ACG Magazine | Vol. 6, No. 4 | Winter 2022

Attend an upcoming

ACG POSTGRADUATE COURSE

2023

ACG’s Hepatology School & Western Regional Postgraduate Course

Caesars Palace | Las Vegas, NV

January 27–29, 2023

ACG/LGS Regional Postgraduate Course

Hilton New Orleans Riverside | New Orleans, LA

February 24–26, 2023

ACG/FGS Annual Spring Symposium

Hyatt Regency Coconut Point | Naples, FL

March 10–12, 2023

ACG’s Hepatology School & ACG Eastern Regional Postgraduate Course

The Westin Hotel | Washington, DC

June 2–4, 2023

ACG’s Functional GI and Motility Disorders School & ACG Midwest Regional Postgraduate Course

Minneapolis, MN

August 25–27, 2023

ACG’s Endoscopy School & ACG/VGS/ODSGNA Regional Postgraduate Course

Williamsburg Lodge | Williamsburg, VA

September 8–10, 2023

MORE INFO: gi.org/acg-course-calendar

FEATURED CONTENTS

COVER STORY

ACG at 90: How It Started. How It's Going.

Reflecting on 90 years of ACG and how the College has evolved to meet current GI clinician needs and support the future of clinical GI PAGE 22

Trainee Hub Section Editor Dr. Katie Dunleavy on what clinician-driven research means for trainees, reflecting on the 2022 AJG Lecture delivered by Dr. Patrick Kamath

MESSAGE

THE

NOVEL & NOTEWORTHY

TRAINEE HUB

REACHING THE CECUM

ACG MAGAZINE

CONNECT WITH ACG MAGAZINE STAFF

youtube.com/ACGastroenterology

Executive Director

Bradley C. Stillman, JD

Editor in Chief; Vice President, Communications

Anne-Louise B. Oliphant

Manager, Communications & Member Publications

Becky Abel

Art Director

Emily Garel

Senior Graphic Designer

Antonella Iseas

BOARD OF TRUSTEES

President: Daniel J. Pambianco, MD, FACG

President-Elect: Jonathan A. Leighton, MD, FACG

Vice President: Amy S. Oxentenko, MD, FACG

Secretary: Costas H. Kefalas, MD, MMM, FACG

Treasurer: William D. Chey, MD, FACG

Immediate Past President: Samir A. Shah, MD, FACG

Past President: David A. Greenwald, MD, FACG

Director, ACG Institute: Neena S. Abraham, MD, MSc, MACG

Co-Editors, The American Journal of Gastroenterology: Jasmohan S. Bajaj, MD, MS, FACG

Millie D. Long, MD, MPH, FACG

Chair, Board of Governors: Dayna S. Early, MD, FACG

Vice Chair, Board of Governors: Sita S. Chokhavatia, MD, MACG

Trustee for Administrative Affairs: Irving M. Pike, MD, FACG

TRUSTEES

Jean-Paul Achkar, MD, FACG

Seth A. Gross, MD, FACG

David J. Hass, MD, FACG

Immanuel K. H. Ho, MD, FACG

James C. Hobley, MD, MSc, FACG

Nicholas J. Shaheen, MD, MPH, MACG

Aasma Shaukat, MD, MPH, FACG

Neil H. Stollman, MD, FACG

Renee L. Williams, MD, MHPE, FACG

Patrick E. Young, MD, FACG

facebook.com/AmCollegeGastro twitter.com/amcollegegastro instagram.com/amcollegegastro bit.ly/ACG-Linked-In 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

American College of Gastroenterology is an international organization with more than 18,000 clinician members representing some 86 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

Mohammad Fahad Ali, MD

Dr. Ali is Chief of Endoscopy & Chair, Department of Medicine at Guthrie Cortland Medical Center in Cortland, NY and is a member of the ACG Research Committee.

Jill K.J. Gaidos, MD,

FACG

Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program. She is a member of ACG’s Digital Communications and Publications Committee.

Laura Chiu, MD, MPH

Dr. Chiu is Assistant Professor of Medicine at Boston University School of Medicine and a past participant of the ACG Institute Young Physician Leadership Scholars Program.

Anca I. Pop, MD, MBA

Dr. Pop is Head of Medical Affairs in Gastroenterology at Sanofi Genzyme and was previously a member of ACG’s Women in GI Committee.

Rahul S. Dalal, MD, MPH

Dr. Dalal is an advanced IBD fellow at Brigham and Women’s Medical Center. He is the recipient of a 2021 North American Training Grant and a member of the ACG Training Committee.

Amanda B. Pressman,

MD, FACG

Dr. Pressman is Assistant Professor of Medicine at Brown University and Director of the Program in Pelvic Floor Disorders at Women’s Medicine Collaborative in Providence, RI. She is a member of ACG’s Professionalism Committee.

Kenneth R. DeVault, MD, MACG

ACG Past President Dr. DeVault is Professor of Medicine at Mayo Clinic Jacksonville. He currently serves as Chair of the ACG Archives Committee and a member of the ACG Finance and Budget Committee.

Lawrence

R. Schiller, MD, MACG

Among his many ACG leadership roles, Past President Dr. Schiller is most recently past chair of the ACG Archives Committee.

Katie

A. Dunleavy, MB BCh BAO

Dr. Dunleavy is a second-year GI fellow at Mayo Clinic Rochester and is a member of ACG’s Digital Communications and Publications Committee. She serves as the Editor of ACG MAGAZINE’s Trainee Hub section.

Savita Srivastava, MD

Dr. Srivastava is a gastroenterologist at Augusta Health Gastroenterology in Fishersville, VA.

MESSAGE FROM THE PRESIDENT

By Daniel J. Pambianco, MD, FACG THE

YEAR AHEAD

DEAR COLLEAGUES:

I wish to express my appreciation to all who attended, participated, and conducted the ACG Annual Scientific Meeting in Charlotte in person or virtually, making it a most successful meeting, bringing us all up to date with the latest advances in gastroenterology research and patient care. I especially would like to cite our incredible ACG staff for the monumental job of organizing our meeting as a hybrid, both live and virtually, allowing this to be one of our most wellattended meetings. I would encourage anyone who could not attend, or those wishing to review the presentations, to access the ACG Education Universe library of recorded lectures. Most importantly, it was exciting and rewarding to experience the vibrance and positive sentiment of everyone sharing these moments together.

As a private practitioner, it is with great pride and humility that I will be serving you this next year as president of such an outstanding organization. It will certainly be a crowning moment in my professional career on a macro level. I hope to shape the agenda of the College to bring added focus the education of our fellows in preparation for their future, albeit in academics or the practice of gastroenterology of which the vast majority will be destined.

In addition, we need to gain a greater understanding of the transformation of the practice of gastroenterology from a cottage industry to growing group consolidation. I believe we are in the most challenging times for the practice of medicine in general and particularly GI. Approximately 50 percent of GIs are currently employed by hospitals or healthcare organizations, and this number is rising. Due to the decreasing ability for private practice self-capitalization, there is increasing interest in consolidation with other GI groups and increasing healthcare private equity group interest in GI. My goal as president is to broaden our educational support for our members to help understand this current phenomenon and prepare our trainees and practices to make the most intelligent decisions for the betterment of our patient care.

Another area of focus will also be ACG’s continued involvement with helping to improve the ABIM’s MOC testing in making the process less onerous, more educational, and bringing added practical assessment of our specific areas of expertise. The ACG has taken the lead with our sister societies in moving the ABIM to an ongoing learning model.

The GI OnDEMAND platform that the ACG has pioneered will be another continued initiative I hope to grow to bring tertiary multidisciplinary care access to our practices and our patients virtually with genetic testing and counseling for colon cancer, dietary and psychologic GI specific counseling access for IBS and IBD patients to name a few of its attributes.

The ACG has worked arduously in bringing our voice to Washington and we have been successful in crafting legislation that has been passed to enable patient access to colon cancer screening and prevention. Our current Legislative & Public Policy Council, under the auspices of Louis Wilson, will be transformational in our patient and practitioner advocacy in DC. The LPPC is developing even stronger relationships with the congressional GOP Doctors Caucus and other lawmakers. In conjunction with the Board of Governors, the LPPC is also operationalizing the National Affairs Advocacy Network, a system to identify, support, and educate legislators as to CMS’ improvements to physician reimbursements, easing regulatory burdens, and allowing greater patient access to care.

Lastly, the ACG Institute under the leadership of Neena Abraham has been progressively evolving educational programs and funding research initiatives, in young physician career and leadership development as well as diversity, equity, and inclusion. These programs will produce the next generation of clinical and research gastroenterologists. I hope to promote adding a component of developing a clinical research education and opportunities for private practice clinicians to participate in clinical trials, since I feel community-based research is vital to advancing a greater understanding of GI diseases and new treatments across a needed spectrum of our diverse population.

I would like to conclude by adding some personal thoughts on professional career development on a micro level that I hope to be a reminder at this season of evocation. I would encourage us all to appreciate the gift we have all been given and that is the gift of service to our patients. When we walk into that room and close the door, our patients share with us their innermost selves. That is a gift like no other to entrust to a relative stranger. The trust and faith and desire to help and wanting to be helped is the foundation of being a healer and is the best reimbursement.

I send everyone best wishes for the holiday season!

—DJP

“The trust and faith and desire to help and wanting to be helped is the foundation of being a healer and is the best reimbursement.”

Note wor thy Note wor thy

IN THIS ISSUE we have lots of news with an international flavor, including ACG faculty participation in meetings abroad, and Training Grants through the ACG International Relations Committee that encourage education and exchange in GI globally.

A round-up of highlights from ACG 2022 in Charlotte, NC, features links to this year’s Leadership & Awards booklet, celebrates winners of the SCOPY Awards and GI Jeopardy competition, and recognizes the “Prescriptions for Success” program and #DiversityinGI Virtual 5K. Among the kudos for achievements by ACG members, Dr. Vani Paleti reached new heights this year at the summit of Mount Kilimanjaro.

Send your news or story ideas to ACGmag@gi.org

DANUBE WALTZ

SZÉCHENYI CHAIN BRIDGE, BUDAPEST Lawrence R. Schiller, MD, MACG

The moment. Traveling with friends adds a delightful dimension to trips. A few years ago, Jack Di Palma invited several of us on a Viking River Cruise on the Danube from Passau, Germany, to Budapest, Hungary. Towards the end of the trip we arrived in Budapest, capital of Hungary, and moored next to the historic Széchenyi Chain Bridge across the river from Buda Castle.

Dinner was served at sunset onboard our ship. After dinner, I arrived back at our cabin, looked out the window, and—for the first time—saw the bridge brilliantly illuminated. Being something of a bridge fanboy from my youth, I was overwhelmed and wanted to memorialize that moment with a photograph.

The shot. Traditional exterior photography at night using film is fraught. Whereas our eyes and visual system readily deal with high contrast, unevenly illuminated views to create a detailed, coherent 3-D picture of the real world with great depth of field, the photographer using film must balance film speed, aperture, and exposure time, and must eliminate camera motion to make the best possible 2-D image, but often this results in compromises that make the recorded image less vivid than one’s memory of the scene. Algorithmic HDR as implemented on many cell phone cameras can produce lucid, detailed images with great depth of field without much fuss, even at night.

This image was captured by my old iPhone 6 Plus with its fixed 4.15 mm f/2.2 lens, exposure time of 1/15 sec, and ISO320. I was—and remain—enraptured by this image: the detail in the stonework of the towers, the reflected highlights in the water, and looming over it all, the dome of Buda Castle in perfect focus. I don’t think

that I could have done a better job with a fancy DSLR camera. Looking at this photo always takes me right back to the instant that I first saw this scene.

Reflections on

photography. We live in a world saturated with images of all types: online,

in print, on signs, and on TV. As gastroenterologists, we make images everyday during endoscopic procedures. In our personal lives, photographs and videos are part of family celebrations and life events, documenting the passage of time and the relationships that make life meaningful. While many of

these images are banal, some evoke strong emotions and can transport us across time to different places. They remind us of our hopes and dreams, friends and acquaintances, feelings and reactions. Photography makes us better people by allowing us to remember the past vividly.

Dr. Schiller is ACG Past President (2011 to 2012) Most recently among his extensive service to the College, he was a member of the Archives Committee from 2015 to 2021, and its chair from 2018 to 2021. He directed the GI fellowship program at Baylor University Medical Center in Dallas from 1996 to 2021.

This photo: The Széchenyi Chain Bridge opened in 1849 and was the first permanent bridge spanning the Danube in Budapest. It was designed by the British engineer, William T. Clark, and was fabricated in the United Kingdom. The bridge was destroyed by retreating German soldiers in 1945 and was reconstructed after the war. Photo bottom right: Travelers down the Danube L to R: Jack Di Palma, Larry Schiller, Renee Remily, Frank Farraye, Mark Cleveland, Lilly Cleveland, Ann Schiller, Ann Di Palma.

EL SALVADOR MEETING

ACG sponsored two faculty speakers for the Central American Gastroenterology Association’s meeting in El Salvador in July: Aasma Shaukat, MD, MPH, FACG, and Douglas Morgan, MD, MPH, FACG. ACG Governor for Central America, Jose-Miguel Moreno, MD, FACG, was instrumental in securing the College’s support for the meeting that also included Ronnie Fass, MD, MACG among the

[AWARDEES]

2022 ACG INTERNATIONAL GI TRAINING GRANT AWARD

Each year the ACG International Relations Committee recommends awards for international gastroenterologists to train in the U.S. and for North American gastroenterologists to expand their horizons and train abroad. This year four awards were granted.

2022 ACG International GI Training Grant Awardees

Kartik Natarajan, MBBS, of Apollo Main Hospital in Chennai, Tamil Nadu, India, will travel to Mayo Clinic Rochester.

Stella-Maris Chinma Egboh, MD, MSc, of the Federal Medical Center in Yenagoa, Bayelsa State, Nigeria, will train at Massachusetts General Hospital.

2022 ACG North American International GI Training Grant Awardees

Andrew M. Moon, MD, MPH, of the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, will train at the Barcelona Clinic Liver Cancer in Spain.

Rahul S. Dalal, MD, MPH, of Brigham and Women’s Hospital, Boston, Massachusetts, trained at Odense University Hospital in Denmark this summer. Read more about his

TRAIN THE TRAINERS IN

The World Gastroenterology Organisation (WGO) and the Polish Society of Gastroenterology hosted a “Train the Trainers” Workshop in August in Warsaw, Poland. ACG members Carol A. Burke, MD, FACG; Truptesh Kothari, MD, MS, FACG; and Aasma Shaukat, MD, MPH, FACG, attended as faculty on behalf of the College.

[NEW HEIGHTS]

VANI PALETI, MD, of Baylor, Scott & White Health in Killeen, TX, reports on her summit of Mount Kilimanjaro this September:

“The journey of thousand miles begins with one step.” —Lao Tzu

I signed up to hike Mount Kilimanjaro, one of the seven summits, at the height of COVID-19 Delta wave as a distraction from the grueling pandemic and the toll it was taking on health care professionals.

My mantra was to show up, take that one step, and keep moving forward. It was a physically exhausting and spiritually humbling experience watching the amazing sunrise over the roof of Africa at 19,341 feet.

[KUDOS]

Carol A. Burke, MD, FACG, received the Lifetime Achievement Award from the Collaborative Group of the Americas Inherited Gastrointestinal Cancer. Dr. Burke is ACG Past President (2016-2017) and currently Vice Chair of the Department of Gastroenterology, Hepatology and Nutrition and Head of Polyposis at the Sanford R. Weiss, MD, Center for Hereditary Colorectal Neoplasia at the Cleveland Clinic Foundation.

[ADVOCACY]

Dr. Louis Wilson spent two days in Washington, DC, in early December meeting with numerous Members of Congress and Hill staff with a focus on members of the GOP Doctors Caucus. Dr. Wilson serves as Chair of ACG's Legislative & Policy Policy Council. He advocated for clinical gastroenterology, ACG members, and GI patients, fighting for GI reimbursement and patient care.

Jose-Miguel Moreno, MD, MPH, FACG, ACG Governor for Central America

ACG LEADERSHIP & AWARDS

BOOKLET

 Read the ACG “Year in Review” and explore the College’s 2022 awards, committee priorities, and achievements: bit.ly/2022-leadership-and-awards

SCOPY AWARDS

SCOPY celebrates excellence in community education and public awareness efforts to advance colorectal cancer screening and prevention by ACG members and their staffs. See all 2022 awards: bit.ly/SCOPY-Awards-22

INSTITUTE IN FOCUS: AN IMPACT REPORT FOR ACG MEMBERS

The ACG Institute reports on a year of accomplishments, its investment in clinical research, and priorities of The Center for Leadership, Ethics & Equity.

 Read: bit.ly/ACG-Institute-2022

GI JEOPARDY WINNERS

Taking home the coveted trophy from ACG 2022 was the team from St. Luke's University Health Network in Bethlehem, PA, Hussam Tayel, MD and Brian Kim, MD, who prevailed in an intense

#DIVERSITYINGI VIRTUAL 5K

and William Hensley, both of Incubator Comics, who together envisioned an award-winning comic book-style bowel prep guide, “Route #2.”

University in St. Louis School

“PRESCRIPTIONS FOR SUCCESS” PROGRAM FOR HIGH SCHOOL STUDENTS

An annual tradition since 1999, ACG members inspire students at a local high school in the city of the Annual Scientific Meeting as a way to cultivate the pipeline in GI and medicine through the ACG Committee on Diversity, Equity & Inclusion. This year’s visit to Hawthorne Academy of Health Sciences in Charlotte, NC, also included members of the College’s APP Committee.

L to R: John T. Bassett, MD, FACG; Mary Vetter, ANP, Outgoing Chair, APP Committee; Sophie M. Balzora, MD, FACG, Chair DEI Committee; Victor Chedid, MD; Shayla Schoenoff, PA; Corlan Eboh, MD; Sophia Lichenstein-Hill, DNP; Belen Tesfaye, MD; and Baharak Moshiree, MD, MSc, FACG.

Thanks to generous sponsorship from Ironwood Pharmaceuticals and Takeda Pharmaceuticals, and participation by ACG members, the 2022 #DiversityinGI Virtual 5K raised $30,000 for the ACG Summer Scholars, a mentoring program for medical students from groups underrepresented in medicine, administered by the ACG Committee on Diversity, Equity & Inclusion. Learn more: bit.ly/ACG-DiversityinGI-22

of Medicine, with Isaac Fisher

THE EDGAR ACHKAR VISITING PROFESSORSHIP

PROGRAM (EAVP) provides GI training programs the opportunity to learn from and connect with experts on topics that enhance their fellowship curriculum, create informal mentoring opportunities, and encourage one-on-one or small group engagement with fellows. The EAVP experience also provides opportunities for ACG members in the community to connect at Grand Rounds and gut club events whenever possible. Learn more: gi.org/EAVP

At the University of Pittsburgh Medical Center in September, 2022: Kenneth E. Fanasella, MD, GI Fellowship Program Director, with EAVP Allison R. Schulman, MD, MPH of the University of Michigan who participated in pancreaticobiliary grand rounds.

Dr. Schulman had a chance to connect with UPMC GI fellows during her visit. L to R: Dr. Schulman; Jacob S. Lipkin, MD; Alan G. Noll, MD; Joseph Sleiman, MD; Zain M. Moosvi, MD; and Michal Kloska, MD.

Brian E. Lacy, MD, PhD, FACG of the Mayo Clinic Jacksonville visited GI fellows at the University of South Alabama in September and was welcomed by Jack A. Di Palma, MD, MACG.

Dr. Lacy’s EAVP visit also included a presentation to the Gulf Coast Gut Club.

Edward V. Loftus, Jr., MD, FACG, Director of the Advanced IBD Fellowship at the Mayo Clinic in Rochester, visits GI fellows at the University of California, Riverside in September.

Small group interaction and lots of time for questions is always a highlight of EAVP visits. Dr. Loftus’ host at UC Riverside, Dr. George Saffouri, said the only complaint, if it can be called one, was that the visit wasn’t long enough!

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults.

DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen:

Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Early in the evening prior to colonoscopy, open one bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy.

Packaging and tablets not shown actual size.

CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury. Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185

See Full Prescribing Information and Medication Guide at SUTAB.com.

References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020

3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

For additional information, please call 1-800-874-6756

©2021 Braintree Laboratories, Inc. All rights reserved. 201-133-v1-A January 2021

A

A NEW TABLET CHOICE IN BOWEL PREPARATION

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2†

• 52% of all SUTAB and MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡

• More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1% of these reports considered severe2‡

78% OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2†

*Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

†Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

*Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

‡Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion of study drug, rating the intensity as mild, moderate, or severe.

†Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG.

‡Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion of study drug, rating the intensity as mild, moderate, or severe.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG.

IMPORTANT SAFETY INFORMATION

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing

IMPORTANT SAFETY INFORMATION

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing

TRAINEE HUB

Trainee Perspective on: “The

Transformative Power of Research Out by Busy Clinicians

By Katie Dunleavy, MB, BCh, BAO

I SAT DOWN WITH DR. PATRICK KAMATH days before his keynote The American Journal of Gastroenterology lecture at ACG 2022. Dr. Kamath is a Professor of Medicine at Mayo Clinic in Rochester, MN. He focuses on the study of acute-onchronic liver failure, alcohol-related liver disease, polycystic liver disease, Budd-Chiari syndrome, and hereditary hemorrhagic telangiectasia. He and his co-workers were instrumental in developing the Model for End-Stage Liver Disease (MELD) score, which is used worldwide to determine prognosis in liver disease and to prioritize organ allocation

for liver transplantation. He is also an incredible clinician educator, winning more than a dozen “Teacher of the Year” awards in more than two decades of teaching before being inducted into the Hall of Fame. As AJG Co-Editor-in-Chief Dr. Jasmohan Bajaj said in introducing Dr. Kamath, “he has trained excellent human beings.” First and foremost, Dr. Kamath is a clinician who has dedicated his life to his patients but has evaded the omnipresent burnout through the transformative power of research.

As a GI fellow at Mayo Clinic, working with Dr. Kamath has been an absolute privilege. Though he still jokes that I should give up IBD and return to the liver! Whether learning the genealogy of a Ulysses butterfly or the pathophysiology of ascites, you will never have a boring day on service with Dr. Kamath as he strives to teach you 10 new facts daily. He always provides “homework” creating healthy competition to find a fact he’s never heard of. While his status is legendary, his humble demeanor and soft-spoken voice exemplifies his true nature. He leads with humility, teaches with grace, and lives in service to patients. It’s no wonder the excitement was palpable in Charlotte as he took the stage.

The Overlap of Job & Career

As we apply for residency and fellowship, we are all faced with the question, why do you want to be a gastroenterologist? As time progresses, we must honestly reflect on our answer and adjust our job to fit the career we desire. GI fellowship is the ideal time for exploration and skill building, as we try different “careers” on for size. Why not foray into medical education research or quality improvement projects? Consider visiting academic, community, and private practices for exposure to different work environments. Spend time writing your personal vision statement and evaluate the skills you need to achieve it. Dr. Kamath would agree that a strong clinical foundation is paramount, but without thought to the future, you run the risk of burnout. The mindset of pursuing gastroenterology as a career, rather than a job, is one you can start cultivating in fellowship as you strive to align values and ignite passion.

The Sweet Spot: High Impact-Low Effort Research

In GI fellowship, we are all busy clinicians — from clinic, to inpatient services, to endoscopy and overnight call — we are full time clinicians with many “side gigs.” At the same time, we can use our time in fellowship to become inquisitive about research. But with such limited time, we must focus our attention on

what Dr. Kamath calls “high impact-low effort” research. These research projects are founded on astute clinical observations that are cultivated during our busy clinical lives. In contrast, he warns against validation studies which yield limited patient outcomes and require high effort. We must keep the patient at the center, and work towards research that has meaningful impact on patient care.

Research Prevents Burnout?

It’s no surprise that physician burnout is on the rise, with 63% of physicians experiencing at least one symptom of burnout in 2022, compared to 44% in 2017.1 Burnout can be characterized by feelings of depletion, declining sense of personal accomplishment, and a lack of empathy. As technology pervades our daily lives, work-life balance is continually disrupted with only 30% of physicians satisfied, compared to 43% five years prior. Additionally, many current GI fellows worked on the frontlines of COVID during their internal medicine residencies, carrying loss and moral injury.1 If you started fellowship with a deficit, now is the time to work towards growth.

Do Dr. Kamath’s insights hold the key to burnout? In his lecture he highlights why research is meaningful to a clinician. Firstly, it can improve patient care so you can help the person sitting in front of you. Secondly, you know the problems you face better than anyone, which means you are uniquely poised to find the solution. Thirdly, the impact of clinical research is immediate, helping to fulfill

“GI fellowship is the ideal time for exploration and skill building, as we try different 'careers' on for size. Why not foray into medical education research or quality improvement projects? Consider visiting academic, community, and private practices for exposure to different work environments. Spend time writing your personal vision statement and evaluate the skills you need to achieve it.”

From Dr. Kamath’s AJG Lecture at ACG 2022: Focus on High Impact-Low Effort Research

a generation raised on instant gratification. Most importantly, according to Dr. Kamath, “research makes you an expert, your job a career, and can reduce burnout." He suggests that by spending more than 20% of our time (or one day a week) doing meaningful activities, we have the power to transform our career. That can be different for each physician and may change over time. For fellows, I would start by taking stock of the activities that bring you joy. When you’re scoping, does your attending see that you’re smiling a bit more than usual? Which patient stories stay with you?

Exploring the Galaxy of Research Myths

MYTH #1: You need a lot of funds and resources to do research.

FACT: Through the study of astronomy, Dr. Kamath explores the incredible story of Robert Evans, an 86-year-old retired pastor from Australia with a passion for supernovae. With a used $15 telescope, one personnel (himself), and unlimited time, he tracked 40 supernovae! Compared to the rest of the world who tracked 120 supernovae using hundreds of millions of dollars and thousands of personnel. How did he do it? Three simple words – OBSERVE, STUDY, have patience –TIME!

Time Travel 101: Finding Time for Research

• Make sure your job and career overlap

• Carry papers/manuscripts with you (i.e., devices)

• Write in the time between patients and procedures

• Leave the last sentence of a manuscript unfinished to avoid a cold start (as recommended by the great Stephen King)

• Take advantage of travel delays to have uninterrupted writing time

• REMEMBER: HOME IS FOR THE FAMILY

MYTH #2: Simple research cannot have a major impact.

FACT: Dr. Kamath expertly persuades the audience that unfunded clinical observational research may have more of an impact than even NIH-funded studies. An in-depth look at the most cited papers at Mayo Clinic since 1975 shows us that about 50% are based on clinical observations. He further highlights this

point as he walks us through Dr. Pere Gines’ research in ascites. Dr. Gines' seven major studies began with simple questions (i.e., Spironolactone or Furosemide, paracentesis or diuretics, etc.) that led to significant impact in patient care. In short, simple is the solution.

Never Give Up: The story Behind MELD

The story of MELD began with a simple question: Can we predict which patient is at high risk for dying following a transjugular intrahepatic portosystemic shunt (TIPS) procedure? It was 1991 when Dr. Kamath came to Mayo Clinic as a busy young clinician. At the time, he did not have significant funding or a study coordinator and would keep his records in handwritten notebooks. By 1992 he was collaborating with Dr. Mike McKusick in interventional radiology to perform their first TIPS procedure. The first patient did remarkably well, though several others did not. As Dr. Kamath spent time with the trial patients, he got to know their stories and their families. Eventually, he asked why are some patients doing well and others are dying?

Despite rejection from top medical journals, including New England Journal of Medicine and Gastroenterology before being accepted (with two revisions) to Hepatology, Dr. Kamath is firm that you must never get mad when your paper is rejected, but rather move on. Following his first publication on the MELD score in 2000, he had a chance encounter that shaped the future of his career. As a fellow, I’ve often heard the need to create your ‘elevator pitch,’ but I didn’t realize the importance until I heard this story. One day, Dr. Kamath was riding up the elevators at Methodist Hospital in Rochester, when he met Dr. Russell Wiesner, the first medical director of liver transplant at Mayo Clinic. As Dr. Wiesner congratulated Dr. Kamath on his recent publication, Dr. Kamath

“Overcoming the hurdles in research can be hard, but it starts with your mindset. Dr. Kamath’s story highlights the need to persevere despite failure and setbacks. You must not give up on yourself! He also emphasizes that research cannot be completed without a mentor who is there to hone research questions, provide background information, and open doors for opportunities.”

took the opportunity to tell him that the model was predictive in all of cirrhosis, not just patients undergoing TIPS, using data from colleagues in Barcelona. As chance would have it, Dr. Wiesner was on the United Network for Organ Sharing (UNOS) committee tasked with finding a new classification for prioritizing liver transplantation. And >10,000 citations later, the rest is history… Of course, it’s entirely possible MELD may have been as impactful without the elevator meeting, but I’m sentimental.

Eliminating the Roadblocks

Overcoming the hurdles in research can be hard, but it starts with your mindset. Dr. Kamath’s story highlights the need to persevere despite failure and setbacks. You must not give up on yourself! He also emphasizes that research cannot be completed without a mentor who is there to hone research questions, provide background information, and open doors for opportunities. As a busy clinician researcher, or GI fellow, it is your responsibility to find them. Bonus points for the institutions that value collaborative mentorship and prioritize clinical and research mentors for all GI fellows. When choosing your field of study, you must be original. This means finding the areas that people avoid studying and asking simple questions. Consider studying GI or liver diseases in special populations such as pregnancy, elderly, veterans, and health care disparities. You can find a home in the “in-between” fields such as liver disease in IBD, or endocrinology disorders in hepatology, as this allows for collaboration across divisions. Once you have these elements, you must prioritize research and find meaning in your work.

https://doi.org/10.1016/j.mayocp.2022.09.002.

THE #DRPATRICKKAMATH LESSONS

1. Unless you remain healthy, you cannot make others healthy.

2. Dream big! Do not let your dreams die.

3. Never stop learning.

4. Put service to patients before self.

5. Be honest, humble, helpful, and kind.

6. Spend 1 day a week doing something meaningful.

7. Ask the right questions! Simple is better.

8. Find time for research, but home is for family.

9. Study the feared “in-between”.

10. Don’t take “setbacks” or “failures” personally!

She is passionate about academic medical education and as a former coloratura soprano, she mentors several students with interests in music and medicine. On the weekends you can find her at the farmer’s market, singing, and doing yoga.

REFERENCE: 1. Tait D. Shanafelt, Colin P. West, Lotte N. Dyrbye, Mickey Trockel, Michael Tutty, Hanhan Wang, Lindsey E. Carlasare, Christine Sinsky, Changes in Burnout and Satisfaction

With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic, Mayo Clinic Proceedings, 2022,

Katie Dunleavy, MB BCh BAO – Dr. Katie Dunleavy is a second-year gastroenterology and hepatology fellow at Mayo Clinic, Rochester. She received her medical degree from the Royal College of Surgeons in Ireland and completed her internal medicine residency at Icahn School of Medicine at Mount Sinai Hospital in New York. Her area of clinical interests includes the overlap of inflammatory bowel disease and neurogastroenterology, ergonomics in endoscopy, and clinical trials research.

Image top: Dr. Kamath #Mythbuster. Image bottom: Dr. Kamath #Legendary

GETTING IT

Help Decrease Your Risk of Burnout

Amanda Pressman, MD, FACG

THIS ARTICLE PROVIDES SUGGESTIONS AND REFERENCES to help foster a better work-life balance. Physician burnout remains a significant problem for many ACG members. This article outlines suggested steps to help you reclaim your schedule and wellness.

SOURCES OF BURNOUT

The face of GI practice has shifted, with the majority of GI physicians now working as employees of hospitals or large physician groups (Carol Kane, AMA, 2017). Although this brings some advantages, such as access to EMRs, negotiated group rates with insurances/equipment suppliers, and coverage of the business aspects of practice, there are drawbacks. Employed physicians may have reduced autonomy, feel pressure to meet RVU productivity goals, face additional bureaucratic tasks, and feel a lack of respect from administrators. All of these things are known drivers of burnout. Although some

institutions do recognize the problem and encourage physician wellness with offers of discounted yoga and meditation programs, this is often insufficient to address the underlying drivers of burnout. As many of these institutions are being run by non-physician administrators with a business background, fundamental change to the workday that may improve burnout but that will decrease productivity and revenue is unlikely.

Carol A. Burke, MD, FACG, in her 2017 ACG membership survey, found that younger women physicians are among those with a higher rate of burnout, as well as those with children, those who take on more domestic chores/household management, and who take fewer than 20 days of vacation per year are particularly at high risk. This underlines the fact that for many gastroenterologists, particularly for working mothers, the “Work-Life Balance” is WAY out of balance. The pandemic and other challenges have only made matters worse. According to the recent study, a dramatic increase in burnout and decrease in satisfaction with work-life integration occurred in U.S. physicians between 2020 and 2021,“suggesting the increase in physician distress was overwhelmingly work-related.” (Shanafelt, Mayo Clinic, 2022)

RECLAIM YOUR TIME

It is time to reclaim control of our schedules and bring balance back to our lives, to combat the threat of burnout. Each individual must identify the key drivers of burnout in their practice, and take action to change. How?

Here are some ideas on how to uproot the sources of burnout and improve your life:

• Creative Use of Administrative Time. Many employed physicians have a day of administrative time built into their schedule. Rather than taking this as one block of time, consider using this time to end your clinical sessions an hour earlier, or to start an hour later each

day. This can give you time to finish notes, return calls and EMR messages, or to add in that urgent office visit. Building in some flexible time into each workday can allow you to KEEP WORK CONFINED TO THE WORKDAY.

• Use Your Vacation Days: ALL OF THEM. In 2014, the Medscape Lifestyle Report stated that less than 20% of gastroenterologists take more than 4 weeks of vacation per year. Studies have shown that health and wellbeing improve for employees who take vacations and are able to psychologically detach from work. (DeBloom, 2012)

• Practice Saying NO. If you are struggling to meet RVU goals, say NO to committee work or administrative roles that are unfunded and take time away from your clinical revenuegenerating time. If you are struggling to maintain boundaries between work and home life, say NO to meetings or CME activities that happen outside of business hours. Re-frame the conversation, focusing on avoiding burnout, such as saying, “Due to my many current obligations, I am unable to participate in that meeting.” Saying NO allows us to say YES to other aspects of our professional/personal lives that we deem important and may serve as an antidote to burnout (e.g., personal time, volunteer opportunities, professional improvement activities). Until physicians start saying NO, the culture of the workplace will not change.

• Incorporate Ergonomics and Build In Musculoskeletal Recovery Time During Your Endoscopy Sessions. Emotional and physical exhaustion is one of the three dimensions defining burnout. (Maslach, 1997) The musculoskeletal strain of endoscopy is well-documented, with many gastroenterologists suffering from thumb/hand, wrist, neck, back pain. These injuries contribute to physical exhaustion. To combat this, consider blocking 5-10 minutes between endoscopy cases to stretch, to allow “microbreaks,” to reduce your daily caseload and to improve musculoskeletal trauma. ACG also offers a useful video tutorial on ergonomics in endoscopy by Patrick E. Young, MD,

FACG, and Manish B. Singla, MD, FACG. (See references below.)

• Working Smarter, Not Harder. Consider changing your practice model to incorporate mid-levels, scribes, or a team-based approach. During COVID, many of us had our first experiences with telemedicine. Incorporating a telemedicine session with appropriate followup visits may be a way to work efficiently while making your schedule more flexible. The ACG Practice Management Toolbox offers a wealth of “tools” to help practices be more efficient and effective. For example, the Toolbox offers guidance on how to make your EHR system more user-friendly and actually work for you.

REFERENCES & RESOURCES: Importance of Vacation

• DeBloom J, Geurts SA, Kompier MAJ. Effects of short vacations, vacation activities and experiences on employee health and well-being. Stress Health. 2012 Oct;28(4):305-18.

• Sonnentag S, Arbeus H, Mahn C, Fritz C. Exhaustion and lack of psychological detachment from work during off-job time: moderator effects of time pressure and leisure experiences. J Occup Health Psychol. 2014 Apr:19(2)206-16.

Factors Impacting Burnout

• Kane, CK. Updated data on physician practice arrangements: physician ownership drops below 50 percent [Internet]. Chicago (IL): American Medical Association; 2017. Policy Research Perspective 2017-2

• Shanafelt, TD, et al. Changes in Burnout and Satisfaction with Work-Life Integration in Physicians Over the First 2 Years of the COVID-19 Pandemic: Mayo Clinic Proceedings, September 2022, https://www.mayoclinicproceedings. org/article/S0025-6196(22)005158/fulltext

• Hoff T, Lee DR. Burnout and Physician Gender: What Do We Know? Med Care. 2021 Aug 1;59(8):711-720.

• Maslach, C and Leiter, MP. The truth about burnout: How organizations cause personal stress and what to do about it Wiley, 2008.

• Paturel A. Why women leave medicine. (October 1, 2019) https://www.aamc. org/news-insights/why-women-leavemedicine

Keeping Work Confined to The Workday

• Reddy S, Rippey P, et al. Seven Habits for Reducing Work After Clinic. Fam Pract Manag. 2019 MayJune;26(3):10-16.

• Shanafelt TD, Noseworthy J. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. January 2017;92(1):129-146. https://www. mayoclinicproceedings.org/article/ S0025-6196(16)30625-5/fulltext

• Saunders E. How to Leave Work at Work. https://hbr.org/2020/02/how-toleave-work-at-work

• Shanafelt TD, et al. Principles to promote physician satisfaction and work-life balance. Minn Med. 2008; 91: 41-43

• Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016; 91: 422-431

Saying No

• Hinton AO Jr, McReynolds M, et al. The power of saying no. EMBO Rep 2020 July 3;21(7): e50918.

• Saunders E. How to Leave Work at Work. https://hbr.org/2020/02/how-toleave-work-at-work

• Zuckerman C. How to Beat Burnout — Without Quitting Your Job. https:// www.nytimes.com/2021/04/30/well/ workplace-burnout-advice.html

• Learning how to say no at work to avoid burnout. https://www.halftheskyasia. com/blog/2021/01/learning-how-tosay-no-at-work-to-avoid-burnout

• Kua P. Avoid Burnout and Start Saying No. Here’s How. https://www.patkua. com/blog/start-saying-no/

• Farris GE. Annals Graphic Medicine-Dr. Mom: Saying No. Ann Intern Med. 2021 Dec;174(12):W118-W119.

Endoscopic Ergonomics

• Singla M, Kwok R, Deriban G, Young P. Training the Endo-Athlete: An Update in Ergonomics in Endoscopy. Clinical Gastroenterology and Hepatology. 2018 July; 16 (7):1003-1006.

• Hallbeck MS, Lowndes BR, et al. The impact of intraoperative microbreaks with exercises on surgeons: A multicenter cohort study. Appl Ergon. 2017 Apr;60:334-341.

• Young P, Singla M. ACG Video of the Week: Ergonomics of Endoscopy with Patrick E. Young, MD, FACG, and Manish B. Singla, MD, FACG. https://gi.org/ ergonomics-of-endoscopy/

Working Smarter, Not Harder

• Lee MS, Nambudiri VE. Electronic consultations and clinician burnout: An antidote to our emotional pandemic? J Am Med Inform Assoc. 2021 May; 28(5):1038-41

• Mehta M, Nemec R. Leveraging the EHR to Your Advantage: Make the electronic beast work for you! ACG Practice Management Toolbox. ACG Magazine Winter 2021. https://issuu. com/amcollegegastro/docs/21acgmagwinter.web/21

Amanda Pressman, MD, FACG Center for Women’s Gastrointestinal Medicine/LifeSpan, Providence, RI, Member of the ACG Professionalism Committee

“It is time to reclaim control of our schedules and bring balance back to our lives, to combat the threat of burnout. Each individual must identify the key drivers of burnout in their practice, and take action to change.”

— Dr. Pressman

ACG AT 90

How It Started . How It's Going .

HONORING ACG'S PAST, CELEBRATING THE COLLEGE TODAY, AND LOOKING TO THE FUTURE.

A modern, relevant, and celebratory historical project marking the College’s 90th anniversary. This project of the Archives Committee puts the spotlight on ACG's current vibrant, diverse, and high impact programs, leaders, and accomplishments while honoring the College's heritage and longstanding commitment to clinical practitioners.

Founding Principles

HOW IT STARTED

1932

A group of 10 clinical gastroenterologists in and around New York City who believed that there was a need for an organization to serve the interests of practicing clinicians involved in patient care and research meet at the home of Samuel Weiss, MD and found the New York Society for the Advancement of Gastroenterology.

1934

The organization name is changed to the National Society for the Advancement of Gastroenterology to reflect the aspirations of the organizational leadership and the interests of clinical gastroenterologists from around the country. The Review of Gastroenterology is first published in 1934.

Weiss, MD

1938

The organization again changes its name, this time to the National Gastroenterological Association.

1954

The modern organization takes shape as the NGA is renamed the American College of Gastroenterology and creates a Board of Governors to connect the Board of Trustees to local gastroenterologists throughout the United States. The journal is renamed The American Journal of Gastroenterology.

Samuel

In an era during which the pursuits of some medical organizations were perceived as exclusive in tone and action, the medical society now known as ACG is envisioned by its founders as “a more inclusive organization of physicians interested especially in the clinical aspects of digestive disorders.”

ACG at 90 is a vibrant, diverse, and forward-looking organization with a vision and mission that have evolved to keep pace with the times but have never strayed from our founding principles. ACG is proud of its heritage of inclusion and dedication to clinical gastroenterology.

HOW IT’S GOING

Today, the American College of Gastroenterology remains true to its roots as a broadly inclusive organization dedicated to the advancement of clinical gastroenterology that champions the interests of clinical GI practitioners.

As the College looks back with pride at our rich 90-year history, we also celebrate ACG today – a vibrant, diverse, and forward-looking organization with a vision and mission that have evolved to keep pace with the times but have never strayed from our founding principles.

Vision Statement

The ACG is the preeminent professional organization that champions the prevention, diagnosis, and treatment of digestive disorders, serving as a beacon to guide the delivery of the highest quality, compassionate, and evidence-based patient care.

Mission Statement

Our mission is to enhance the ability of our members to provide world class care to patients with digestive disorders and advance the profession through excellence and innovation based upon the pillars of Patient Care, Education, Scientific Investigation, Advocacy, and Practice Management.

Arthur E. Lindner, MD, MACG

Dreiling, MD

The Review of Gastroenterology is first published in 1934 and Samuel Weiss, MD served as Editor-in-Chief until 1964. In 1954, the journal officially is renamed The American Journal of Gastroenterology and gets its distinctive red cover. A tradition of outstanding editorial leadership and dedication to clinical science continues as new titles are added to the family of ACG journals: Clinical and Translational Gastroenterology (2010); ACG Case Reports Journal (2013); and Evidence-Based Gastroenterology (2021).

HOW IT’S GOING

Leadership

Anthony Bassler, MD served as president from 1936-1948

HOW IT STARTED

ACG Board of Trustees 1995

Front Row L to R: Dr. Christina Surawicz, Dr. William Carey, Dr. Joel Richter, Dr. Seymour Katz, Dr. Marvin Schuster, Dr. Gregory Foutch

Back Row L to R: Dr. David Lyon, Dr. Victor Groisser, Dr. Daniel Pelot, Dr. Leslie Bernstein, Dr. David Peura, Dr. Sarkis Chobanian, Dr. Frank Lanza, Dr. Arnold Wald, Dr. Christopher Gostout

In 1954, the organization is renamed the American College of Gastroenterology and its First Annual Convocation is held in Washington, DC.

ACG Past Presidents 2000

Front Row L to R: Dr. Myron Lewis, Dr. John McMahon, Dr. Christina Surawicz, Dr. Lawrence Brandt, Dr. J. Edward Berk

Back Row L to R: Dr. Seymour Katz, Dr. Arthur Aufses, Dr. William Rosenthal, Dr. James Achord, Dr. Jamie Barkin, Dr. Luis Balart, Dr. Franz Goldstein, Dr. Walter Harvey Jacobs, Dr. William Carey, Dr. John Papp, Dr. Arvey Rogers, Dr. Jerome Waye

Service to the College by dedicated leaders has been a hallmark of ACG’s history. Their guidance, vision, hard work, and commitment to the mission and vision of the College have ensured that ACG evolves, thrives, and is well-positioned for the future.

HOW IT’S GOING

ACG Board of Trustees 2022

Front Row L to R: Dr. Neena Abraham, Dr. William Chey, Dr. Jonathan Leighton, Dr. Samir Shah, Dr. Daniel Pambianco, Dr. Costas Kefalas, Dr. Amy Oxentenko

Back Row L to R: Dr. David Hass, Dr. James Hobley, Dr. Aasma Shaukat, Dr. Jean-Paul Achkar, Dr. John Saltzman, Dr. Jasmohan Bajaj, Dr. Millie Long, Dr. Nicholas Shaheen, Dr. Seth Gross, Dr. Patrick Young, Dr. Irving Pike, Dr. Neil Stollman, Dr. Immanuel Ho, Dr. Renee Williams, Dr. David Greenwald, Dr. Dayna Early

Mark B. Pochapin, MD, FACG presents the ACG President’s Medal to David A. Greenwald, MD, FACG in Central Park, New York City, NY during COVID on October 18, 2020.

ACG Past Presidents 2018

Front Row L to R: Dr. Delbert Chumley, Dr. Ronald Vender, Dr. Irving Pike, Dr. Sunanda Kane, Dr. Burton Korelitz, Dr. Lawrence Brandt, Dr. Philip Katz

Back Row L to R: Dr. Lawrence Schiller, Dr. Jamie Barkin, Dr. Joel Richter, Dr. Jack Di Palma, Dr. Christina Surawicz, Dr. Carol Burke, Dr. Harry Sarles, Dr. David Johnson, Dr. John Popp, Dr. Seymour Katz

Daniel J. Pambianco, MD, FACG 2022-2023 President

Endoscopy

HOW IT STARTED

McNeer G, Early Experience in Flexible Gastroscopy. The Review of Gastroenterology. 1940; 7(6): 457-460

In no area of gastroenterology has there been greater evolution or more rapid pace of innovation than in endoscopy. Education, training, and promoting quality in clinical gastroenterology and endoscopy are centerpieces of the life of the College today.

HOW IT’S GOING

Education

HOW IT STARTED

Postgraduate Course Agenda, 1940

Dr. Jerome Waye, ACG Annual Scientific Meeting 1989

The College is an educational organization dedicated to excellence in CME for the GI profession. Our Postgraduate Course started in the 1940s and remains a timely, relevant, and valuable update in clinical GI, hepatology, and endoscopy. ACG’s agility in evolving to meet the needs of our learners was put to the test during the COVID-19 pandemic, but we nimbly rose to the challenge by offering a Virtual Annual Scientific Meeting & Postgrad Course in 2020 and launching weekly Virtual Grand Rounds.

HOW IT’S GOING

Platform for ACG 2020 Virtual Annual Scientific Meeting

Dr. Stacy Menees

ACG Annual Scientific Meeting 2018

Dr. William Chey

ACG Annual Scientific Meeting 2019

Advocacy and Public Policy

HOW IT STARTED

L

L

L

L

to R: Dr. Willis Maddrey, Dr. Sarkis Chobanian, and Dr. Chesley Hines testify before the House Energy & Commerce Health Subcommittee in 1989.

to R: Dr. William Carey; Nancy Norton (founder of IFFGD) and U.S. Senator John Glenn (D-OH) with Dr. Joel Richter in 1994.

to R: Dr. David Graham, former U.S. President Ronald Reagan, Dr. Edward Cattau. In 1990, President Reagan receives the ACG Distinguished Service Award for his efforts to educate the public about colorectal cancer.

to R: Dr. Chesley Hines, Rep. Henry Waxman (D-CA) of the House Energy & Commerce Committee, ACG President Dr. Sarkis Chobanian in 1989.

Representing the interests of clinical gastroenterology and patients with GI and liver disorders before lawmakers and regulators is a longstanding priority for ACG. Among ACG’s proudest achievements are legislative outcomes that have helped shaped modern GI practice including coverage of colorectal cancer screening. The Board of Governors, in partnership with leadership training participants from the ACG Institute, are the driving force behind ACG’s Advocacy Day. Throughout the year, ACG members interact

HOW IT’S GOING

with Members of Congress and policymakers in the federal agencies to advance ACG’s public policy priorities.

ACG Advocacy Day 2022

L to R: Dr. Alfredo Camero, Dr. Louis Wilson, Dr. Harish Gagneja, Dr. Divya Bhatt

L to R: Dr. Ramona Rajapakse, U.S. Rep. Donald Payne, Jr. (D-NJ), Dr. Sita Chokhavatia

L to R: Dr. Eli Tomar, Dr. James Hobley, U.S. Senator William Cassidy (R-LA), Dr. Wilmer Rodriguez

L to R: U.S. Rep. Brenda Lawrence (D-MI) and Dr. Richard Saad

With U.S. Senator Jack Reed (D-RI) (center) L to R: Dr. Manida Wungjiranirun, Dr. Alyn Adrain, Dr. Abbas Ruppawala, Dr. Samir Shah

Honoring Achievement: ACG Awards

HOW IT STARTED

In 1987, the College presents the inaugural Clinical Achievement Award to Dr. Leonidas Berry

1991 Masters: Dr. Jerome Waye, Dr. Franz Goldstein, Dr. Ivan Beck, Dr. Theodore Hirsch

ACG President Dr. Joel Richter (left) honors Dr. David Graham who delivered the Distinguished Lecture in 1995.

In 1993, ACG President Dr. Arvey Rogers (left) and President-Elect Dr. Lawrence Brandt honor Dr. Sidney Winawer who delivered the Baker Presidential Lecture.

In its history, the College has broadened and deepened the ways it recognizes professional achievement and acknowledges the best in the GI profession. New awards expand ACG’s ability to honor varied and diverse members at different career stages for their contributions to the life of the College, distinguished leadership in the field, outstanding research, and commitment to the care of patients with GI and liver disorders.

HOW IT’S GOING

In 2019, ACG President Dr. Sunanda Kane honors ACG Past President Dr. Stephen Hanauer who delivered the Berk Lecture.

Winners of 2019 Endo Titans Challenge with judges L to R: Dr. Rabia de Latour; Dr. Jason Pan, Dr. Seth Gross, Dr. Fadi Haddad, Dr. Vivek Kaul, Dr. Laith Jamil

2021 GI Jeopardy Winners Dr. Annie Braseth and Dr. Asad Ali, GI fellows from the University of Iowa

Dr. Aasma Shaukat receives 2018 Senior Governor’s Award from ACG President Dr. Irving Pike

Dr. Benjamin Levy honored with “Grand SCOPY” Award in 2021

2021 ACG President Dr. David Greenwald (left) presents Diversity, Equity & Inclusion Award to Dr. Darrell Gray

Women in GI & Diversity in GI

HOW IT STARTED

Pioneering

in ACG L to R: Dr. Christina Surawicz, Dr. Linda Rabeneck, Dr. Rosemarie Fisher, Dr. Freda Arlow

women

Dr. Robyn Karlstadt chaired the Ad Hoc Committee on Women in GI in 1991-1992 – with Dr. Surawicz

Women in GI Committee meeting in 1993, the year it receives full committee status with Dr. Surawicz as Chair

The pioneering women in gastroenterology who forged a path in the organization in the early 1990s paved the way, and in many ways set the tone, for the diverse organization ACG is today. The College honors ACG’s first female president, Christina M. Surawicz, MD, MACG (1998-1999) as a role model and inspiration to the GI profession. ACG celebrates the women who have followed in her footsteps in leadership roles at every level of the organization and all those who have inspired a culture that embraces diversity, equity and inclusion in GI.

HOW IT’S GOING

ACG’s first female president, Dr. Christina M. Surawicz (1998-1999)

ACG

Women in GI and ACG Diversity, Equity & Inclusion Committees team up for their annual reception in 2019 to network and celebrate.

Dr. Sunanda V. Kane ACG President 2018-2019

Dr. Amy E. Foxx-Orenstein ACG President 2007-2008 on the occasion of her MACG in 2017 with Dr. Carol Burke, ACG President 2016-2017

PR Committee in 2019 under the leadership of Dr. Sophie Balzora, champion of #DiversityinGI campaign.

Dr. Shazia Ali and ACG Vice President Dr. Amy Oxentenko in 2019

ACG Institute for Clinical Research & Education

HOW IT STARTED

ACG Institute Board in 2005

Front

Back

1994-1995

Dr. Donald Castell 1997-2004 Dr. Joel Richter 2004-2014 Dr. Edgar Achkar 2014-2020 Dr. Nicholas Shaheen

L to R: Dr. Edgar Achkar, Dr. David Graham, Dr. Christina Surawicz

L to R: Dr. Mitchell Shiffman, Dr. Linda Rabeneck, Dr. Seymour Katz

Past Directors, ACG Institute for Clinical Research & Education

HOW IT’S GOING

Since 1994, the ACG Institute for Clinical Research & Education has served as a forum to advance the research and education mission of the American College of Gastroenterology, making a meaningful and measurable difference in launching the careers of young clinical investigators by protecting time for research, funding innovative patient careoriented research, and serving as an incubator for important initiatives including the launch of The Center for Leadership, Ethics & Equity in 2021.

ACG Institute Director, Dr. Neena Abraham (2020- )

2021-2022 Inaugural Cohort Advanced Leadership Development Program

2021-2022 Young Physician Leadership Scholars

ACG Institute Center for Leadership, Ethics & Equity launched 2021

Clinical Research Funding

1983

HOW IT STARTED

Stephen G. Cole, MD, University of California, San Diego, The Cholesterol Octanoate Breath Test

Gustavo A. Machicado, MD, Endoscopic-Hematoporphyrin Derivative Detection of Early Neoplasia in Ulcerative Colitis, Barrett’s Esophagus, and Villous Adenoma

Susan R. Orenstein, MD, Children’s Hospital of Pittsburgh, Thickening of Infant Feedings for Therapy of Gastroesophageal Reflux

G. Richard Locke, III, MD, MACG (deceased)

Carlo Di Lorenzo, MD

Dr. Rachel Issaka Dr. Maya Balakrishnan

Past Presidents Gallery

Dr. J. Edward Berk 1975-1976

Dr. Sidney J. Winawer 1979-1980

Dr. F. Warren Nugent 1976-1977

Dr. William S. Rosenthal 1977-1978

Dr. Richard Farmer 1978-1979

Dr. John P. Papp 1985-1986

Dr. Jamie Barkin 1989-1990

Dr. Arthur H. Aufses 1986-1987

Dr. Myron Lewis 1987-1988

Dr. Chesley Hines, Jr. 1988-1989

Dr. Seymour Katz

Dr. Luis A. Balart

Dr. Christina Surawicz

Dr. Richard Farmer

ACG recognizes with deep thanks the many contributions of its Presidents over the years, their defining roles, vision, and selfless service.

Dr. Burton I. Korolitz 1980-1981

Dr. Franz Goldstein 1981-1982 Dr. James L. Achord 1983-1984

Dr. Jerome D. Waye 1982-1983

Dr. Walter Harvey Jacobs 1984-1985

Dr. David Y. Graham 1990-1991

Dr. Arvey I. Rogers 1991-1992

Dr. William D. Carey 1993-1994

Dr. Larry Brandt 1992-1993

Dr. Joel E. Richter 1994-1995

Dr. Rowen K. Zetterman

Dr. Edgar Achkar

Dr. Douglas K. Rex 2003-2004

Dr. Frank L. Lanza

Dr. John W. Popp, Jr.

Dr. Delbert L. Chumley

Dr. Lawrence R. Schiller

Dr. Harry E. Sarles, Jr.

Dr. Ronald J. Vender

Dr. Stephen B. Hanauer

Dr. David A. Greenwald

Dr. Samir A. Shah

ACG recognizes with deep thanks the many contributions of

Evolution of Gastric and Esophageal Disorders in

the American College of Gastroenterology Era: 1932 to 2022 and Beyond

By Kenneth R. DeVault, MD, MACG, Chair ACG Archives Committee

THE AMERICAN COLLEGE OF GASTROENTEROLOGY WAS FOUNDED IN 1932. In reflection on changes in our profession in the past 90 years, we thought changes in our understanding of, approach to and treatment of disorders affecting the esophagus and stomach to be an important measure of the evolution of gastroenterology. All areas of our specialty have evolved, but, given the early access to the upper gut using tubes and the early endoscopes, this area has been particularly impacted by changes in both understanding and technology. Comparing what was published in a New England Journal of Medicine review of gastroenterology in 1932 to our current state is very illustrative.

Special ACG at 90 “A Look Back”

Rigid esophagoscopy was available but not widely applied at the time of our society’s founding. It was mainly used to diagnose and more importantly treat patients presenting with dysphagia. The use for diagnosis of esophagitis and other mucosal issues was less common. One of my patients had a lye ingestion as a young child in the late 1930s. He vividly remembers taking a train to Philadelphia and undergoing unsedated rigid endoscopy by Dr. Chevalier Jackson. As he matured, he learned to self-dilate and, in fact, this true American hero carried a Maloney dilator with him on a ship that fought in the Pacific theater during World War II hiding in a bathroom to dilate his esophagus when needed. Interestingly, he thought the trauma of rigid endoscopy was worse than that of having dive bombers attack his ship!

Many, perhaps most, dilations of the esophagus were performed in a blind fashion using a swallowed silk tread followed by a guidewire and then dilators over that wire. Reading descriptions of these procedures is somewhat terrifying to a modern esophagologist who has the advantage of endoscopic and fluoroscopic guidance! Retrograde endoscopy has recently been reported as a “new” technique, but both retrograde rigid endoscopy and retrograde dilation were known techniques in the 1930s used for difficult strictures. This included a ronde vu technique where rigid endoscopes were inserted in both the esophagus and stomach! In addition, the first reports of a semi-flexible endoscope were in the 1930s. The gradual development of fully flexible endoscopes led to massive changes in our profession and society. On the other hand, while the optics have improved the actual process of endoscopy, including the handles and buttons, have changed little. Looking forward, will robotics make its way into the endoscopy lab and will artificial intelligence help us or perhaps replace us at some point in the future? Only time will tell.

Esophageal motility function was not well understood until the development of tube-based studies in the 1970s. On the other hand, some fascinating observations were earlier described. Erosive or ulcerated esophagitis were considered rare conditions, although I cannot say if this is due to lack of common use of endoscopic diagnosis or if there has been that much in a shift in disease over the years. Achalasia was commonly known as cardiospasm in the early part of the last century. Dilation using a specially designed bag or surgery were and are the treatments of choice.

The concept of esophageal spasm producing noncardiac chest pain dates to at least 1889 and that report even includes the use of nitrates to relieve that spastic pain. Clinically, I adopted the term “esophagismus” that was used in that paper! We have all learned that esophageal pain

Early Fiberoptic Gastroscope. From the personal collection of Dr. Robert Kravetz, purchased in 1965. Source: Robert E. Kravetz, MD, MACG, A Look Back: Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology, American College of Gastroenterology, Bethesda, MD, 2020

Pneumatic Dilator for Achalasia. This Mosher dilator dates from the 1950s and is in the collection of Robert E. Kravetz, MD, MACG. Source: A Look Back: Reflections on Medical History & Artifacts from the Pages of The American Journal of Gastroenterology, American College of Gastroenterology, Bethesda, MD, 2020

“The gradual development of fully flexible endoscopes led to massive changes in our profession and society. On the other hand, while the optics have improved the actual process of endoscopy, including the handles and buttons have changed little.”

(and other GI pain) has an emotional component, and Sir William Osler put it very directly (albeit not with political correctness) when he said, “Esophagismus is met with in hysterical patients and hypochondriacs…The idiopathic form is found in females of a marked neurotic habit, but may also occur in elderly men.” Improvements in ambulatory monitoring and high-resolution testing have altered the diagnosis and even nomenclature in esophageal disease, but I recently gave a lecture on achalasia and the slides (and I mean slides) from the ACG motility slide deck from the 1990s still provided the best launching point for a discussion of esophageal physiology! I assume AI and other advances in computing will help us better diagnose esophageal conditions in the future, although to date computer reading has not been able to replace physician driven pattern recognition and. in fact. the computer can send your patient down the wrong therapeutic pathway if care is not taken.

The prevalence and significance of hiatal hernia (HH) has also evolved in the past 90 years. Early in the 20th century, hernias at the esophagogastric hiatus were considered very rare. With more patients getting barium examinations those numbers increased. The numbers were still much lower than we see these days, with only 60 cases out a total of 8,000 upper GI series performed. In a recent study using CT scans for screening of patients independent of GI symptoms, HH were seen in 12.7% of women and 7.0% of male subjects. HH were associated with female gender, advancing age and higher BMI. Whether HH are truly more common these days or if this is some type of discovery bias is not clear but we do know that our patients are living longer and much more likely to be obese than in the past, which could explain this trend. Laparscopic repair boomed in the past 20 years but numbers have fallen back to perhaps a more reasonable number of cases.

Peptic ulcer disease was a common and difficult to control disease in the 1930s. The concept that cholinergic stimulation led to acid secretion was well known. In a study of gastric secretion, atropine (an anticholinergic) was found to decrease acid secretion and perhaps improve

symptoms in patients with acid symptoms. For many years, this and similar agents were studied as treatment for ulcers and acid reflux. Unfortunately, these agents had other adverse effects on the GI tract including decreased saliva, impaired motility, and relaxation of the lower esophageal sphincter limiting their use. A more selective antimuscarinic agent, pirenzepine, was developed in the 1980s and was coming to market just as agents that had an even more specific effect on acid secretion were introduced (histamine receptor blockers and, later, proton pump inhibitors.) Other agents were tried including caffeine which actually increased acid secretion leading to recommendations to decrease caffeine intake in patients with acid issues. Mechanic methods to decrease acid, including placing a gastric tube to aspirate contents, were used in difficult cases and found to be an effective, yet very undesirable treatment for refractory ulcers.

We should never discount the difficulties faced by early gastroenterologists in treating diseases that we now consider routine. Current gastroenterologists rarely see patients with long-term severe ulcer disease of either the esophagus or stomach due to the development of agents that safely and effectively treat the symptoms and mucosal damage caused by gastric acid. It is also important to remember that vagotomy for refractory peptic ulcer disease was still a new concept which had been reported less than 10 years prior to 1932. Despite the incredible advances in therapy, a significant subset of patients with acid related disease (GERD or PUD) have symptoms or mucosal disease refractory to treatment. A new class of drugs (potassium competitive acid lockers, PCAB) will likely come to market in the U.S. in early 2023. Although superior to PPI in GERD, these agents represent an evolution, not revolution, in our approach to difficult to control disease.

1930s physicians were very focused on patients producing too much acid leading to terms like acid dyspepsia, superacidity, and hyperchloracidity in the literature. Turns out that excess acid secretion is rare, but early 20th century explanations for that possible acidity

have persisted

“We should never discount the difficulties faced by early gastroenterologists in treating diseases that we now consider routine. Current gastroenterologists rarely see patients with long-term severe ulcer disease of either the esophagus or stomach due to the development of agents that safely and effectively treat the symptoms and mucosal damage caused by gastric acid.”

as factors associated with dyspepsia including: inborn disposition (anxiety), overwork, abuse of simulants such as coffee and alcohol, and hyperaciditas nicotinica due to smoking. Over consumption of bread was also suggested which may have been a prelude to the current emphasis of gluten as a factor in dyspepsia even in those without genetic celiac disease. Gastric polyps are now considered almost an expected effect of chronic acid suppression with agents like proton pump inhibitors. Interestingly, in 1932 “mucous polyps” were reported in a study of a group of patients with documented hypochlorhydria so this is not a new concept. The number of “normal” patients with low or absent acid secretion was always a challenge to physiologists. Some of these patients probably had autoimmune gastritis but most assuredly some, probably most, were chronically infected with Helicobacter pylori. It was interesting reading about the use of histamine stimulation in testing over 40 years before the use of histamine blockers for acid control were developed. Also, the use of tube based gastric analysis was common in the 1930s and still used, although rarely during my fellowship (1989-1992) and early time on staff at Mayo Clinic.

Another concept that was common in 1932 that was challenged in modern medicine was age related decrease in gastric secretion. A Mayo Clinic study of 3,746 cases reported a steady decline in gastric secretion from youth to old age. The concept was held as truth and many potential causes were hypothesized. The discovery of H. pylori and long term follow up of patients after eradication, suggested that this was not an innate loss of the body’s ability to produce acid but a consequence of chronic infection and subsequent atrophic gastritis that is reversible if H. pylori is eradicated in an early stage. In fact, there seems to be an inverse relationship between H. pylori related ulcer disease and gastroesophageal reflux. Of course, none of this was even imagined in

1932 or even 1992 when, as a fellow, I met this Australian working at the University of Virginia who had the bizarre idea that peptic ulcer was an infectious disease!

Gastric motility was even more of a mystery than esophageal motility but a disorder of gastric motility was reported and described as Myasthenia gastrica (I like that better than the frequently overused and misunderstood term “gastroparesis.”) Overlap with functional disease was well described using the term “nervous dyspepsia.” Some patients were at times labeled as functional and later found to have organic disease including ulcers and malignancy. The chicken and egg argument for functional disorders was already present with some believing the nervous system to cause gastric disease while others felt gastric symptoms to be cause of some cases of “nervous” disease. There is now an entire field of gastroenterology dedicated to “functional disorders” but it is clear that additional knowledge is needed to produce the kind of advances that this frustrated and at times frustrating patient population requires.

Another fascinating gastroduodenal disease that was common in 1932, but very rare 90 years later, was gastric syphilis. At times the presentation was identical to that of “routine” peptic ulcer disease. Imaging might demonstrate persistent deformity of the duodenal bulb and the

diagnosis only made at the time of surgical resection. Tuberculosis of the stomach was also high in the differential diagnosis 90 years ago, but was still very rare (less than 0.05% in a Mayo Clinic Study from that era.) Just when we thought new infections in the gut were less likely, along came COVID! In an early report, over 40% of patients with COVID reported nausea, vomiting or both.

In conclusion, gastroenterology has advanced is many areas as you can see from this brief review of the evolution in the approach to some common issues with the esophagus and stomach. On the other hand, it is humbling to read how much our forebearers knew 90 years ago as the ACG was founded. It is also hard to image what current “truths” will be disproven and new ones developed in the next 90 years.

Barry J. Marshall, MD, FRACP, FACG and J. Robin Warren, AC, MD, MBBS, won the 2005 Nobel Prize for Physiology or Medicine for their discovery of Heliocbacter pylori

Kenneth R. DeVault, MD, MACG, of Mayo Clinic Jacksonville serves as Chair of the Archives Committee and is ACG Past President (2015-2016).

ACG North American International Training Grant

By Rahul S. Dalal, MD, MPH

I was honored to receive the 2022 ACG North American International GI Training Grant to spend four weeks at Odense University Hospital (OUH), University of Southern Denmark. Denmark, which has a universal healthcare system, maintains inpatient and ambulatory data prospectively on all patients since the 1990s in national healthcare registries. This provides a rich resource for studying longitudinal healthcare outcomes for a variety of diseases. My clinical and research interests are in the field of inflammatory bowel diseases and I have specific interests in IBD complications associated with analgesic therapies. I therefore conducted a populationbased study that compared complications associated with the use of tramadol, versus opioids, among adults with IBD.

I had an incredibly productive and educational experience working with the team led by Dr. Bente Mertz Nørgård at the Center for Clinical Epidemiology at OUH. During my first two weeks, I had daily meetings with biostatisticians and epidemiologists to develop and refine the study design that would answer my specific research questions. I spent much of my time writing and revising our protocol, as well as reviewing and analyzing preliminary data. During the latter two weeks of my stay, I designed a number of sensitivity analyses that strengthened the integrity of our results. I was able to complete

nationwide registries.

During my time in Denmark, I was also fortunate to spend time on the outpatient and inpatient gastroenterology units at OUH. This allowed me to observe healthcare delivery in a system completely distinct from my own, which will help me bring a new perspective to the care I provide to my own patients.

I am so thankful to the American College of Gastroenterology for making this international experience possible. I am also grateful to my mentors and collaborators at The Center for Clinical Epidemiology at OUH (Dr. Bente Mertz Nørgård and Dr. Ken Lund, Dr. Floor Zegers, and Dr. Susanne Møllerstrøm) and my local mentor Dr. Sonia Friedman at The Brigham and Women’s Hospital for helping me plan and execute this important research project.

has a universal healthcare system, maintains inpatient and ambulatory data prospectively on all patients since the 1990s in national healthcare registries. This provides a rich resource for studying longitudinal healthcare outcomes

Rahul S. Dalal, MD, MPH, Advanced Fellow in Inflammatory Bowel Diseases, Brigham and Women’s Hospital, Harvard Medical School

Photo top: (L to R) Floor Zegers, Bente Mertz Nørgård, Rahul Dalal, Ken Lund, Sonia Friedman

Hello Holidays

HOLIDAYS ARE ALWAYS A PERFECT TIME TO REFLECT on the year behind us, new challenges, friendships, success, and opportunities. This has been a hard year for many of us from around the globe as we watched wars, natural disasters, and political unrest. The beacon of light through this year has been connection, to friends, family, and colleagues.

With the year’s end in sight, we could think of nothing better than sharing a wonderful meal with all of you from around the world. Happy holidays, Slava Ukraini, Woman, Life, Liberty!

MOHAMMAD ALI, MD

Chief of Endoscopy & Chair, Department of Medicine, Guthrie Cortland Medical Center, Cortland, NY

I am a first-generation immigrant hailing from the tiny South Asian nation of Bangladesh. It is a country rich in culture and steeped in history. For instance, International Mother Language Day—which is observed every year on February 21st

and aims to promote linguistic and cultural diversity—honors Bengalis who sacrificed their lives for their mother tongue. Just like this historical event, our food and local cuisine are an integral part of our identity.

My recollection of events like family gatherings during Eid (a religious holiday), birthdays, and game nights are inextricably linked to the foods accompanying them. I fondly remember items like pickles (achar), mashed vegetables (bhorta fish fry (mach bhaji), chicken and beef curries, and the list goes on and on. Just writing about these dishes brings back vivid memories, both visual and olfactory, instantaneously transporting me to my formative years. Cooking and preparing them in our kitchen, now with my daughter, not only strengthens my ties to the land I left over two decades ago, but also allows me to pass on a small part of who we are as a people to my daughter.

One fare that has been ubiquitous in all the above-mentioned occasions is the samosa.

(SERVES 6)

—The #ACGFoodies (Vani, Alex, Christina)

Culinary Connections:

Vani Paleti, MD, Alexander Perelman, DO, and Christina Tennyson, MD

SAMOSAS

It is a pastry with a savory filling, including ingredients such as potatoes, onions, and peas. It may take various shapes and forms, the most common being triangular, and is often accompanied by a dip or chutney. A quick search on Wikipedia shows that the samosa has a Central Asian origin. “The earliest mention of the samosa was by Abbasid-era poet Ishaq al-Mawsili, praising the sanbusaj. Recipes are found in 10th to 13th-century Arab cookery books, under the names sanbusak, sanbusaq, and sanbusaj, all deriving from the Persian word sanbosag.”

While traditionally being deep-fried, the recipe has evolved to being baked (or air-fried), making them healthier while still retaining the taste and overall deliciousness. Choosing vegetable samosas over meat-filled pastries cuts down on saturated fats and calorie intake while also providing vitamins and minerals. Not to mention, this snack also offers a healthy dose of dietary fiber which can improve digestive health.

It is easy to make and quick to serve!

 Steps

1. Put a frying pan on medium flame and add a tablespoon of oil to it. Add garlic paste and onion, and sauté for a few seconds.

2. Add all the veggies and spices, required for the filling in the pan and stir fry for 2-4 minutes. Keep it aside.

3. To prepare the shells of the samosas, mix salt, semolina, 1 tsp oil and allpurpose flour together in a large bowl, and knead into a soft dough. Roll into small oval shaped flatbreads (chapattis), making sure that they are not too soft nor hard.

4. Cut each chapatti in half and roll into a cone. Fill with 2 Tbsp of prepared filling. Brush edges with water and then pinch the edges and seal samosa. Repeat with the rest of the dough and use all of the mixture.

5. Bake the sealed samosas at 300°-375° degrees Celsius for about 10 minutes.

6. Serve immediately with green chutney and tomato ketchup.

Sources: https://en.wikipedia.org/wiki/Samosa https://recipes.timesofindia.com/us/recipes/vegetable-samosa/ rs55435214.cms

LAURA CHIU, MD

Boston University School of Medicine

“Laughter is brightest where food is best,” was the Irish proverb I once learned from my junior high school teacher (back when home economics class was a thing in the ‘90s!) while growing up in New York City, a community drenched deeply in multicultural roots. It was a priority to teach healthy eating in the public school system, but the lessons of nutrition and cooking basics revolved around all-time favorites from different cultural holidays. I laughed and tasted my way around the world with classmates while learning how to make traditional potato latkes, spicy beef empanadas, and the perfect American bean chili that impressed all guests during Thanksgiving dinner one year. Food is a way to express your dedication to family and community, and this experience unquestionably cemented

“Food is a way to express your dedication to family and community, and this experience unquestionably cemented this value in my love for cooking.”

— Dr. Chiu

family’s Chinese kitchen to share with my roommates when we returned home from classes. Food in the form of epic dinner potlucks became the traditional post-grueling test gathering among my friends during medical school. During medical residency and fellowship in Boston, I learned to adore my slow/pressure cooker, as it provided many life-saving meals for my now husband and I after our long inpatient and call-shift days at the hospital.

As a current gastroenterologist in my first year as an attending faculty member at Boston University, life has not gotten easier, as I balance the exciting responsibilities of developing my professional career and taking care of my young family (14-monthold baby and 3-year-old, 140-lb. Newfoundland dog). This comforting soup tastes long simmered, but it is cooked in a pressure cooker, making it very much a weeknight possibility.

of mushroom varieties, combined with high-fiber, micronutrient-rich wild rice, unquestionably makes this warm, nutritious meal a favorite on our dinner table.

SAVITA SRIVASTAVA, MD Augusta Health, Gastroenterology, Fishersville,

Food and the enjoyment of food for authentic living is an expression of love in Indian culture. Gathering built around food is a way to nourish the body and soul. My mother moved to the U.S. from India in the 1970's and she espoused the importance of food and healthy lifestyle for vitality and living. I grew up in a household where lentils (dal), homemade yogurt (dahi), and fermented fruits and vegetables (achar) were staples and a part of everyday life. In her preparation of amazing meals where she could easily bring together healthy ingredients into delicious dishes, we took

her household is a reflection of social connection, funny interludes, serious conversation, feeling included, and being human.

After leaving my mother's home and being nourished by real food, I veered for many decades towards the standard American diet—processed ingredients, high protein and fats, low fiber, and fast food. Being a physician in training for so many years, it was hard to find work-life balance, eat nutrient dense meals, and embrace the elements of a healthy lifestyle.

Years later, as a physician-scientist who became obsessed with the gut microbiota and finding ways to translate the science at the bench to clinical applications at the bedside, the great revelation from a decade's worth of research is that the gut microbiota is highly dynamic and modulated by lifestyle factors – plantpredominant eating patterns, stress, exercise, sleep, avoidance of alcohol

DR. CHIU'S PRESSURE

 Ingredients

COOKER MUSHROOM

 Steps

AND WILD RICE SOUP

• 4 Tbsp unsalted butter (½ stick)

• 1 yellow or red onion, minced

• 2 lbs. mixed mushrooms (shiitake, maitake, portobello, cremini, lion’s mane, oyster mushrooms), tough stems removed, chopped into ½to 1-inch pieces

• Kosher salt and black pepper

• 2 celery stalks, chopped

• 1 large carrot, peeled and chopped

• 6 garlic cloves, smashed and chopped

• 3 sprigs fresh thyme or 1 tsp dried thyme

• 1 tsp garlic powder

• ¼ cup all-purpose flour

• 5 cups vegetable stock

• ½ cup dry white wine

• 1 cup wild rice (about 6 oz.)

• ½ cup whole-fat Greek yogurt

• 1 Tbsp white miso

• Chopped scallions or chives and fresh dill, for topping

1. Turn on the sauté setting on a 6- to 8-quart electric pressure cooker. Melt the butter, then add the onion. Cook and stir until translucent, about 5 minutes.

2. Add the mushrooms and 1 tsp salt, and cook, stirring occasionally, until the mushrooms have released their liquid and shrunk a bit, about 8 minutes. Add the celery, carrot, chopped garlic, thyme, garlic powder, and several generous grinds of black pepper. Stir to combine. Add the flour and stir until the vegetables are evenly coated and no white spots remain.

3. Pour in the stock and wine and turn off the heat. Scrape the bottom of the pot well to incorporate flour and any browned bits that are stuck to the bottom. (This will add flavor and also prevent a burn warning later.) Stir in the wild rice.

4. Cook on high pressure for 10 to 12 minutes. Turn off the heat and let the pressure reduce naturally for 10 minutes, then release the remaining pressure manually.

5. Stir the soup and check the texture of the wild rice; if it needs a bit more time, repeat the pressure-cooking process for a cook time of 2 minutes and rapidly release the pressure. Turn off the heat.

6. Put the Greek yogurt in a small bowl and slowly whisk in a few spoonfuls of warm soup until smooth, then stir the mixture into the soup. Taste the soup and add salt and pepper to taste.

7. Serve the soup in bowls topped with chopped scallions or chives and dill.

and smoking, and positive relationships. The microbiome is also shaped by early life factors, and the composition of the microbiome in early life influences future metabolic, immune, and brain health. The health destiny of our children is shaped in the first several years of life, influencing future risk of obesity, autoimmune disease, food and environmental allergies, and cancer. Now, as a parent, I realize the great responsibility to raise healthy children with low risk for chronic disease. This means that it's paramount to introduce, early on, a diversity of plants into the diet for the biodiversity of the gut microbiota.

Over the years, my GI practice has evolved to become an integrative gastroenterology practice model, incorporating more nutrition, mind-body medicine, and microbiome science into my patient's plan of care. Our GI practice in Virginia's Shenandoah Valley, called the Digestive Wellness Center, utilizes a farm on campus, a teaching kitchen, and a wellness center to expand where we deliver care. Our patients learn about sustainable farming practices and principles of anti-inflammatory Mediterranean cooking on a beautiful farm and teaching kitchen. We are teaching our patients,

through a hands-on workshop, how to ferment vegetables, make kefir and yogurt, and brew kombucha. We are also delivering demos in a teaching kitchen and working on evolving diets to incorporate more plants – making delicious foods like overnight oats, breakfast bowls, lentil soup, kale salad, and quinoa-stuffed delicata squash.

As I tried to perfect a recipe for lentils this month, I appreciated that I was celebrating my mother’s legacy to the culinary arts and using culinary medicine to help restore health in my children and patients.

In many ways, the circle of life leads you back to home. I am inspired that my practice of medicine incorporates so many lessons that I learned from my mother about eating, mindfulness, and human connection. I am sharing a roasted Brussels sprouts salad recipe from my mother that we have used during the holiday season as a side dish. It’s a vibrant dish that celebrates seasonal eating, plant diversity, the colors of fall foliage, and is a perfect piece of culinary art for the holiday table. For over 30 years, my mom worked in the kitchen at one of the first

Wegmans grocery stores in the country and helped to create their menu of prepared foods that emphasize their decades-old campaign to ‘eat the rainbow.’ As kids, we were guinea pigs for Wegmans as it tried to crack the code for creating healthy colorful dishes that appealed to children. As immigrants, Thanksgiving has always been a favorite holiday that makes me appreciate how my mother is a courageous woman who left India to start a new life somewhere foreign to her and is an amazing chef who can create delicious dishes from all over the world to connect humans. This dish is a reflection of her making rainbows.

 We would love to hear from you. If you have personal connections with GI and gastronomy. Contact ACG MAGAZINE staff at acgmag@ gi.org to share your story with the ACG community. You can also tweet using #ACGfoodies to connect with the community. Wishing you all good health and great meals from our Culinary Connections #ACGfoodies team.

ROASTED BRUSSELS SPROUTS AND BUTTERNUT SQUASH SALAD WITH PUMPKIN SEEDS AND DEHYDRATED CRANBERRIES

 Ingredients

Roasted Brussels Sprouts:

• 3 cups Brussels sprouts, halved, ends trimmed, any yellow leaves removed

• 3 Tbsp olive oil

• Salt, to taste

Roasted Butternut Squash:

• 4 cups butternut squash, cubed

• 2 Tbsp olive oil

• 3 Tbsp maple syrup

• ½ tsp ground cinnamon

Other Ingredients:

• ½ cup pumpkin seeds

• 1 cup dried cranberries

• 2-4 Tbsp maple syrup (optional)

 Steps

Roasted Brussels sprouts:

1. Preheat oven to 400 F.

2. Lightly grease the foil-lined baking sheet with 1 Tbsp olive oil.

3. In a bowl, combine Brussels sprouts, 2 tablespoons of olive oil, pinch of salt.

4. Roast sprouts on a foil-lined baking sheet in the oven at 400° F for 20-25 minutes, turning halfway through.

Roasted butternut squash:

1. Preheat oven to 400° F. Lightly grease the foil-lined baking sheet. with 1 Tbsp olive oil.

2. In a bowl, combine cubed butternut squash, 1 Tbsp of olive oil, maple syrup, and cinnamon.

3. Mix thoroughly with a mixing spoon.

4. Place butternut squash on the baking sheet.

5. Bake on greased baking sheet for 20-25 minutes until softened.

• Combine roasted Brussels sprouts, roasted butternut squash, pumpkin seeds, and cranberries; mix to combine ingredients evenly.

• For more sweetness, add 2-4 Tbsp maple syrup (optional)

Conversations with Women in GI

a private practice, I started to deal with more of the business side of medicine. You have less availability for your patients to get the medications they need due to lack of insurance, lack of money, lack of co-pay money. If you look at my trajectory, I have a lot of points that I can connect but they are not on the same path, it’s not a linear path, it’s a zigzag, but I find that was very useful.

JG: When we were on the ACG Women in GI Committee, you were in private practice. Did you start your career in private practice?

AP: I grew up in Romania and I came here right after I finished medical school. I did my residency and fellowship in Detroit, and I followed that with a one-year liver transplant fellowship in Memphis. I was on a visa so when I finished fellowship, I went to an underserved area. I worked in East Tennessee at the VA for 5 years as the Head of the GI Division until I got my Green Card. I was also an Associate Professor at the local medical school and had the opportunity to teach students and residents. It was an amazing experience. The VA was a great place to work, great people, great patients, and a high need for physicians. I was the only VA GI specialist for a 100-mile radius. I took leadership of the hepatitis C clinic and started doing transplant evaluations in rural East Tennessee and worked closely with Vanderbilt for referrals and post-transplant care. I was also able to be the principal investigator on the PEGASYS (pegylated Interferon for hepatitis C) trials, which has helped me to understand that aspect of drug development and it has been helpful especially now that I am in industry. I learned a lot. It was a very satisfying experience because I didn’t have to deal with the bureaucracy of a practice, issues such as prior authorizations, etc. Then moving to

JG: What lead you to consider a transition to a career in the pharmaceutical industry? AP: After being in practice for over 20 years, I became interested in the business aspect of medicine. I was in a private practice; I was a partner, so I wanted to learn more. I completed a Master’s in Business of Medicine. I loved it! I loved the aspects that we were never taught in medical school, the least of which was negotiation, conflict resolution, not to mention the financial aspects of business. I said, “This is something new. This is a part of my brain I haven’t used before.” So, I continued at MIT where I completed an executive certificate program in strategy and innovation. I did an entrepreneurship course. All of this I find enriched my thinking and got me out of a box, that box being just patient care. I saw the aspect of medicine from a different angle. After doing that, I wanted to use what I learned. Not necessarily to be the CEO of a hospital or management in my private practice. So I did a stint in an underserved area where I developed a GI service line at a hospital without a gastroenterologist for the previous several years. I decided afterwards that coming to industry would marry the clinical knowledge I had, the experience I had and the business aspect. I entered industry in 2019 at UCB working on Crohn’s disease. Then I started learning exactly what working in industry was really about because it’s a whole world that I didn’t know about. For example, learning about the life cycle of a drug. Working on a drug at the end of life before the loss of exclusivity is totally different than working in a company trying to launch a drug. I realized that you can have another lifetime in the industry and still keep learning. So, that is how I journeyed from clinical practice to industry, which was basically due to a

hunger for learning new things.

“It’s exciting to start from scratch, building a new gastroenterology team in a new therapeutic area for the company and creating relationships between the GI community, the health care providers, and the medical affairs professionals in the company.”

Jill K. J. Gaidos, MD, FACG in Conversation with Anca I. Pop, MD, MBA, Head, Medical Affairs Gastroenterology at Sanofi Genzyme

Dr. Jill Gaidos talks with Dr. Anca Pop about her transition from private practice to a career in the pharmaceutical industry. The two initially met while they were members of the ACG Women in GI Committee and Dr. Pop was on the faculty for the ACG Bridging the Leadership Gap in GI Conference in 2020.

JG: I hear from many women who are interested in leadership positions, whether that is in academics, private practice or industry, they feel like they need to get a more education such as an MBA or an Master’s of Health Administration to be adequately prepared. Did you feel like you needed a Master’s degree for a leadership position in industry?

AP: For me, a leadership position was never the intent. It was to get me out of my box, if you will, and to do something for myself. And, by the way, having an MBA does not guarantee you are going to get a leadership role in industry. In industry, a lot of people have MBAs, PhDs and PharmDs. MDs are actually less prevalent. So, I think the MD experience actually got me the leadership position in industry, not the MBA.

JG: Would you encourage others to get an MBA? Did you feel like it would be useful for leadership position in a private practice?

AP: It depends on where you are coming from. Our MBA class in Indiana had only physicians. It was the first class that did the business of medicine program and was geared toward physicians. The physicians that came from an academic institution or hospital system and wanted to stay in that hospital system used their MBA to be promoted to leadership positions. So some of my MBA colleagues became CEO of the hospital or service-line leaders and took on more and more responsibilities. Others just used their experience in their own practice and developed more from a business perspective and some joined the industry or became published authors. For me, I used it to think in a different way. I have a different perspective that’s centered on patient care and benefit. I believe it’s tremendously helpful to have physicians who know patient care. Also having a Master’s in Business doesn’t hurt, but I wouldn’t go into it with the idea that this is a guaranteed promotion to a leadership position.

JG: You were the head of medical affairs of gastroenterology at UCB?

AP: Yes, I was the Head of Medical Affairs of Gastroenterology at UCB for two years and now I am at Sanofi.

That experience taught me one side of a drug life cycle management and continued with my current experience in pre-launch and launch of a new asset. Currently I am the U.S. Medical Affairs Head at Sanofi. We successfully launched dupilumab in eosinophilic esophagitis. Launching a new asset, especially in a therapeutic area where there is no FDA-approved drug for a certain disease such as eosinophilic esophagitis in my case, is another new experience where I learned tremendously. It’s exciting to start from scratch, building a new gastroenterology team in a new therapeutic area for the company and creating relationships between the GI community, the health care providers, and the medical affairs professionals in the company.

JG: I imagine your first job at UCB wasn’t Head of Medical Affairs for Gastroenterology, was it?

AP: It was.

JG: It was? Your first position in the pharmaceutical industry was to be in charge?

AP: I entered industry as the UCB Head of GI Medical Affairs for the United States and, again, this is the lesson I learned. The MD experience, the gastroenterology experience, got me the position, not the MBA. They had other very capable MBAs in the company. What I noticed is that clinical or research experience could be the valuable stepping stone on which you build in industry. There are a lot of PharmDs and PhDs in industry, but not as many MDs. We are trying to change that. I have had a goal to recruit on my team more professionals with direct clinical experience including physicians and advanced practice providers. An added MBA or a Public Health degree was not something I was looking for to push them over the line.

JG: It seems intimidating to have your first job in industry to be the lead for a whole team. Did you have any hesitation taking that role or did you feel 100% prepared?

AP: It’s not intimidating if you come in with a strategic mind. One important thing in industry is relationships. I

found that my hiring manager, the head of the unit that hired me, was extremely open and we had a good conversation before I took the job. I asked point blank, “What would my day be like? What do you need from me?” Because obviously, I have a lot of deficiencies; I haven’t worked in the industry, I don’t know standard operating procedures and all that, so I will have a learning curve.” I asked, “Why do you need me?” and “Do you think I can do the job?” He explained that what he needed at that time was the clinical experience. He needed to learn strategically, how do we show value for an asset toward the end of its lifecycle? Strategically and competitively, what would bring value to a physician and his or her patient? Communication is key, knowing who your team is going to be is key, knowing exactly what you are expected to deliver is key. Because you are going to learn more and more every month, but at the basic level the question is, what qualifications will allow you to do the job? I think that his approach made me comfortable with joining industry and that specific role. It took six months to become comfortable in the job, to be honest. I was kind of crying for six months because I was at a crossroads, and I kept wondering if I should go back. Because I worked for 20 years, and I saw patients and I missed my patients. I was afraid I was going to lose everything I built, licensing and credentialing – what is going to happen to that? I never thought I was going to stay, but the longer I stay and the more new things I learn and do, I feel fulfilled here. I’m crying less (laughs)

JG: That’s good to hear (laughing). There is a perception that people understand what a life in industry is like. Can you give me an idea of what your day-to-day schedule looks like?

AP: The day-to-day, if you look at the calendar, consists of a lot of meetings. The working from home situation and Zoom just increased the volume. We were talking to each other more, stopping in the hallway, going to lunch before the pandemic. When the pandemic hit, we were home and we filled the calendar with meetings. So, that is what we still do. But also, now that we are back to in-person interactions, we travel to internal and external face-to-face meetings, congresses, as well as national and in some cases international meetings. Hopefully, in the future, we will do more advisory

boards in person; we have been doing advisory boards virtually. Medical affairs is responsible for synthesizing information about the science, disease state, and available product data, and is a trusted resource internally to functions ranging from research to commercial. It is customarily about two to three years before a new launch to create relationships and educate the community about the unmet needs in that therapeutic area and the science (immunology, in my case) behind the pathophysiology of the disease. The team is comprised of headquarter individuals and field individuals. Field individuals have Medical Science Liaison roles. There is an MSL lead or director who manages the MSLs. Headquarter roles are directors led by section heads and higher management that ranges from country to global. The headquarter roles are mostly strategic and are involved in creating a medical plan each year, including strategy, tactics, and budgetary aspects. That is where the business part helps. In discussing strategic and tactical aspects, we frequently need to align with multiple individuals in large teams. We are very crossfunctional and enjoy being a valuable resource for other teams. Compliant behavior is paramount and we are frequently learning important legal and compliance aspects that are essential to our day to day job.

JG: How does it feel being a woman in industry? Do you feel outnumbered? I’m sure it’s company specific, but do you feel supported?

AP: There are a lot of women in industry, but you are correct that it depends on the company. Both companies I have worked in are global, both are based in Europe, and I feel they are both doing a lot to promote women. Where I work now, at Sanofi, we have a leadership management path where everybody is helped and mentored to grow and move into the next role if they wish to. This upward mobility, including women, is encouraged. It’s actually one of the tasks for manager, such as myself, to have discussions with my MSLs and my directors, and find a way to develop their career so they can go for promotions if they want to.

JG: How is that established? Is there a curriculum or do you have scheduled meetings where you have time to talk about it?

AP: We are mandated by human resources to do a rating for how each of our employees did that year. As a manager, we evaluate them overall on what they do and how, but also their ambition, what do they need to grow and their desired career path. So if an MSL says they want to be a director, there are multiple ways where they can gain the necessary learning and expertise to empower them for the next step. As a manager, one of my jobs is to promote my team members, even if it means they leave my team. I think it’s a great system put in place where leaders have to mentor their team members and give them the tools to advance if they want to. In addition, our company has specific goals for promoting women, especially, towards leadership positions.

JG: Did you have anything like that in your private practice experience?

AP: In private practice, no, I did not have that. When I started, I joined a male-driven group. For the duration of my partnership we had less than 10% women physicians or advanced practice providers in the group. There was no formal mentoring process and no formal path towards a leadership role. Going to business school was my own initiative, not sponsored by the group. I wanted to grow my skills and perhaps get more tools to avoid feeling like an imposter if I go and ask for a promotion inside the group or a leadership job. I wanted to have more in my toolbox.

JG: What advice would you give other women who may be interested in pursuing a career in industry?

AP: I’m looking at the way that industry is changing and what I need to say is you need to have a strong scientific background, plus expertise either in research or clinical practice. So, it would be useful if you have done bench research or have experience as the Principal Investigator on clinical trials. Similarly, it would help if you have deep expertise in a therapeutic area or led a clinic that specializes in a disease state, for example a hepatology clinic focusing on NASH. An MD degree is highly valued with or without added degrees such as an MBA or a Master’s in Public Health. Communication skills are very important because all of

these internally and externally facing relationships need to be maintained, you need to interact with people, and be an effective speaker. Strategic thinking is essential if you intend to have a leadership position.

The way to negotiate, the ability to interact and influence people, and especially to function in a team are essential in the industry. See, this is also what we do as gastroenterologists. When you do endoscopy or work in a clinic, you work in a team setting. This is crucial in industry as well. In order to align people who come from different functions, like attorneys, business partners, medical or marketing colleagues, you have to express your opinion on a topic and ideally they have to align with it. In that case, if there is a conflict, how are you going to resolve it, how are you going to negotiate, how are you going to get them to see your way, and how are you going to see their way and the rationale behind their opinions? Conflict resolution is huge. I would like to see it be taught in medical school, residency, and fellowship, much more than finance or budgets. How to talk to people, how to be empathetic, and how to understand what they want to achieve and to be able to find a common ground despite differences, that is harder to achieve.

JG: Absolutely. Those are very important skills to have.

Jill K. J. Gaidos, MD, FACG, is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Anca I. Pop, MD, MBA, Head, Medical Affairs Gastroenterology at Sanofi Genzyme

AN UPDATE TO THE ACG GASTROPARESIS GUIDELINE AND A

PODCAST with lead author Michael Camilleri, MD, DSc, MRCP (UK), MACG, are recent highlights for the Red Journal.

In October, AJG published a supplement with a newly updated edition of ACG’s Monograph on GI Diseases and Endoscopy in Pregnancy and Postpartum Period.

A novel approach to understanding social determinants of health in cirrhosis and the microbiome was published in Clinical and Translational Gastroenterology by Jasmohan S. Bajaj, MD, MS, FACG, and colleagues.

ACG Case Reports Journal continues its strong tradition of publishing interesting and relevant cases with the experience of using virtual reality and mindfulness approaches in treating rumination syndrome.

Evidence-Based GI, ACG’s newest publication, marked its first anniversary with an editorial by Editor-in-Chief Philip Schoenfeld, MD, MSEd, MSc (Epi), FACG.

[THE

ACG Clinical Guideline: Gastroparesis Guideline

Michael

: August 2022 - Volume 117 - Issue 8 - p 1197-1220 doi: 10.14309/ajg.0000000000001874

 An update to the College’s 2013 clinical guidelines on gastroparesis published in August 2022. The authors summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus.) They note, “It is necessary to acknowledge the limitations of guideline recommendations on therapies in the absence of Food and Drug Administration (FDA)approved therapies for gastroparesis in the United States and the limitation in duration of prescription to 3 months for the only currently approved medication, metoclopramide.”  READ bit.ly/acg-gastroparesis-guideline  LISTEN In the AJG Author Podcast, Dr. Camilleri talks with ACG Co-Editor-in-Chief Millie D. Long, MD, MPH, FACG: bit.ly/ajgpodcast-gastroparesis

Area Deprivation Index and Gut-Brain Axis in Cirrhosis

Jasmohan S. Bajaj, MD, MS, FACG; Andrew Fagan, BS; Sara McGeorge, BS; Richard K. Sterling, MD, MS, FACG; Shari Rogal, MD; Masoumeh Sikaroodi, PhD; Patrick M. Gillevet, PhD, Clinical and Translational Gastroenterology: June 2022 - Volume 13 - Issue 6 - p e00495 doi: 10.14309/ctg.000000000000049

 In a novel approach to understanding social determinants of health in cirrhosis and the microbiome, investigators examined whether cirrhosis-related variables may be more influential in determining gut microbiome composition and cognitive impairment than area deprivation index (ADI), which ranks neighborhoods by socioeconomic disadvantage. Investigators concluded, “neighborhood disadvantage, which is a surrogate measure of income, education, employment, and housing quality, was associated with gut microbiota composition in cirrhosis on univariable analysis. However, when cirrhosis-related variables were included, the influence of area deprivation index on cognitive impairment and microbial composition did not remain significant.” Visual Abstract

 READ bit.ly/ctg-bajaj-cirrhosis

Virtual Reality and Mindfulness Approaches in the Treatment of Rumination Syndrome

BASEDGI(EBGI) evaluates new GI and Hepatology journals using quality studies published on important topics summarizing the study for quick reference and data is applicable to clinical practice. for easy listening on the go. summaries or stream the entire issue all at once.

Jeff Angelo Taclob, MD; M Ammar Kalas, MD; Marcus Juan Esteban, MD; Claudia Didia, MD; Richard McCallum, MD, ACG Case Reports Journal: October 2022 - Volume 9 - Issue 10 - p e00871 doi: 10.14309/crj.0000000000000871  In this case report, the authors discuss the use of virtual reality and mindfulness exercises as therapeutic tools for the management of rumination syndrome. The patient, a 26-yearold woman, was diagnosed using the ROME IV criteria and did not respond to standard treatment approaches (antiemetics and antispasmodics). Following treatment involving two weeks of VR sessions and two weeks of mindfulness sessions, the patient reported symptom improvement based on the Patient Assessment of Gastrointestinal Disorders Symptom Severity Index.  READ bit.ly/acgcrj-taclob-vr-rumination

Camilleri, MD, DSc, MRCP (UK), MACG; Braden Kuo, MD, MSc, FACG; Linda Nguyen, MD, FACG; Vida M. Vaughn, MLIS, MBA; Jessica Petrey, MSLS; Katarina Greer, MD, MS Epi; Rena Yadlapati, MD, MSHS, FACG; Thomas L. Abell, MD, FACG, The American Journal of Gastroenterology

EVIDENCE-BASED GI JOURNAL REVIEW

Clinical take-aways and evidence-based summaries of articles in GI, Hepatology & Endoscopy.

ACG PUBLICATION EVIDENCE-

BASED GI (EBGI) evaluates new research articles published across GI and Hepatology journals using evidence-based criteria.

ACG Editors identify the highest quality studies published on important topics and create structured abstracts summarizing the study for quick reference and provide commentary on how the data is applicable to clinical practice.

Editors record audio summaries for easy listening on the go. Listen to individual article summaries or stream the entire issue all at once.

PDF: gi.org/ebgi

GASTROPARESIS About (Poor

Stomach Emptying)

Understanding the ACG Gastroparesis Clinical Guidelines: Information for Patients, Parents & Caregivers from the American College of Gastroenterology

Gastroparesis, which is poor or slow stomach emptying, has symptoms such as feeling sick to your stomach or feeling easily full. This is a common problem. It is confirmed by a test to see how fast your stomach empties food after you eat. The ACG Gastroparesis Clinical Guidelines describe what puts you at risk for the disease, how to know you have the disease, and how to treat the problem, including what you should eat, and what medications or new treatments you should try.

KEY TAKEAWAYS

• The best way to see if you have gastroparesis is with a radiology test or a breath test where the meal includes special substances that can be tracked to see how quickly your stomach empties the food

• Eating smaller amounts during meals may help you feel better

• If you have diabetes, controlling your blood sugar lowers your risk for gastroparesis

• Some medications may help symptoms in gastroparesis, but some of these medications may cause other problems

• A small medical device called a gastric electrical stimulator (which is like a battery-operated pacemaker) may be inserted into your abdomen (belly) for symptom control

• Cutting of the exit of the stomach (called the pylorus) is better than no treatment; but Botox® (botulinum toxin) injections are not recommended

LEARN MORE

Questions You Should ask Your Physician about Gastroparesis Care

• Is my stomach emptying correctly?

• Are there medications I can try?

• What treatment would you recommend based on my nutritional health?

Warning Signs or Alarm Symptoms

• Call your doctor right away if you have significant weight loss and are often dehydrated (not getting enough liquids in your body)

ACG Patient Information: Scan QR Code or visit gi.org/topics/gastroparesis

Find a gastroenterologist near you: gi.org/FindaGI

Read the American College of Gastroenterology 2022 Gastroparesis Guidelines bit.ly/acg-gastroparesis-guideline

American College of Gastroenterology | gi.org | Follow ACG on Twitter @AmCollegeGastro

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults.

DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen:

Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Early in the evening prior to colonoscopy, open one bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy.

Packaging and tablets not shown actual size.

CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury. Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production. Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185

See Full Prescribing Information and Medication Guide at SUTAB.com.

References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020

3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

For additional information, please call 1-800-874-6756

©2021 Braintree Laboratories, Inc. All rights reserved. 201-133-v1-A January 2021

A

A NEW TABLET CHOICE IN BOWEL PREPARATION

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2†

• 52% of all SUTAB and MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡

• More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1% of these reports considered severe2‡

78% OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2†

*Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

†Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

*Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

‡Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion of study drug, rating the intensity as mild, moderate, or severe.

†Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG.

‡Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion of study drug, rating the intensity as mild, moderate, or severe.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG.

IMPORTANT SAFETY INFORMATION

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing

IMPORTANT SAFETY INFORMATION

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. Please see Brief Summary of Prescribing