-up makes sense ly ongoing phase III studies will close an important recommendations.

in an predicts c meabsolute us as a al eosit study

 READ the full article:

gap in terms of long-term EoE management bit.ly/CTGDec18 (NCT02493335 and NCT03245840, clinicaltrials.gov) particularly in the context of very high histological response rates ( > 93%) with the budesonide regimen in the short-term38. However, the trials are not expected to be completed and published within the next two years. Until more data exist, one of the two or a blend of the two

al journal of the American College of Gastroenterology

Inside the Journals | 43


M CECUM THE CECU HING THE REACHING REAC By Robert E. Kravetz, MD, MACG Scottsdale, AZ

A LOOK BACK

PNEUMATIC DILATOR for ACHALASIA

A

This archival reflection originally appeared in The American Journal of Gastroenterology in May 2002.

chalasia is a common motor disorder of the esophagus that was first described by Sir Thomas Willis in London in 1674. He used a whale bone attached to a sponge to dilate his patient. Von Mikulicz in 1881 believed that there was a spasm at the cardia; the entity was labeled cardiospasm. In 1937, Lendum noted incomplete relaxation of the lower esophageal sphincter, which was named achalasia, the term in current use. Forceful dilation that tears the circular muscles of the esophagus is necessary to achieve a lasting effect. In 1924, Starck, a German physician, utilized a mechanical dilator with expanding metal arms, but its popularity was brief. Hydrostatic balloon dilators filled with water were popular in Europe, but the standard therapy became forceful pneumatic balloon dilation. The first

44 | GI.ORG/ACGMAGAZINE

pneumatic dilator was described by Mosher in 1923. Several other pneumatic dilators have been used since that time with both success and complications. Currently cylindrical air-filled balloon Rigid-flex dilators passed over a guidewire are most popular. The Mosher style pneumatic dilator illustrated here dates from the 1950s. It consists of a flexible metalspring perforated bougie tip that is passed into the stomach. The rubber-covered silk bag is placed at the esophagogastric junction. A metal and whale bone staff is used for introduction of the bag, and an inflating bulb and gauge to measure pressure. The complication rate confined to larger perforations has remained constant over the years.


IMPORTANT SAFETY INFORMATION SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution. INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. WARNINGS AND PRECAUTIONS: SUPREP Bowel Prep Kit is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults. Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Pre-dose and post-colonoscopy ECGs should be considered in patients at increased risk of serious cardiac arrhythmias. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance. Pregnancy: Pregnancy Category C. Animal reproduction studies have not been conducted. It is not known whether this product can cause fetal harm or can affect reproductive capacity. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 375 patients who took SUPREP Bowel Prep Kit in clinical trials, 94 (25%) were 65 years of age or older, while 25 (7%) were 75 years of age or older. No overall differences in safety or effectiveness of SUPREP Bowel Prep Kit administered as a split-dose (2-day) regimen were observed between geriatric patients and younger patients. DRUG INTERACTIONS: Oral medication administered within one hour of the start of administration of SUPREP may not be absorbed completely. ADVERSE REACTIONS: Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache. Oral Administration: Split-Dose (Two-Day) Regimen: Early in the evening prior to the colonoscopy: Pour the contents of one bottle of SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Consume only a light breakfast or have only clear liquids on the day before colonoscopy. Day of Colonoscopy (10 to 12 hours after the evening dose): Pour the contents of the second SUPREP Bowel Prep Kit into the mixing container provided. Fill the container with water to the 16 ounce fill line, and drink the entire amount. Drink two additional containers filled to the 16 ounce line with water over the next hour. Complete all SUPREP Bowel Prep Kit and required water at least two hours prior to colonoscopy. Consume only clear liquids until after the colonoscopy. STORAGE: Store at 20°-25°C (68°-77°F). Excursions permitted between 15°-30°C (59°-86°F). Rx only. Distributed by Braintree Laboratories, Inc. Braintree, MA 02185.

For additional information, please call 1-800-874-6756 or visit www.suprepkit.com

©2018 Braintree Laboratories, Inc. All rights reserved.

HH27314A

September 2018


THE ORIGINAL 1 LITER PRESCRIPTION BOWEL PREP SOLUTION

1 MOST PRESCRIBED,

#

BRANDED BOWEL PREP KIT1 WITH MORE THAN 15 MILLION KITS DISPENSED SINCE 20101 2

FIVE-STAR EFF1CACY WITH SUPREP ® Distinctive results in all colon segments • SUPREP Bowel Prep Kit has been FDA-approved as a split-dose oral regimen3 • 98% of patients receiving SUPREP Bowel Prep Kit had “good” or “excellent” bowel cleansing2* †

• >90% of patients had no residual stool in all colon segments2*

These cleansing results for the cecum included 91% of patients2*

Aligned with Gastrointestinal Quality Improvement Consortium (GIQuIC) performance target of ≥85% quality cleansing for outpatient colonoscopies.4 *This clinical trial was not included in the product labeling. †Based on investigator grading. References: 1. IQVIA. National Prescription Audit Report. September 2018. 2. Rex DK, DiPalma JA, Rodriguez R, McGowan J, Cleveland M. A randomized clinical study comparing reduced-volume oral sulfate solution with standard 4-liter sulfate-free electrolyte lavage solution as preparation for colonoscopy. Gastrointest Endosc. 2010;72(2):328-336. 3. SUPREP Bowel Prep Kit [package insert]. Braintree, MA: Braintree Laboratories, Inc; 2017. 4. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53.

©2018 Braintree Laboratories, Inc. All rights reserved.

HH27314A

September 2018


ACG MAGAZINE ARCHIVE 2018 ACG MAGAZINE Fall 2018

ACG MAGAZINE Spring 2018

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Summer 2018

MEMBERS. MEDICINE. MEANING.

GIVING RISE to

MEMBERS. MEDICINE. MEANING.

Winter 2018

MEMBERS. MEDICINE. MEANING.

Banishing

Burnout& Building Resilience The Essential ed anc Roles of Adv viders Practice Pro in GI

Resolved to

ACG MAGAZINE

BEAT

COLON

GI in RWANDA

CANCER

Vol. 2 No. 1 // Spring 2018

Vol. 2 No. 2 // Summer 2018

Vol. 2 No. 3 // Fall 2018

Vol. 2 No. 4 // Winter 2018

2017 Volume 1, Number 1

ACG MAGAZINE Members. Medicine. Meaning.

Striking

Gold

ACG MAGAZINE Summer 2017

MEMBERS. MEDICINE. MEANING.

FINDING DISCOMFORT

ACG MAGAZINE Fall 2017

MEMBERS. MEDICINE. MEANING.

ACG MAGAZINE Winter 2017

MEMBERS. MEDICINE. MEANING.

THE RACING LIFE OF DR. FRED POORDAD

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Vol. 1 No. 1 // Spring 2017

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