Mixed Topics

Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based. 

“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”

Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.

Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.

The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.

“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
 

Reference

Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.

Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based. 

“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”

Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.

Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.

The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.

“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
 

Reference

Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.

Hospitalists know that a small percentage of patients account for a disproportionately large percentage of overall health care spending, much of which comes from inpatient admissions. Many programs have been developed around the country to work with this population, and most of these programs are – appropriately – outpatient based. 

“However, a subset of frequently admitted patients either don’t make it to outpatient care or are unengaged with outpatient care and programs, for whom hospital stays can give us a unique opportunity to coordinate and streamline care, and to build trust that can then lead to increased patient engagement,” said Kirstin Knox, MD, PhD, of the Hospital of the University of Pennsylvania in Philadelphia, and lead author of an abstract describing a method to address this challenge. “Our program works with these patients, the ‘outliers among the outliers’ to re-engage them in care, streamline admissions, coordinate inpatient and outpatient care, and address the underlying barriers/drivers that lead to frequent hospitalization.”

Their program designed and implemented a multidisciplinary intervention targeting the highest utilizers on their inpatient general medicine service. Each was assigned an inpatient continuity team, and the patient case was then presented to a multidisciplinary high-utilizer care committee that included physicians, nurses, and social workers, as well as representatives from a community health worker program, home care, and risk management to develop a care plan.

Analysis comparing the 6 months before and after intervention showed admissions and total hospital days were reduced by 55% and 47% respectively, and 30-day readmissions were reduced by 65%. Total direct costs were reduced from $2,923,000 to $1,284,000.

The top takeaway, Dr. Knox said, is that, through efforts to coordinate care and address underlying drivers of high utilization, hospital-based programs for the most frequently admitted patients can streamline inpatient care and decrease utilization for many high-risk, high-cost patients.

“I hope that hospitalists will consider starting inpatient-based high-utilizer programs at their own institutions, if they haven’t already,” she said. “Even starting with one or two of your most frequently admitted patients can be incredibly eye opening, and streamlining/coordinating care (as well as working overtime to address the underlying drivers/barriers that lead to high utilization) for these patients is incredibly rewarding.”
 

Reference

Knox K et al. Breaking the cycle: a successful inpatient based intervention for hospital high utilizers. Abstract published at Hospital Medicine 2018; Apr 8-11; Orlando, Fla., Abstract 319. Accessed 2018 Oct 2.

“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.” 

But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.

Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.

Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.

“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”

The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.

“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
 

Reference

Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.

“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.” 

But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.

Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.

Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.

“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”

The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.

“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
 

Reference

Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.

“As a hospitalist, I believe that my specialty improves care for inpatients,” said Ethan Kuperman, MD, MS, FHM, clinical associate professor of medicine at University of Iowa Health Care in Iowa City. “I want hospitalists involved with as many hospitals as possible because I believe we will lead to better patient outcomes.” 

But, he adds, it’s not feasible to place dedicated hospitalists in every rural hospital in the United States – especially those running far below the average hospitalist census. “As a university, academic hospitalist, I wanted to make sure that the innovations and knowledge of the University of Iowa could penetrate into the greater community, and I wanted to strengthen the continuity of care between our partners in rural Iowa and our physical location in Iowa City,” he said.

Enter the virtual hospitalist: A telemedicine “virtual hospitalist” may expand capabilities at a fractional cost of an on-site provider.

Dr. Kuperman’s 6-month pilot program provided “virtual hospitalist” coverage to patients at a critical access hospital in rural Iowa.

“Our rural partners want to ensure that they are providing high-quality care within their communities and aren’t transferring patients without a good indication to larger centers,” he said. “For patients, this program means more of them can remain in their communities, surrounded by their families. I don’t think the virtual hospitalist program delivers equivalent care to the university hospital – I think we deliver better care because of that continuity with local providers and the ability of patients to remain in contact with their support structures.”

The study concludes that the virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally, and a single virtual hospitalist may be able to cover multiple critical access hospitals simultaneously.

“We have the technology to deliver hospitalist expertise to rural hospitals through telehealth in a way that benefits patients, rural hospitals, and academic hospitals,” he said.
 

Reference

Kuperman E et al. The Virtual Hospitalist: A single-site implementation bringing hospitalist coverage to critical access hospitals. Journal of Hospital Medicine. Published online first 2018 Sep 26. doi: 10.12788/jhm.3061. Accessed 2018 Oct 2.

And now, 37 words from our sponsor

If you’re looking for gluten-free news of the health and medical sciences that’s low in sugar, we here at LOTME Farms promise to use no artificial colors or flavors to tell you about a study of the health claims on cereal boxes.

NorthStar203/iStock/Getty Images Plus

Researchers identified 37 such claims that appeared on the boxes of 460 different breakfast cereals and grouped them into four categories: adding positives (high fiber, probiotics), not adding negatives (GMO free, no high-fructose corn syrup), removing negatives (low cholesterol, no trans fat), and not removing positives (made with whole grains, fresh).

What they found is that words matter: None of the 37 claims explicitly said that the product inside would make people healthier or help them lose weight, but that was how respondents interpreted them. There is, of course, a reason none of the products claimed to improve health. “The correlation between the type of ‘healthy’ claim made and the actual nutritional quality of the breakfast cereal was almost zero,” investigator Pierre Chandon said.

This is, perhaps, not such a surprise. But we here at the pure, all-natural LOTME deal with facts, which are low in calories and contain no artificial growth hormones, and we would never insult (NEW LOTME LIGHT! NO ARTIFICIAL SWEETENERS!) our wholesome, low-fat readers by resorting (TRY FRESH LOTME ORGANIC!) to hyperbole or doublespeak. Not a chance (MMM … HOMEMADE LOTME).

Now, who’s up for a bowl of Froot Loops?
 

Captain Bacteria: Civil War

In the never-ending struggle of bacteria versus the world, Clostridium difficile has become a particularly stubborn foe. It is far more likely to be resistant to antibiotics, and the antibiotics that can do the job are either incredibly expensive or destroy the patient’s entire microbiota. However, we may have a new ally in the fight against C. diff: other bacteria.

Chereliss/iStock/Getty Images Plus

Specifically, we’re talking about fecal transplants. According to an article published in the Journal of the American Osteopathic Association, the wide variety of bacteria that get transferred into the body along with the poop can block C. diff’s ability to germinate and produce the toxins that affect the human body. The treatment is especially beneficial for patients with C. diff whose microbiotas have been compromised by some other treatment, like chemotherapy, antibiotics, or proton pump inhibitors.

We here at LOTME would like to take a moment to salute the brave bacteria in our guts, fighting the good fight against those who would do us harm, and to the fecal transplants that let our own bacteria join the battle. Poop, you never let us down!
 

Dracula side effects

The Kim Kardashian effect is having dire ramifications. Back in 2013, the social media influencer posted a photo of herself getting a “vampire facial” – a dermatologic procedure in which a person’s own blood is injected into their face as a way to freshen and rejuvenate their skin. At least they aren’t drinking it.

domoyega/iStock/Getty Images Plus

Vampire facials have skyrocketed in popularity since, despite the ick factor. Unfortunately, it seems to be as dangerous as an encounter with a real vampire: Recently, two people in New Mexico were diagnosed with HIV after getting vampire facials.

The New Mexico Department of Health noted that both cases have been traced to the same spa, which was shut down in 2018 after at least three government agencies noted its lack of attention to hygiene and cleanliness. Warning to all: Just because a Kardashian does it doesn’t mean you should, too.
 

Shave that beard, Fido

The adage “a dog’s mouth is cleaner than a person’s” is getting an upgrade and this time it’s backed by science. A clinic in Zurich looked at the pathogenic microorganisms that reside in men’s beards and dogs’ fur and guess what – the beards were dirtier.

supersizer/E+

Despite beards’ manly cache among Millennials and hipsters, the results many have some reaching for the razor. The clinicians took a look at the bacterial load of colony-forming units of human-pathogenic microorganisms, and compared samples of beards and dog’s necks (since dogs don’t have beards, but how cute would that be?). They found high microbial counts in all beard samples, but only 23 of 30 dogs’ hair samples. Half of the human subjects carried so much bacteria that they were in danger of illness, the researchers noted.

Does this mean men are dirty? Or are dogs clean? The clinicians didn’t survey the men on their habits so it could be likely that they spend lots of time rolling around in the grass or drinking water from the toilet. More research is definitely needed here.

And now, 37 words from our sponsor

If you’re looking for gluten-free news of the health and medical sciences that’s low in sugar, we here at LOTME Farms promise to use no artificial colors or flavors to tell you about a study of the health claims on cereal boxes.

NorthStar203/iStock/Getty Images Plus

Researchers identified 37 such claims that appeared on the boxes of 460 different breakfast cereals and grouped them into four categories: adding positives (high fiber, probiotics), not adding negatives (GMO free, no high-fructose corn syrup), removing negatives (low cholesterol, no trans fat), and not removing positives (made with whole grains, fresh).

What they found is that words matter: None of the 37 claims explicitly said that the product inside would make people healthier or help them lose weight, but that was how respondents interpreted them. There is, of course, a reason none of the products claimed to improve health. “The correlation between the type of ‘healthy’ claim made and the actual nutritional quality of the breakfast cereal was almost zero,” investigator Pierre Chandon said.

This is, perhaps, not such a surprise. But we here at the pure, all-natural LOTME deal with facts, which are low in calories and contain no artificial growth hormones, and we would never insult (NEW LOTME LIGHT! NO ARTIFICIAL SWEETENERS!) our wholesome, low-fat readers by resorting (TRY FRESH LOTME ORGANIC!) to hyperbole or doublespeak. Not a chance (MMM … HOMEMADE LOTME).

Now, who’s up for a bowl of Froot Loops?
 

Captain Bacteria: Civil War

In the never-ending struggle of bacteria versus the world, Clostridium difficile has become a particularly stubborn foe. It is far more likely to be resistant to antibiotics, and the antibiotics that can do the job are either incredibly expensive or destroy the patient’s entire microbiota. However, we may have a new ally in the fight against C. diff: other bacteria.

Chereliss/iStock/Getty Images Plus

Specifically, we’re talking about fecal transplants. According to an article published in the Journal of the American Osteopathic Association, the wide variety of bacteria that get transferred into the body along with the poop can block C. diff’s ability to germinate and produce the toxins that affect the human body. The treatment is especially beneficial for patients with C. diff whose microbiotas have been compromised by some other treatment, like chemotherapy, antibiotics, or proton pump inhibitors.

We here at LOTME would like to take a moment to salute the brave bacteria in our guts, fighting the good fight against those who would do us harm, and to the fecal transplants that let our own bacteria join the battle. Poop, you never let us down!
 

Dracula side effects

The Kim Kardashian effect is having dire ramifications. Back in 2013, the social media influencer posted a photo of herself getting a “vampire facial” – a dermatologic procedure in which a person’s own blood is injected into their face as a way to freshen and rejuvenate their skin. At least they aren’t drinking it.

domoyega/iStock/Getty Images Plus

Vampire facials have skyrocketed in popularity since, despite the ick factor. Unfortunately, it seems to be as dangerous as an encounter with a real vampire: Recently, two people in New Mexico were diagnosed with HIV after getting vampire facials.

The New Mexico Department of Health noted that both cases have been traced to the same spa, which was shut down in 2018 after at least three government agencies noted its lack of attention to hygiene and cleanliness. Warning to all: Just because a Kardashian does it doesn’t mean you should, too.
 

Shave that beard, Fido

The adage “a dog’s mouth is cleaner than a person’s” is getting an upgrade and this time it’s backed by science. A clinic in Zurich looked at the pathogenic microorganisms that reside in men’s beards and dogs’ fur and guess what – the beards were dirtier.

supersizer/E+

Despite beards’ manly cache among Millennials and hipsters, the results many have some reaching for the razor. The clinicians took a look at the bacterial load of colony-forming units of human-pathogenic microorganisms, and compared samples of beards and dog’s necks (since dogs don’t have beards, but how cute would that be?). They found high microbial counts in all beard samples, but only 23 of 30 dogs’ hair samples. Half of the human subjects carried so much bacteria that they were in danger of illness, the researchers noted.

Does this mean men are dirty? Or are dogs clean? The clinicians didn’t survey the men on their habits so it could be likely that they spend lots of time rolling around in the grass or drinking water from the toilet. More research is definitely needed here.

And now, 37 words from our sponsor

If you’re looking for gluten-free news of the health and medical sciences that’s low in sugar, we here at LOTME Farms promise to use no artificial colors or flavors to tell you about a study of the health claims on cereal boxes.

NorthStar203/iStock/Getty Images Plus

Researchers identified 37 such claims that appeared on the boxes of 460 different breakfast cereals and grouped them into four categories: adding positives (high fiber, probiotics), not adding negatives (GMO free, no high-fructose corn syrup), removing negatives (low cholesterol, no trans fat), and not removing positives (made with whole grains, fresh).

What they found is that words matter: None of the 37 claims explicitly said that the product inside would make people healthier or help them lose weight, but that was how respondents interpreted them. There is, of course, a reason none of the products claimed to improve health. “The correlation between the type of ‘healthy’ claim made and the actual nutritional quality of the breakfast cereal was almost zero,” investigator Pierre Chandon said.

This is, perhaps, not such a surprise. But we here at the pure, all-natural LOTME deal with facts, which are low in calories and contain no artificial growth hormones, and we would never insult (NEW LOTME LIGHT! NO ARTIFICIAL SWEETENERS!) our wholesome, low-fat readers by resorting (TRY FRESH LOTME ORGANIC!) to hyperbole or doublespeak. Not a chance (MMM … HOMEMADE LOTME).

Now, who’s up for a bowl of Froot Loops?
 

Captain Bacteria: Civil War

In the never-ending struggle of bacteria versus the world, Clostridium difficile has become a particularly stubborn foe. It is far more likely to be resistant to antibiotics, and the antibiotics that can do the job are either incredibly expensive or destroy the patient’s entire microbiota. However, we may have a new ally in the fight against C. diff: other bacteria.

Chereliss/iStock/Getty Images Plus

Specifically, we’re talking about fecal transplants. According to an article published in the Journal of the American Osteopathic Association, the wide variety of bacteria that get transferred into the body along with the poop can block C. diff’s ability to germinate and produce the toxins that affect the human body. The treatment is especially beneficial for patients with C. diff whose microbiotas have been compromised by some other treatment, like chemotherapy, antibiotics, or proton pump inhibitors.

We here at LOTME would like to take a moment to salute the brave bacteria in our guts, fighting the good fight against those who would do us harm, and to the fecal transplants that let our own bacteria join the battle. Poop, you never let us down!
 

Dracula side effects

The Kim Kardashian effect is having dire ramifications. Back in 2013, the social media influencer posted a photo of herself getting a “vampire facial” – a dermatologic procedure in which a person’s own blood is injected into their face as a way to freshen and rejuvenate their skin. At least they aren’t drinking it.

domoyega/iStock/Getty Images Plus

Vampire facials have skyrocketed in popularity since, despite the ick factor. Unfortunately, it seems to be as dangerous as an encounter with a real vampire: Recently, two people in New Mexico were diagnosed with HIV after getting vampire facials.

The New Mexico Department of Health noted that both cases have been traced to the same spa, which was shut down in 2018 after at least three government agencies noted its lack of attention to hygiene and cleanliness. Warning to all: Just because a Kardashian does it doesn’t mean you should, too.
 

Shave that beard, Fido

The adage “a dog’s mouth is cleaner than a person’s” is getting an upgrade and this time it’s backed by science. A clinic in Zurich looked at the pathogenic microorganisms that reside in men’s beards and dogs’ fur and guess what – the beards were dirtier.

supersizer/E+

Despite beards’ manly cache among Millennials and hipsters, the results many have some reaching for the razor. The clinicians took a look at the bacterial load of colony-forming units of human-pathogenic microorganisms, and compared samples of beards and dog’s necks (since dogs don’t have beards, but how cute would that be?). They found high microbial counts in all beard samples, but only 23 of 30 dogs’ hair samples. Half of the human subjects carried so much bacteria that they were in danger of illness, the researchers noted.

Does this mean men are dirty? Or are dogs clean? The clinicians didn’t survey the men on their habits so it could be likely that they spend lots of time rolling around in the grass or drinking water from the toilet. More research is definitely needed here.

“What is my veteran status?” “Should I receive any benefits from VA, like the GI Bill?”

Now women veterans have another convenient way to get answers to questions like those. Texting 855.829.6636 (855.VA.WOMEN) connects women veterans to the Women Veterans Call Center, where they will find information about VA benefits, health care, and resources. The new texting feature aligns the service with those of other VA call centers, the VA says.

Women are among the fastest-growing veteran demographics , the VA says, accounting for > 30% of the increase in veterans who served between 2014 and 2018. The number of women using VA health care services has tripled since 2000 from about 160,000 to > 500,000. But the VA has found that women veterans underuse VA care, largely due to a lack of knowledge about benefits, services, and their eligibility for them. As the number of women veterans continues to grow, the VA says, it is expanding its outreach to ensure they receive enrollment and benefits information through user-friendly and responsive means. The VA says it works to meet the unique requirements of women, “offering privacy, dignity, and sensitivity to gender-specific needs.” In addition to linking callers to information, the call center staff make direct referrals to Women Veteran Program Managers at every VAMC.

Since 2013, the call center has received nearly 83,000 inbound calls and has initiated almost 1.3 million outbound calls, resulting in communication with > 650,000 veterans.

Staffed by trained, compassionate female VA employees (many are also veterans), the call center is available Monday through Friday 8 am to 10 pm ET and Saturdays from 8 am to 6:30 pm ET. Veterans can call for themselves or on behalf of another woman veteran. Calls are free and confidential, texts and chats are anonymous. Veterans can call as often as they like, the VA says—“until you have the answer to your questions.”

For more information about the Women Veterans Call Center, visit https://www.womenshealth.va.gov/programoverview/wvcc.asp.

“What is my veteran status?” “Should I receive any benefits from VA, like the GI Bill?”

Now women veterans have another convenient way to get answers to questions like those. Texting 855.829.6636 (855.VA.WOMEN) connects women veterans to the Women Veterans Call Center, where they will find information about VA benefits, health care, and resources. The new texting feature aligns the service with those of other VA call centers, the VA says.

Women are among the fastest-growing veteran demographics , the VA says, accounting for > 30% of the increase in veterans who served between 2014 and 2018. The number of women using VA health care services has tripled since 2000 from about 160,000 to > 500,000. But the VA has found that women veterans underuse VA care, largely due to a lack of knowledge about benefits, services, and their eligibility for them. As the number of women veterans continues to grow, the VA says, it is expanding its outreach to ensure they receive enrollment and benefits information through user-friendly and responsive means. The VA says it works to meet the unique requirements of women, “offering privacy, dignity, and sensitivity to gender-specific needs.” In addition to linking callers to information, the call center staff make direct referrals to Women Veteran Program Managers at every VAMC.

Since 2013, the call center has received nearly 83,000 inbound calls and has initiated almost 1.3 million outbound calls, resulting in communication with > 650,000 veterans.

Staffed by trained, compassionate female VA employees (many are also veterans), the call center is available Monday through Friday 8 am to 10 pm ET and Saturdays from 8 am to 6:30 pm ET. Veterans can call for themselves or on behalf of another woman veteran. Calls are free and confidential, texts and chats are anonymous. Veterans can call as often as they like, the VA says—“until you have the answer to your questions.”

For more information about the Women Veterans Call Center, visit https://www.womenshealth.va.gov/programoverview/wvcc.asp.

“What is my veteran status?” “Should I receive any benefits from VA, like the GI Bill?”

Now women veterans have another convenient way to get answers to questions like those. Texting 855.829.6636 (855.VA.WOMEN) connects women veterans to the Women Veterans Call Center, where they will find information about VA benefits, health care, and resources. The new texting feature aligns the service with those of other VA call centers, the VA says.

Women are among the fastest-growing veteran demographics , the VA says, accounting for > 30% of the increase in veterans who served between 2014 and 2018. The number of women using VA health care services has tripled since 2000 from about 160,000 to > 500,000. But the VA has found that women veterans underuse VA care, largely due to a lack of knowledge about benefits, services, and their eligibility for them. As the number of women veterans continues to grow, the VA says, it is expanding its outreach to ensure they receive enrollment and benefits information through user-friendly and responsive means. The VA says it works to meet the unique requirements of women, “offering privacy, dignity, and sensitivity to gender-specific needs.” In addition to linking callers to information, the call center staff make direct referrals to Women Veteran Program Managers at every VAMC.

Since 2013, the call center has received nearly 83,000 inbound calls and has initiated almost 1.3 million outbound calls, resulting in communication with > 650,000 veterans.

Staffed by trained, compassionate female VA employees (many are also veterans), the call center is available Monday through Friday 8 am to 10 pm ET and Saturdays from 8 am to 6:30 pm ET. Veterans can call for themselves or on behalf of another woman veteran. Calls are free and confidential, texts and chats are anonymous. Veterans can call as often as they like, the VA says—“until you have the answer to your questions.”

For more information about the Women Veterans Call Center, visit https://www.womenshealth.va.gov/programoverview/wvcc.asp.

The “human microbiota” describes all microorganisms within the human body, including bacteria, viruses, and eukaryotes. The related term “microbiome” refers to the complete catalog of these microbes and their genes.¹ There is a growing awareness that the human microbiota plays an important role in maintaining mental health, and that a disruption in its composition can contribute to manifestations of psychiatric disorders. A growing body of evidence has also linked mental health outcomes to the gut microbiome, suggesting that the gut microbiota can modulate the gut-brain axis.²

Numerous neurotransmitters, including dopamine, serotonin, gamma-aminobutyric acid, and acetylcholine, are produced in the gastrointestinal (GI) tract, and our diet is vital in sustaining and replenishing them. At the same time, our brain regulates our GI tract by secretion of hormones such as oxytocin, leptin, ghrelin, neuropeptide Y, corticotrophin-releasing factor, and a plethora of others. Dysregulation of this microbiome can lead to both physical and mental illnesses. Symptoms of psychiatric disorders, such as depression, psychosis, anxiety, and autism, can be a consequence of this dysregulation.²

Our diet can also modify the gut micro­organisms and therefore many of its metabolic pathways. More attention has been given to pre- and probiotics and their effects on DNA by epigenetic changes. One can quickly start to appreciate how this intricate crosstalk can lead to a variety of pathologic and psychiatric problems that have an adverse effect on autoimmune, inflammatory, metabolic, cognitive, and behavioral processes.^2,3

Thus far, links have mostly been reported in animal models, and human studies are limited.⁴ Researchers are just beginning to elucidate how the microbiota affect gut-brain signaling in humans. Such mechanisms may include alterations in microbial composition, immune activation, vagus nerve signaling, alterations in tryptophan metabolism, production of specific microbial neuroactive metabolites, and bacterial cell wall sugars.⁵ The microbiota-gut-brain axis plays a part in regulating/programming the hypothalamic-pituitary-adrenal (HPA) axis throughout the life span.³ The interactions between the gut microbiome, the immune system, and the CNS are regulated through pathways that involve endocrine functions (HPA axis), the immune system, and metabolic factors.^3,4 Recent research focusing on the gut microbiome has also given rise to international projects such as the Human Microbiome Project (Human Microbiome Project Consortium, 2012).³

Several studies have looked into psychiatry and inflammatory/immune pathways. Here we review 3 recent studies that have focused on the gut-brain axis (Table^6-8).

1. Rudzki L, Pawlak D, Pawlak K, et al. Immune suppression of IgG response against dairy proteins in major depression. BMC Psychiatry. 2017;17(1):268.

The aim of this study was to evaluate immunoglobulin G (IgG) response against 40 food products in patients with depression vs those in a control group, along with changes in inflammatory markers, psychological stress, and dietary variables.⁶

Study design

• N = 63, IgG levels against 44 food products, cortisol levels, tumor necrosis factor (TNF)-alpha, interleukin 6 (IL-6), and IL-1 beta levels were recorded. The psychological parameters of 34 participants with depression and 29 controls were compared using the Hamilton Depression Rating scale, (HAM-D-17), Perceived Stress scale, and Symptom Checklist scale. The study was conducted in Poland.

Continue to: Outcomes

Outcomes

• Patients who were depressed had lower IgG levels against dairy products compared to controls when there was high dairy consumption. However, there was no overall difference between patients and controls in mean IgG concentration against food products. 
• Patients who were depressed had higher levels of cortisol. Levels of cortisol had a positive correlation with HAM-D-17 score. Patients with depression had lower levels of TNF-alpha.

Conclusion

• Patients with depression had lower levels of IgG against dairy protein. Patients with depression had high cortisol levels but decreased levels of TNF-alpha, which could explain an immune suppression of IgG in these patients. There were no differences in IL-6 or IL-1beta levels.

Hypercortisolemia is present in approximately 60% of patients with depression. Elevated cortisol levels have a negative effect on lymphocyte function. B-lymphocytes (CD 10+ and CD 19+) are sensitive to glucocorticoids. Studies in mice have demonstrated that elevated glucocorticoid levels are associated with a 50% decrease in serum B-lymphocytes, and this can be explained by downregulation of c-myc protein, which plays a role in cell proliferation and cell survival. Glucocorticoids also decrease levels of protein kinases that are vital for the cell cycle to continue, and they upregulate p27 and p21, which are cell cycle inhibitors. Therefore, if high cortisol suppresses B-lymphocyte production, this can explain how patients with depression have low IgG levels, since B-lymphocytes differentiate into plasma cells that will produce antibodies.⁶

Depression can trigger an inflammatory response by increasing levels of inflammatory cytokines, acute phase reactants, and oxidative molecules. The inflammatory response can lead to intestinal wall disruption, and therefore bacteria can migrate across the GI barrier, along with food antigens, which could then lead to food antigen hypersensitivity.⁶

The significance of diet

Many studies have looked into specific types of diets, such as the Mediterranean diet, the ketogenic diet, and the addition of supplements such as probiotics, omega-3 fatty acids, zinc, and multivitamins.⁷ The Mediterranean diet is high in fiber, nuts, legumes, and fish.⁷ The ketogenic diet includes a controlled amount of fat, but is low in protein and carbohydrates.⁷ The main point is that a balanced diet can have a positive effect on mental health.⁷ The Mediterranean diet has shown to decrease the incidence of cardiovascular disease and lower the risk of depression.⁷ In animal studies, the ketogenic diet has improved anxiety, depression, and autism.⁷ Diet clearly affects gut microbiota and, as a consequence, the body’s level of inflammation.⁷ 

Continue to: The following review...

The following review highlighted the significance of diet on gut microbiome and mental health.⁷

2. Mörkl S, Wagner-Skacel J, Lahousen T, et al. The role of nutrition and the gut- brain axis in psychiatry: a review of the literature. Neuropsychobiology. 2018;17: 1-9.

Study design

• These researchers provided a narrative review of the significance of a healthy diet and nutritional supplements on the gut microbiome and the treatment of patients with psychiatric illness. 

Outcomes

• This review suggested dietary coaching as a nonpharmacologic treatment for patients with psychiatric illness. 

Conclusion

• The utilization of nutritional advice, along with medication management, therapy, and physical activity, can provide a holistic approach to the biopsychosocial treatment of patients with psychiatric illness.

This review also emphasized the poor dietary trends of Westernized countries, which include calorie-dense, genetically altered, processed meals. As Mörkl et al⁷ noted, we are overfed but undernourished. Mörkl et al⁷ reviewed studies that involve dietary coaching as part of the treatment plan of patients with mental illness. In one of these studies, patients who received nutritional advice and coaching over 6 weeks had a 40% to 50% decrease in depressive symptoms. These effects persisted for 2 more years. Mörkl et al⁷ also reviewed an Italian study that found that providing nutritional advice in patients with affective disorders and psychosis helped improve symptom severity and sleep.⁷

Continue to: Mörkl et al...

Mörkl et al⁷ also reviewed dietary supplements. Some studies have linked use of omega-3 fatty acids with improvement in affective disorders, Alzheimer’s disease, and posttraumatic stress disorder, as well as cardiovascular conditions. Omega-3 fatty acids may exert beneficial effects by enhancing brain-derived neurotrophic factor and neurogenesis as well as by decreasing inflammation.⁷

Zinc supplementation can also improve depression, as it has been linked to cytokine variation and hippocampal neuronal growth. Vitamin B₉ deficiency and vitamin D deficiency also have been associated with depression. Mörkl et al⁷ emphasized that a balanced diet that incorporates a variety of nutrients is more beneficial than supplementation of any individual vitamin alone.

Researchers have long emphasized the importance of a healthy balanced diet when treating patients with medical conditions such as cardiovascular or cerebrovascular diseases. Based on the studies Mörkl et al⁷ reviewed, the same emphasis should be communicated to our patients who suffer from psychiatric conditions.

The gut and anxiety

The gut microbiome has also been an area of research when studying generalized anxiety disorder (GAD).⁸

3. Jiang HY, Zhang X, Yu ZH, et al. Altered gut microbiota profile in patients with generalized anxiety disorder. J Psychiatr Res. 2018;104:130-136.

The aim of the study was to determine if there were changes in the composition of the gut microbiome in patients with GAD compared with healthy controls.⁸

Continue to: Study design

Study design

• A cross-sectional study of 76 patients in Zhejiang, China. Forty patients with GAD in the active state and 36 healthy controls were compared in terms of composition of GI microbacterial flora.
• Researchers also examined a subgroup of 12 patients who were treatment-naïve and 17 controls. Stool samples were collected from the 12 patients who were treatment-naïve before initiating medication.
• Researchers also conducted a prospective study in a subgroup of 9 patients with GAD in both the active state and remissive state. Two stool samples were collected from each patient—one during the active state of GAD and one during the remissive state—for a total of 18 samples. Stool samples analyzed with the use of polymerase chain reaction and microbial analysis.
• Patients completed the Hamilton Anxiety Rating (HAM-A) scale and were classified into groups. Those with HAM-A scores >14 were classified as being in the active state of GAD, and those with scores <7 were classified as being in the remissive state. 

Outcomes

• Among the samples collected, 8 bacterial taxa were found in different amounts in patients with GAD and healthy controls. Bacteroidetes, Ruminococcus gnavus, and Fusobacterium were increased in patients with GAD compared with controls, while Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus were increased in healthy controls.
• Bacterial variety was notably lower in the 12 patients who were treatment-naïve compared with the control group.
• There was no notable difference in microbial composition between patients in the active vs remissive state.

Conclusion

• Patients with GAD had less short chain fatty acid–producing bacteria (Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus) compared with controls. Decreased formation of short chain fatty acids could lead to GI barrier disruption. Fusobacterium and Ruminococcus were increased in patients with GAD. Fusobacterium can cause disease and be invasive when it disseminates within the body. The inflammatory characteristics of Fusobacterium contribute to the immunologic activation in GAD. Ruminococcus breaks down mucin, which could then increase GI permeability by mucous degradation of the GI lumen.

Changes in food processing and manufacturing have led to changes in our diets. Changes in our normal GI microbacterial flora could lead to increased gut permeability, bacterial dissemination, and subsequent systemic inflammation. Research has shown that the composition of the microbiota changes across the life span.⁹ A balanced intake of nutrients is important for both our physical and mental health and safeguards the basis of gut microbiome regulation. A well-regulated gut microbiome ensures low levels of inflammation in the brain and body. Lifestyle modifications and dietary coaching could be practical interventions for patients with psychiatric conditions.⁵ Current advances in technology now offer precise analyses of thousands of metabolites, enabling metabolomics to offer the promise of discovering new drug targets and biomarkers that may help pave a way to precision medicine.

The “human microbiota” describes all microorganisms within the human body, including bacteria, viruses, and eukaryotes. The related term “microbiome” refers to the complete catalog of these microbes and their genes.¹ There is a growing awareness that the human microbiota plays an important role in maintaining mental health, and that a disruption in its composition can contribute to manifestations of psychiatric disorders. A growing body of evidence has also linked mental health outcomes to the gut microbiome, suggesting that the gut microbiota can modulate the gut-brain axis.²

Numerous neurotransmitters, including dopamine, serotonin, gamma-aminobutyric acid, and acetylcholine, are produced in the gastrointestinal (GI) tract, and our diet is vital in sustaining and replenishing them. At the same time, our brain regulates our GI tract by secretion of hormones such as oxytocin, leptin, ghrelin, neuropeptide Y, corticotrophin-releasing factor, and a plethora of others. Dysregulation of this microbiome can lead to both physical and mental illnesses. Symptoms of psychiatric disorders, such as depression, psychosis, anxiety, and autism, can be a consequence of this dysregulation.²

Our diet can also modify the gut micro­organisms and therefore many of its metabolic pathways. More attention has been given to pre- and probiotics and their effects on DNA by epigenetic changes. One can quickly start to appreciate how this intricate crosstalk can lead to a variety of pathologic and psychiatric problems that have an adverse effect on autoimmune, inflammatory, metabolic, cognitive, and behavioral processes.^2,3

Thus far, links have mostly been reported in animal models, and human studies are limited.⁴ Researchers are just beginning to elucidate how the microbiota affect gut-brain signaling in humans. Such mechanisms may include alterations in microbial composition, immune activation, vagus nerve signaling, alterations in tryptophan metabolism, production of specific microbial neuroactive metabolites, and bacterial cell wall sugars.⁵ The microbiota-gut-brain axis plays a part in regulating/programming the hypothalamic-pituitary-adrenal (HPA) axis throughout the life span.³ The interactions between the gut microbiome, the immune system, and the CNS are regulated through pathways that involve endocrine functions (HPA axis), the immune system, and metabolic factors.^3,4 Recent research focusing on the gut microbiome has also given rise to international projects such as the Human Microbiome Project (Human Microbiome Project Consortium, 2012).³

Several studies have looked into psychiatry and inflammatory/immune pathways. Here we review 3 recent studies that have focused on the gut-brain axis (Table^6-8).

1. Rudzki L, Pawlak D, Pawlak K, et al. Immune suppression of IgG response against dairy proteins in major depression. BMC Psychiatry. 2017;17(1):268.

The aim of this study was to evaluate immunoglobulin G (IgG) response against 40 food products in patients with depression vs those in a control group, along with changes in inflammatory markers, psychological stress, and dietary variables.⁶

Study design

• N = 63, IgG levels against 44 food products, cortisol levels, tumor necrosis factor (TNF)-alpha, interleukin 6 (IL-6), and IL-1 beta levels were recorded. The psychological parameters of 34 participants with depression and 29 controls were compared using the Hamilton Depression Rating scale, (HAM-D-17), Perceived Stress scale, and Symptom Checklist scale. The study was conducted in Poland.

Continue to: Outcomes

Outcomes

• Patients who were depressed had lower IgG levels against dairy products compared to controls when there was high dairy consumption. However, there was no overall difference between patients and controls in mean IgG concentration against food products. 
• Patients who were depressed had higher levels of cortisol. Levels of cortisol had a positive correlation with HAM-D-17 score. Patients with depression had lower levels of TNF-alpha.

Conclusion

• Patients with depression had lower levels of IgG against dairy protein. Patients with depression had high cortisol levels but decreased levels of TNF-alpha, which could explain an immune suppression of IgG in these patients. There were no differences in IL-6 or IL-1beta levels.

Hypercortisolemia is present in approximately 60% of patients with depression. Elevated cortisol levels have a negative effect on lymphocyte function. B-lymphocytes (CD 10+ and CD 19+) are sensitive to glucocorticoids. Studies in mice have demonstrated that elevated glucocorticoid levels are associated with a 50% decrease in serum B-lymphocytes, and this can be explained by downregulation of c-myc protein, which plays a role in cell proliferation and cell survival. Glucocorticoids also decrease levels of protein kinases that are vital for the cell cycle to continue, and they upregulate p27 and p21, which are cell cycle inhibitors. Therefore, if high cortisol suppresses B-lymphocyte production, this can explain how patients with depression have low IgG levels, since B-lymphocytes differentiate into plasma cells that will produce antibodies.⁶

Depression can trigger an inflammatory response by increasing levels of inflammatory cytokines, acute phase reactants, and oxidative molecules. The inflammatory response can lead to intestinal wall disruption, and therefore bacteria can migrate across the GI barrier, along with food antigens, which could then lead to food antigen hypersensitivity.⁶

The significance of diet

Many studies have looked into specific types of diets, such as the Mediterranean diet, the ketogenic diet, and the addition of supplements such as probiotics, omega-3 fatty acids, zinc, and multivitamins.⁷ The Mediterranean diet is high in fiber, nuts, legumes, and fish.⁷ The ketogenic diet includes a controlled amount of fat, but is low in protein and carbohydrates.⁷ The main point is that a balanced diet can have a positive effect on mental health.⁷ The Mediterranean diet has shown to decrease the incidence of cardiovascular disease and lower the risk of depression.⁷ In animal studies, the ketogenic diet has improved anxiety, depression, and autism.⁷ Diet clearly affects gut microbiota and, as a consequence, the body’s level of inflammation.⁷ 

Continue to: The following review...

The following review highlighted the significance of diet on gut microbiome and mental health.⁷

2. Mörkl S, Wagner-Skacel J, Lahousen T, et al. The role of nutrition and the gut- brain axis in psychiatry: a review of the literature. Neuropsychobiology. 2018;17: 1-9.

Study design

• These researchers provided a narrative review of the significance of a healthy diet and nutritional supplements on the gut microbiome and the treatment of patients with psychiatric illness. 

Outcomes

• This review suggested dietary coaching as a nonpharmacologic treatment for patients with psychiatric illness. 

Conclusion

• The utilization of nutritional advice, along with medication management, therapy, and physical activity, can provide a holistic approach to the biopsychosocial treatment of patients with psychiatric illness.

This review also emphasized the poor dietary trends of Westernized countries, which include calorie-dense, genetically altered, processed meals. As Mörkl et al⁷ noted, we are overfed but undernourished. Mörkl et al⁷ reviewed studies that involve dietary coaching as part of the treatment plan of patients with mental illness. In one of these studies, patients who received nutritional advice and coaching over 6 weeks had a 40% to 50% decrease in depressive symptoms. These effects persisted for 2 more years. Mörkl et al⁷ also reviewed an Italian study that found that providing nutritional advice in patients with affective disorders and psychosis helped improve symptom severity and sleep.⁷

Continue to: Mörkl et al...

Mörkl et al⁷ also reviewed dietary supplements. Some studies have linked use of omega-3 fatty acids with improvement in affective disorders, Alzheimer’s disease, and posttraumatic stress disorder, as well as cardiovascular conditions. Omega-3 fatty acids may exert beneficial effects by enhancing brain-derived neurotrophic factor and neurogenesis as well as by decreasing inflammation.⁷

Zinc supplementation can also improve depression, as it has been linked to cytokine variation and hippocampal neuronal growth. Vitamin B₉ deficiency and vitamin D deficiency also have been associated with depression. Mörkl et al⁷ emphasized that a balanced diet that incorporates a variety of nutrients is more beneficial than supplementation of any individual vitamin alone.

Researchers have long emphasized the importance of a healthy balanced diet when treating patients with medical conditions such as cardiovascular or cerebrovascular diseases. Based on the studies Mörkl et al⁷ reviewed, the same emphasis should be communicated to our patients who suffer from psychiatric conditions.

The gut and anxiety

The gut microbiome has also been an area of research when studying generalized anxiety disorder (GAD).⁸

3. Jiang HY, Zhang X, Yu ZH, et al. Altered gut microbiota profile in patients with generalized anxiety disorder. J Psychiatr Res. 2018;104:130-136.

The aim of the study was to determine if there were changes in the composition of the gut microbiome in patients with GAD compared with healthy controls.⁸

Continue to: Study design

Study design

• A cross-sectional study of 76 patients in Zhejiang, China. Forty patients with GAD in the active state and 36 healthy controls were compared in terms of composition of GI microbacterial flora.
• Researchers also examined a subgroup of 12 patients who were treatment-naïve and 17 controls. Stool samples were collected from the 12 patients who were treatment-naïve before initiating medication.
• Researchers also conducted a prospective study in a subgroup of 9 patients with GAD in both the active state and remissive state. Two stool samples were collected from each patient—one during the active state of GAD and one during the remissive state—for a total of 18 samples. Stool samples analyzed with the use of polymerase chain reaction and microbial analysis.
• Patients completed the Hamilton Anxiety Rating (HAM-A) scale and were classified into groups. Those with HAM-A scores >14 were classified as being in the active state of GAD, and those with scores <7 were classified as being in the remissive state. 

Outcomes

• Among the samples collected, 8 bacterial taxa were found in different amounts in patients with GAD and healthy controls. Bacteroidetes, Ruminococcus gnavus, and Fusobacterium were increased in patients with GAD compared with controls, while Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus were increased in healthy controls.
• Bacterial variety was notably lower in the 12 patients who were treatment-naïve compared with the control group.
• There was no notable difference in microbial composition between patients in the active vs remissive state.

Conclusion

• Patients with GAD had less short chain fatty acid–producing bacteria (Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus) compared with controls. Decreased formation of short chain fatty acids could lead to GI barrier disruption. Fusobacterium and Ruminococcus were increased in patients with GAD. Fusobacterium can cause disease and be invasive when it disseminates within the body. The inflammatory characteristics of Fusobacterium contribute to the immunologic activation in GAD. Ruminococcus breaks down mucin, which could then increase GI permeability by mucous degradation of the GI lumen.

Changes in food processing and manufacturing have led to changes in our diets. Changes in our normal GI microbacterial flora could lead to increased gut permeability, bacterial dissemination, and subsequent systemic inflammation. Research has shown that the composition of the microbiota changes across the life span.⁹ A balanced intake of nutrients is important for both our physical and mental health and safeguards the basis of gut microbiome regulation. A well-regulated gut microbiome ensures low levels of inflammation in the brain and body. Lifestyle modifications and dietary coaching could be practical interventions for patients with psychiatric conditions.⁵ Current advances in technology now offer precise analyses of thousands of metabolites, enabling metabolomics to offer the promise of discovering new drug targets and biomarkers that may help pave a way to precision medicine.

The “human microbiota” describes all microorganisms within the human body, including bacteria, viruses, and eukaryotes. The related term “microbiome” refers to the complete catalog of these microbes and their genes.¹ There is a growing awareness that the human microbiota plays an important role in maintaining mental health, and that a disruption in its composition can contribute to manifestations of psychiatric disorders. A growing body of evidence has also linked mental health outcomes to the gut microbiome, suggesting that the gut microbiota can modulate the gut-brain axis.²

Numerous neurotransmitters, including dopamine, serotonin, gamma-aminobutyric acid, and acetylcholine, are produced in the gastrointestinal (GI) tract, and our diet is vital in sustaining and replenishing them. At the same time, our brain regulates our GI tract by secretion of hormones such as oxytocin, leptin, ghrelin, neuropeptide Y, corticotrophin-releasing factor, and a plethora of others. Dysregulation of this microbiome can lead to both physical and mental illnesses. Symptoms of psychiatric disorders, such as depression, psychosis, anxiety, and autism, can be a consequence of this dysregulation.²

Our diet can also modify the gut micro­organisms and therefore many of its metabolic pathways. More attention has been given to pre- and probiotics and their effects on DNA by epigenetic changes. One can quickly start to appreciate how this intricate crosstalk can lead to a variety of pathologic and psychiatric problems that have an adverse effect on autoimmune, inflammatory, metabolic, cognitive, and behavioral processes.^2,3

Thus far, links have mostly been reported in animal models, and human studies are limited.⁴ Researchers are just beginning to elucidate how the microbiota affect gut-brain signaling in humans. Such mechanisms may include alterations in microbial composition, immune activation, vagus nerve signaling, alterations in tryptophan metabolism, production of specific microbial neuroactive metabolites, and bacterial cell wall sugars.⁵ The microbiota-gut-brain axis plays a part in regulating/programming the hypothalamic-pituitary-adrenal (HPA) axis throughout the life span.³ The interactions between the gut microbiome, the immune system, and the CNS are regulated through pathways that involve endocrine functions (HPA axis), the immune system, and metabolic factors.^3,4 Recent research focusing on the gut microbiome has also given rise to international projects such as the Human Microbiome Project (Human Microbiome Project Consortium, 2012).³

Several studies have looked into psychiatry and inflammatory/immune pathways. Here we review 3 recent studies that have focused on the gut-brain axis (Table^6-8).

1. Rudzki L, Pawlak D, Pawlak K, et al. Immune suppression of IgG response against dairy proteins in major depression. BMC Psychiatry. 2017;17(1):268.

The aim of this study was to evaluate immunoglobulin G (IgG) response against 40 food products in patients with depression vs those in a control group, along with changes in inflammatory markers, psychological stress, and dietary variables.⁶

Study design

• N = 63, IgG levels against 44 food products, cortisol levels, tumor necrosis factor (TNF)-alpha, interleukin 6 (IL-6), and IL-1 beta levels were recorded. The psychological parameters of 34 participants with depression and 29 controls were compared using the Hamilton Depression Rating scale, (HAM-D-17), Perceived Stress scale, and Symptom Checklist scale. The study was conducted in Poland.

Continue to: Outcomes

Outcomes

• Patients who were depressed had lower IgG levels against dairy products compared to controls when there was high dairy consumption. However, there was no overall difference between patients and controls in mean IgG concentration against food products. 
• Patients who were depressed had higher levels of cortisol. Levels of cortisol had a positive correlation with HAM-D-17 score. Patients with depression had lower levels of TNF-alpha.

Conclusion

• Patients with depression had lower levels of IgG against dairy protein. Patients with depression had high cortisol levels but decreased levels of TNF-alpha, which could explain an immune suppression of IgG in these patients. There were no differences in IL-6 or IL-1beta levels.

Hypercortisolemia is present in approximately 60% of patients with depression. Elevated cortisol levels have a negative effect on lymphocyte function. B-lymphocytes (CD 10+ and CD 19+) are sensitive to glucocorticoids. Studies in mice have demonstrated that elevated glucocorticoid levels are associated with a 50% decrease in serum B-lymphocytes, and this can be explained by downregulation of c-myc protein, which plays a role in cell proliferation and cell survival. Glucocorticoids also decrease levels of protein kinases that are vital for the cell cycle to continue, and they upregulate p27 and p21, which are cell cycle inhibitors. Therefore, if high cortisol suppresses B-lymphocyte production, this can explain how patients with depression have low IgG levels, since B-lymphocytes differentiate into plasma cells that will produce antibodies.⁶

Depression can trigger an inflammatory response by increasing levels of inflammatory cytokines, acute phase reactants, and oxidative molecules. The inflammatory response can lead to intestinal wall disruption, and therefore bacteria can migrate across the GI barrier, along with food antigens, which could then lead to food antigen hypersensitivity.⁶

The significance of diet

Many studies have looked into specific types of diets, such as the Mediterranean diet, the ketogenic diet, and the addition of supplements such as probiotics, omega-3 fatty acids, zinc, and multivitamins.⁷ The Mediterranean diet is high in fiber, nuts, legumes, and fish.⁷ The ketogenic diet includes a controlled amount of fat, but is low in protein and carbohydrates.⁷ The main point is that a balanced diet can have a positive effect on mental health.⁷ The Mediterranean diet has shown to decrease the incidence of cardiovascular disease and lower the risk of depression.⁷ In animal studies, the ketogenic diet has improved anxiety, depression, and autism.⁷ Diet clearly affects gut microbiota and, as a consequence, the body’s level of inflammation.⁷ 

Continue to: The following review...

The following review highlighted the significance of diet on gut microbiome and mental health.⁷

2. Mörkl S, Wagner-Skacel J, Lahousen T, et al. The role of nutrition and the gut- brain axis in psychiatry: a review of the literature. Neuropsychobiology. 2018;17: 1-9.

Study design

• These researchers provided a narrative review of the significance of a healthy diet and nutritional supplements on the gut microbiome and the treatment of patients with psychiatric illness. 

Outcomes

• This review suggested dietary coaching as a nonpharmacologic treatment for patients with psychiatric illness. 

Conclusion

• The utilization of nutritional advice, along with medication management, therapy, and physical activity, can provide a holistic approach to the biopsychosocial treatment of patients with psychiatric illness.

This review also emphasized the poor dietary trends of Westernized countries, which include calorie-dense, genetically altered, processed meals. As Mörkl et al⁷ noted, we are overfed but undernourished. Mörkl et al⁷ reviewed studies that involve dietary coaching as part of the treatment plan of patients with mental illness. In one of these studies, patients who received nutritional advice and coaching over 6 weeks had a 40% to 50% decrease in depressive symptoms. These effects persisted for 2 more years. Mörkl et al⁷ also reviewed an Italian study that found that providing nutritional advice in patients with affective disorders and psychosis helped improve symptom severity and sleep.⁷

Continue to: Mörkl et al...

Mörkl et al⁷ also reviewed dietary supplements. Some studies have linked use of omega-3 fatty acids with improvement in affective disorders, Alzheimer’s disease, and posttraumatic stress disorder, as well as cardiovascular conditions. Omega-3 fatty acids may exert beneficial effects by enhancing brain-derived neurotrophic factor and neurogenesis as well as by decreasing inflammation.⁷

Zinc supplementation can also improve depression, as it has been linked to cytokine variation and hippocampal neuronal growth. Vitamin B₉ deficiency and vitamin D deficiency also have been associated with depression. Mörkl et al⁷ emphasized that a balanced diet that incorporates a variety of nutrients is more beneficial than supplementation of any individual vitamin alone.

Researchers have long emphasized the importance of a healthy balanced diet when treating patients with medical conditions such as cardiovascular or cerebrovascular diseases. Based on the studies Mörkl et al⁷ reviewed, the same emphasis should be communicated to our patients who suffer from psychiatric conditions.

The gut and anxiety

The gut microbiome has also been an area of research when studying generalized anxiety disorder (GAD).⁸

3. Jiang HY, Zhang X, Yu ZH, et al. Altered gut microbiota profile in patients with generalized anxiety disorder. J Psychiatr Res. 2018;104:130-136.

The aim of the study was to determine if there were changes in the composition of the gut microbiome in patients with GAD compared with healthy controls.⁸

Continue to: Study design

Study design

• A cross-sectional study of 76 patients in Zhejiang, China. Forty patients with GAD in the active state and 36 healthy controls were compared in terms of composition of GI microbacterial flora.
• Researchers also examined a subgroup of 12 patients who were treatment-naïve and 17 controls. Stool samples were collected from the 12 patients who were treatment-naïve before initiating medication.
• Researchers also conducted a prospective study in a subgroup of 9 patients with GAD in both the active state and remissive state. Two stool samples were collected from each patient—one during the active state of GAD and one during the remissive state—for a total of 18 samples. Stool samples analyzed with the use of polymerase chain reaction and microbial analysis.
• Patients completed the Hamilton Anxiety Rating (HAM-A) scale and were classified into groups. Those with HAM-A scores >14 were classified as being in the active state of GAD, and those with scores <7 were classified as being in the remissive state. 

Outcomes

• Among the samples collected, 8 bacterial taxa were found in different amounts in patients with GAD and healthy controls. Bacteroidetes, Ruminococcus gnavus, and Fusobacterium were increased in patients with GAD compared with controls, while Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus were increased in healthy controls.
• Bacterial variety was notably lower in the 12 patients who were treatment-naïve compared with the control group.
• There was no notable difference in microbial composition between patients in the active vs remissive state.

Conclusion

• Patients with GAD had less short chain fatty acid–producing bacteria (Faecalibacterium, Eubacterium rectale, Sutterella, Lachnospira, and Butyricicoccus) compared with controls. Decreased formation of short chain fatty acids could lead to GI barrier disruption. Fusobacterium and Ruminococcus were increased in patients with GAD. Fusobacterium can cause disease and be invasive when it disseminates within the body. The inflammatory characteristics of Fusobacterium contribute to the immunologic activation in GAD. Ruminococcus breaks down mucin, which could then increase GI permeability by mucous degradation of the GI lumen.

Changes in food processing and manufacturing have led to changes in our diets. Changes in our normal GI microbacterial flora could lead to increased gut permeability, bacterial dissemination, and subsequent systemic inflammation. Research has shown that the composition of the microbiota changes across the life span.⁹ A balanced intake of nutrients is important for both our physical and mental health and safeguards the basis of gut microbiome regulation. A well-regulated gut microbiome ensures low levels of inflammation in the brain and body. Lifestyle modifications and dietary coaching could be practical interventions for patients with psychiatric conditions.⁵ Current advances in technology now offer precise analyses of thousands of metabolites, enabling metabolomics to offer the promise of discovering new drug targets and biomarkers that may help pave a way to precision medicine.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

“Hi Dr. Burke, thanks for coming in today. My daughter struggles with depression and I feel like every time I try to reach out, I hit a dead end with her. How do I connect with someone, who by the nature of their disease, is hard to reach?”

The answer? I’m not quite sure. I stood in front of a classroom of parents, siblings, and persons struggling with mental health issues, lecturing about depression. I can tell you about the complex interplay of biologic, psychological, and social factors that can lead one to become depressed. I can tell you the prevalence of depression in today’s society, and how it is rising among all age groups. I can tell you a myriad of different treatments, from pharmacologic to therapeutic to procedural, for depression. But how, from a parent’s perspective, can you connect with your child struggling with depression when they do not want your help? That I cannot tell you, at least not yet, anyways.

I had connected with the National Alliance on Mental Illness (NAMI) in the Fall of 2018, when a patient of mine was discharged from hospitalization and told by a faith-based substance use treatment program that he would not be allowed to use any “mind-altering” medications when he returned to their program. Concerned about my patient, whom I had just stabilized with the use of medications, I did my best to work through that organization’s resistance to psychotropic medications. When that failed, I reached out to NAMI for help in advocating for persons with mental illness. My involvement escalated to giving a lecture on “Living with Depression” to our local chapter of approximately 25 individuals that night. I had expected to lecture to an engaged crowd about what I thought was my immense knowledge of depression, from diagnosis to development to treatment. What I had not expected, however, was to have a learning experience of my own.

I stood at the front of the room, listening to story after story of persons with depression and their family members discussing their experiences. Throughout the 90-minute lecture, my emotions ranged from being impressed to shocked, scared, and, ultimately, proud. For the past year and 7 months, I had been spending time with persons with mental illness on what was likely the worst days of their lives. I had seen a variety of severe presentations, from grossly psychotic to acutely manic to majorly depressed to highly agitated. With that wealth of experience, I had thought I was becoming an expert; however, at the front of that classroom that night, I realized how little I actually knew. Yes, I had contemplated before how much severe mental illness and hospitalization could affect a person and their loved ones. However, it was a different level of understanding to hear first-hand accounts of the loss of relationships, the struggle to connect, and the fall-out from intensive inpatient treatment.

In residency, we spend what seems like an immeasurable amount of time on inpatient psychiatric units, in outpatient clinics, and everywhere in between. We see so many patients on a daily, weekly, monthly, and yearly basis that it becomes easy to lose the individuality of each patient. We start associating patients with their disorder, rather than with who they are. However, if we take a step back and allow a larger perspective—one that considers not only the patient but their families and communities—we likely would be able to provide greater and more comprehensive care.

My experience at NAMI was one that I will treasure forever. It opened my eyes to struggles that had I failed to even notice, and for that, and many other connections I made, I am grateful to have been blessed with this experience. My greatest recommendation to my fellow residents would be to engage with your local community organizations in the hope that you, too, can have an eye-opening experience that will strengthen your practice.

Spring has always been an exciting time for gastroenterologists, beginning with Colon Cancer Awareness month in March and finishing with our flagship scientific meeting in May. Gastroenterologists have led the fight against colon cancer; publishing seminal research (the National Polyp Study was published April 1, 26 years ago), building a distributed network of high-value ambulatory endoscopy centers, educating primary care physicians and the public about screening and early detection, and advocating continuously to make cancer prevention affordable for all people.

This year, AGA has sponsored two meetings where truly ground-breaking science was presented and we have highlighted them on our front page this month. On March 23-24, the AGA worked with the European Society of Neurogastroenterology and Motility to bring you the 8th annual Gut Microbiota for Health World Summit in Miami. World leaders in microbiome research presented a breath-taking array of clinically relevant research on topics that impact your patients. Dr. Stanley Hazen (Cleveland Clinic) presented his work linking dietary choices to a blood marker of atherosclerotic risk (TMAO) where the key associative link is the diet-influenced microbiome.

The AGA also brought you the 10th annual AGA Tech Summit from San Francisco, April 10-12. This meeting has become the best single source to learn about new technology emerging in our field. In this issue of GI & Hepatology News, we highlight two presentations about managing visceral pain with virtual reality technology and how predictive analysis is being used to personalize IBD therapy.

Spring wraps up with DDW^® in San Diego (May 18-21). DDW begins with the AGA Postgraduate Course (May 18-19) that provides the best annual summary of both gastroenterology and hepatology combined in a single setting. The live meeting will feature key updates and new science about biosimilars, cancer prevention, celiac disease, endoscopy, the microbiome, hepatology, IBD, nutrition, and care delivery.

As usual, GIHN will feature key presentations from DDW including those from the Presidential Plenary session (Monday morning May 20).

John I. Allen, MD, MBA, AGAF
Editor in Chief

Spring has always been an exciting time for gastroenterologists, beginning with Colon Cancer Awareness month in March and finishing with our flagship scientific meeting in May. Gastroenterologists have led the fight against colon cancer; publishing seminal research (the National Polyp Study was published April 1, 26 years ago), building a distributed network of high-value ambulatory endoscopy centers, educating primary care physicians and the public about screening and early detection, and advocating continuously to make cancer prevention affordable for all people.

This year, AGA has sponsored two meetings where truly ground-breaking science was presented and we have highlighted them on our front page this month. On March 23-24, the AGA worked with the European Society of Neurogastroenterology and Motility to bring you the 8th annual Gut Microbiota for Health World Summit in Miami. World leaders in microbiome research presented a breath-taking array of clinically relevant research on topics that impact your patients. Dr. Stanley Hazen (Cleveland Clinic) presented his work linking dietary choices to a blood marker of atherosclerotic risk (TMAO) where the key associative link is the diet-influenced microbiome.

The AGA also brought you the 10th annual AGA Tech Summit from San Francisco, April 10-12. This meeting has become the best single source to learn about new technology emerging in our field. In this issue of GI & Hepatology News, we highlight two presentations about managing visceral pain with virtual reality technology and how predictive analysis is being used to personalize IBD therapy.

Spring wraps up with DDW^® in San Diego (May 18-21). DDW begins with the AGA Postgraduate Course (May 18-19) that provides the best annual summary of both gastroenterology and hepatology combined in a single setting. The live meeting will feature key updates and new science about biosimilars, cancer prevention, celiac disease, endoscopy, the microbiome, hepatology, IBD, nutrition, and care delivery.

As usual, GIHN will feature key presentations from DDW including those from the Presidential Plenary session (Monday morning May 20).

John I. Allen, MD, MBA, AGAF
Editor in Chief

Spring has always been an exciting time for gastroenterologists, beginning with Colon Cancer Awareness month in March and finishing with our flagship scientific meeting in May. Gastroenterologists have led the fight against colon cancer; publishing seminal research (the National Polyp Study was published April 1, 26 years ago), building a distributed network of high-value ambulatory endoscopy centers, educating primary care physicians and the public about screening and early detection, and advocating continuously to make cancer prevention affordable for all people.

This year, AGA has sponsored two meetings where truly ground-breaking science was presented and we have highlighted them on our front page this month. On March 23-24, the AGA worked with the European Society of Neurogastroenterology and Motility to bring you the 8th annual Gut Microbiota for Health World Summit in Miami. World leaders in microbiome research presented a breath-taking array of clinically relevant research on topics that impact your patients. Dr. Stanley Hazen (Cleveland Clinic) presented his work linking dietary choices to a blood marker of atherosclerotic risk (TMAO) where the key associative link is the diet-influenced microbiome.

The AGA also brought you the 10th annual AGA Tech Summit from San Francisco, April 10-12. This meeting has become the best single source to learn about new technology emerging in our field. In this issue of GI & Hepatology News, we highlight two presentations about managing visceral pain with virtual reality technology and how predictive analysis is being used to personalize IBD therapy.

Spring wraps up with DDW^® in San Diego (May 18-21). DDW begins with the AGA Postgraduate Course (May 18-19) that provides the best annual summary of both gastroenterology and hepatology combined in a single setting. The live meeting will feature key updates and new science about biosimilars, cancer prevention, celiac disease, endoscopy, the microbiome, hepatology, IBD, nutrition, and care delivery.

As usual, GIHN will feature key presentations from DDW including those from the Presidential Plenary session (Monday morning May 20).

John I. Allen, MD, MBA, AGAF
Editor in Chief

Q2. Correct Answer: B

Rationale:

The PRSS1 mutation has been shown to be the causative genetic factor in hereditary pancreatitis. Hereditary pancreatitis is an autosomal dominant gene mutation with 80% penetrance. Symptoms start in childhood with acute recurrent pancreatitis and progress to chronic pancreatitis, diabetes, and exocrine insufficiency. The incidence of pancreatic cancer is increased to 40% by age 70. BRCA1 mutations have been associated with familial pancreas cancer families. SPINK mutations have been associated with chronic tropical pancreatitis. Delta F508 is the most common mutation in cystic fibrosis that leads to pancreas insufficiency in childhood. The clinical scenario is classic for hereditary pancreatitis.

Reference

1. Shelton CA, Umapathy C, Stello K, Yadav D, Whitcomb DC. Hereditary pancreatitis in the United States: Survival and rates of pancreatic cancer. Am J Gastroenterol. 2018 Sep;113(9):1376-84.

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Q2. Correct Answer: B

Rationale:

The PRSS1 mutation has been shown to be the causative genetic factor in hereditary pancreatitis. Hereditary pancreatitis is an autosomal dominant gene mutation with 80% penetrance. Symptoms start in childhood with acute recurrent pancreatitis and progress to chronic pancreatitis, diabetes, and exocrine insufficiency. The incidence of pancreatic cancer is increased to 40% by age 70. BRCA1 mutations have been associated with familial pancreas cancer families. SPINK mutations have been associated with chronic tropical pancreatitis. Delta F508 is the most common mutation in cystic fibrosis that leads to pancreas insufficiency in childhood. The clinical scenario is classic for hereditary pancreatitis.

Reference

1. Shelton CA, Umapathy C, Stello K, Yadav D, Whitcomb DC. Hereditary pancreatitis in the United States: Survival and rates of pancreatic cancer. Am J Gastroenterol. 2018 Sep;113(9):1376-84.

[email protected]

Q2. Correct Answer: B

Rationale:

The PRSS1 mutation has been shown to be the causative genetic factor in hereditary pancreatitis. Hereditary pancreatitis is an autosomal dominant gene mutation with 80% penetrance. Symptoms start in childhood with acute recurrent pancreatitis and progress to chronic pancreatitis, diabetes, and exocrine insufficiency. The incidence of pancreatic cancer is increased to 40% by age 70. BRCA1 mutations have been associated with familial pancreas cancer families. SPINK mutations have been associated with chronic tropical pancreatitis. Delta F508 is the most common mutation in cystic fibrosis that leads to pancreas insufficiency in childhood. The clinical scenario is classic for hereditary pancreatitis.

Reference

1. Shelton CA, Umapathy C, Stello K, Yadav D, Whitcomb DC. Hereditary pancreatitis in the United States: Survival and rates of pancreatic cancer. Am J Gastroenterol. 2018 Sep;113(9):1376-84.

[email protected]

Q1. Correct Answer: A

Rationale:

This is an example of Yersinia infection. Transmission of yersiniosis is largely foodborne.

Risk factors associated with yersiniosis include consumption of undercooked or raw pork products and exposure to untreated water. Y. enterocolitica infection has also been associated with iron-overload states (such as hemochromatosis) and blood transfusions, because iron likely promotes virulence of this organism. The incubation period for yersiniosis is typically 4-6 days. Clinical manifestations of acute yersiniosis include diarrhea, abdominal pain, and fever; nausea and vomiting may also occur. Localization of abdominal pain to the right lower quadrant is also a diagnostic clue for yersiniosis. However, both Yersinia and Campylobacter can present with right lower quadrant pain that may be confused as appendicitis (pseudo appendicitis). Another diagnostic clue is pharyngitis, which may be an accompanying symptom. Yersinia causes diarrhea through penetration of the mucosa and proliferation in the submucosa. Pathogenic Y. enterocolitica pass through the stomach, adhere to gut epithelial cells, invade the gut wall, localize in lymphoid tissue within the gut wall and in regional mesenteric lymph nodes, and evade the host’s cell-mediated immune response. Vibrio cholerae and enterotoxigenic E. coli (ETEC) secrete enterotoxins that stimulate secretion and/or impair absorption.

Some bacteria produce toxins in contaminated food; when ingested, the toxins cause acute symptoms, usually nausea and vomiting. Examples of these are Staphylococcus aureus and Bacillus cereus. Enteropathogenic E. coli (EPEC) and enterohemorrhagic E. coli (EHEC) adhere to the intestinal mucosa, where they attach and cause effacement of the microvilli. Shigella, enteroinvasive E. coli, and Campylobacter jejuni penetrate the mucosa, spread, and cause mucosal damage with erosions and ulcers.
 

Reference

1. Cover TL, Aber RC. Yersinia enterocolitica. N Engl J Med. Jul 6 1989;321(1):16-24.

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Q1. Correct Answer: A

Rationale:

This is an example of Yersinia infection. Transmission of yersiniosis is largely foodborne.

Risk factors associated with yersiniosis include consumption of undercooked or raw pork products and exposure to untreated water. Y. enterocolitica infection has also been associated with iron-overload states (such as hemochromatosis) and blood transfusions, because iron likely promotes virulence of this organism. The incubation period for yersiniosis is typically 4-6 days. Clinical manifestations of acute yersiniosis include diarrhea, abdominal pain, and fever; nausea and vomiting may also occur. Localization of abdominal pain to the right lower quadrant is also a diagnostic clue for yersiniosis. However, both Yersinia and Campylobacter can present with right lower quadrant pain that may be confused as appendicitis (pseudo appendicitis). Another diagnostic clue is pharyngitis, which may be an accompanying symptom. Yersinia causes diarrhea through penetration of the mucosa and proliferation in the submucosa. Pathogenic Y. enterocolitica pass through the stomach, adhere to gut epithelial cells, invade the gut wall, localize in lymphoid tissue within the gut wall and in regional mesenteric lymph nodes, and evade the host’s cell-mediated immune response. Vibrio cholerae and enterotoxigenic E. coli (ETEC) secrete enterotoxins that stimulate secretion and/or impair absorption.

Some bacteria produce toxins in contaminated food; when ingested, the toxins cause acute symptoms, usually nausea and vomiting. Examples of these are Staphylococcus aureus and Bacillus cereus. Enteropathogenic E. coli (EPEC) and enterohemorrhagic E. coli (EHEC) adhere to the intestinal mucosa, where they attach and cause effacement of the microvilli. Shigella, enteroinvasive E. coli, and Campylobacter jejuni penetrate the mucosa, spread, and cause mucosal damage with erosions and ulcers.
 

Reference

1. Cover TL, Aber RC. Yersinia enterocolitica. N Engl J Med. Jul 6 1989;321(1):16-24.

[email protected]

Q1. Correct Answer: A

Rationale:

This is an example of Yersinia infection. Transmission of yersiniosis is largely foodborne.

Risk factors associated with yersiniosis include consumption of undercooked or raw pork products and exposure to untreated water. Y. enterocolitica infection has also been associated with iron-overload states (such as hemochromatosis) and blood transfusions, because iron likely promotes virulence of this organism. The incubation period for yersiniosis is typically 4-6 days. Clinical manifestations of acute yersiniosis include diarrhea, abdominal pain, and fever; nausea and vomiting may also occur. Localization of abdominal pain to the right lower quadrant is also a diagnostic clue for yersiniosis. However, both Yersinia and Campylobacter can present with right lower quadrant pain that may be confused as appendicitis (pseudo appendicitis). Another diagnostic clue is pharyngitis, which may be an accompanying symptom. Yersinia causes diarrhea through penetration of the mucosa and proliferation in the submucosa. Pathogenic Y. enterocolitica pass through the stomach, adhere to gut epithelial cells, invade the gut wall, localize in lymphoid tissue within the gut wall and in regional mesenteric lymph nodes, and evade the host’s cell-mediated immune response. Vibrio cholerae and enterotoxigenic E. coli (ETEC) secrete enterotoxins that stimulate secretion and/or impair absorption.

Some bacteria produce toxins in contaminated food; when ingested, the toxins cause acute symptoms, usually nausea and vomiting. Examples of these are Staphylococcus aureus and Bacillus cereus. Enteropathogenic E. coli (EPEC) and enterohemorrhagic E. coli (EHEC) adhere to the intestinal mucosa, where they attach and cause effacement of the microvilli. Shigella, enteroinvasive E. coli, and Campylobacter jejuni penetrate the mucosa, spread, and cause mucosal damage with erosions and ulcers.
 

Reference

1. Cover TL, Aber RC. Yersinia enterocolitica. N Engl J Med. Jul 6 1989;321(1):16-24.

[email protected]

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.
 

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.
 

BALTIMORE – The upfront costs of laparoscopic magnetic sphincter augmentation are higher than those of laparoscopic Nissen fundoplication, but the cost differential can even out over time because the former procedure is associated with lower medical therapy costs after the procedure.

The finding comes from to a prospective observational study from the Allegheny Health Network in Pittsburgh, reported by Shahin Ayazi, MD, at the annual meeting of the American Society of Gastrointestinal Endoscopic Surgeons.

“Magnetic sphincter augmentation (MSA) results in comparable symptom control, proton-pump inhibitor (PPI) elimination rate, and GERD health-related quality of life and Reflux Symptom Index measures compared to values reported for laparoscopic Nissen fundoplication (LNF) in the literature,” said Dr. Ayazi of the University of Rochester (N.Y.). “Unlike reported values for LNF, the majority of patients after MSA were discharged on the same day of surgery.”

Dr. Ayazi reported on 180 patients who had MSA and 1,131 who had LNF over a 2-year period beginning in September 2015 at Allegheny Health, a network of eight hospitals and related facilities in western Pennsylvania and western New York State. The study analyzed Highmark claims data to calculate costs for 12 months before and after surgery in four categories: total procedure payer cost, payer costs of PPI, disease-related costs, and all medical costs.

Dr. Ayazi noted that many payers have been reluctant to cover the costs of MSA because the device costs around $5,000 on average. “There’s also a paucity of data in the literature in regard to the cost analysis of MSA in the management of reflux disease,” he said, adding that this is the first study that uses payer data to analyze the cost of antireflux surgery.

In this study, MSA costs slightly more up front than LNF ($13,522 vs. $13,388, respectively; P = .02). Per-member/per-month (PMPM) costs in the 12 months before their procedures were higher in the MSA group ($305 vs. $233). After surgery, these costs were significantly lower at $104 for MSA patients versus $126 for LNF patients, Dr. Ayazi said.

In the MSA group, 89% of patients were discharged on the same day as surgery, 90.7% said they were satisfied with the outcome, and 91.8% discontinued PPI therapy, Dr. Ayazi said.

He noted the claims data did not provide access to clinical data, Highmark did not provide information on the etiology of the costs differences, and the follow-up for cost analysis is relatively short-term.

During the discussion, Michel Gagner, MD, of Westmount, Quebec, warned against reading too much into the study because of its short duration and gave the example of experience with the laparoscopic adjustable gastric band. “The 10 years after, when you look at the reoperation, the removal, the conversions, some of the disasters in this area – all this needs to be added to the cost, and then when you looked at this, it was no longer cost effective. So I’m wondering if the same story could happen in the next 10 years. You may find that your conclusions are totally reversed.”

Peter Crookes, MD, of the University of Southern California, Los Angeles, challenged the study’s comparison of procedure cost, noting that the trend is toward same-day discharge after LNF, whereas study patients were hospitalized after LNF. Dr. Ayazi noted that the data presented reported procedure cost, not the hospital stay costs, because Highmark did not provide that data.

Lead researcher Blair Jobe, MD, director of the Esophageal and Lung Institute at Allegheny Health Network, added, “The higher initial cost of a LINX (Ethicon) procedure compared to a Nissen fundoplication is perceived as a drawback by insurers, which can make getting insurance approvals challenging. This study suggests that perception may be short sighted in that insurance plans can provide better care for their GERD patients at a similar cost to laparoscopic Nissen fundoplication when you factor in the greater reductions in medical costs after the procedure.”

Dr. Ayazi has no relevant financial relationships to disclose. Dr. Jobe reported he is a consultant for Ethicon.

SOURCE: Ayazi S et al. SAGES 2019, Session SS04.