High fat diet has lasting effects on the liver

Consuming a high-fat, high-sugar diet causes a harmful accumulation of fat in the liver that may not reverse even after switching to a healthier diet, according to a new study by scientists from Weill Cornell Medicine and Memorial Sloan Kettering Cancer Center.

For the study, published Oct. 3 in Science Translational Medicine, the investigators developed a nanosensor that can detect and noninvasively track the accumulation of fat in the liver. They used the sensor to assess the effects of a high-fat, high-sugar diet on the livers of mice. They then evaluated the outcomes when the mice returned to a healthy diet. Unexpectedly, the researchers found that, while the fat accumulation decreases after returning to a healthy diet, some residual fat remains in certain liver cells long afterwards.

“Going on a short-term unhealthy diet binge is a bad idea,” said senior author Dr. Daniel Heller, an associate professor in the Pharmacology and Physiology, Biophysics and Systems Biology program at the Weill Cornell Graduate School of Medical Sciences and head of the Cancer Nanomedicine Laboratory at Memorial Sloan Kettering Cancer Center. “The liver remembers.”

Nonalcoholic fatty liver disease (NAFLD) affects up to 30 percent of people in the United States, where a high-fat, high-sugar diet is common. Patients with NAFLD develop an accumulation of excess fat in their livers. The condition can progress to a more serious disease involving inflammation, scarring and even liver cancer (called nonalcoholic steatohepatitis, or NASH). People who accumulate fat inside liver cells called Kupffer cells, specifically a part of these cells named lysosomes that act like cellular garbage collectors, appear more likely to progress to serious liver disease.

“Fatty liver disease is a growing concern in the clinic and has rapidly become one of the top causes of liver disease in the United States and Europe,” said co-author and hepatologist Dr. Robert Schwartz, an assistant professor of medicine at Weill Cornell Medicine and an assistant professor in the Physiology, Biophysics and Systems Biology program at the Weill Cornell Graduate School of Medical Sciences. “Currently, we have no medical therapies for fatty liver disease. We tell our patients to eat better and to exercise more, which, as you can imagine, is not very effective.”

Currently, some imaging tools like ultrasound or magnetic resonance imaging can help identify people with fatty livers, but these techniques often provide less detailed information. Dr. Heller’s nanosensor is the first to noninvasively detect fat in the lysosomes of the Kupffer cells, potentially identifying those most at risk of progressing.

The tiny sensor is about 1,000 times smaller than the width of a human hair and made of single-stranded DNA wrapped around a single-walled carbon nanotube. Fat accumulation in the lysosomes changes the color of light emitted by the nanosensor, and was first observed in live cells in Dr. Heller’s lab by MSKCC research associate Prakrit Jena and Weill Cornell Graduate School of Medical Sciences student Thomas Galassi, the first author of the paper.

When the nanosensors are injected into a mouse, the liver filters them out of the blood and then are consumed by the organ’s lysosomes. Shining a near-infrared flashlight-like device on rodents injected with these nanosensors causes the sensors to glow. The color of the light corresponds to the fat content in the liver, allowing Dr. Heller and his colleagues to measure fat non-invasively using the device.

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FDA Takes on Flatulent Cows

TUESDAY, Nov. 6, 2018 — The first drug to combat farting in livestock has been approved by the U.S. Food and Drug Administration.

Yes, you read that right: When fed to beef cattle under specific conditions, Experior results in less ammonia gas released by the animals and their waste.

“Today we’re announcing the approval of the first animal drug that reduces ammonia gas emissions from an animal or its waste. These ammonia gasses can come from many sources and can affect the health of people, animals and the environment,” Steven Solomon, director of the FDA’s Center for Veterinary Medicine, said in an agency news release.

Ammonia gas emissions can cause atmospheric haze and noxious odors, and high concentrations of ammonia can cause irritation of the eyes, nose and throat in both humans and animals, according to the FDA.

Also, ammonia gases can contribute to bodies of water being loaded with excess nutrients, especially nitrogen and phosphorous. This can cause algae blooms that block sunlight to aquatic plants, eventually resulting in the death of fish and other creatures due to a lack of oxygen in the water.

Studies showed that the drug partially reduces ammonia gas emissions from manure produced by a single animal or a pen of animals, but did not assess its effectiveness on a larger scale.

Other studies showed that Experior is safe to feed to beef cattle and that meat from cattle treated with the drug is safe for people to eat, according to the FDA.

More information

Texas A&M has more on cattle and ammonia emissions.

Posted: November 2018

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Internists note that final CMS payment rule improves on proposed changes to E/M codes

The American College of Physicians (ACP) appreciates that the final Medicare Physician Fee Schedule and the Quality Payment Program (QPP) rules for 2019 are responsive to many of the concerns that ACP raised with the Centers for Medicare and Medicaid Services (CMS).

“Internists appreciate CMS’ decision not to finalize changes in payments for evaluation and management (E/M) services until 2021. We are hopeful that the additional two calendar years leave time for physicians and other health care stakeholders to work together with regulators to develop and test alternatives that preserve higher payment for more complex, cognitive care,'” said Ana María López, MD, MPH, MACP, president, ACP. “We are pleased that CMS will be moving forward with plans to simplify documentation for such visits, with significant improvements going into effect next year, and with additional streamlined documentation options becoming available later.”

Under the final rule, starting in 2021, CMS will begin paying levels 2, 3, and 4 office visits the same flat amount; level 5 visits would continue to get higher payment, as they currently do, recognizing the greater work involved in caring for the sickest patients. The proposed rule would have paid them all the same amount, devaluing complex, cognitive care.

“While we are encouraged that CMS has recognized the principle that more complex, cognitive care should be reimbursed at a higher level by paying more for level 5, we have reservations about paying level 4 visits, the second most complex visits, at the same amount as levels 2 and 3 visits,” Dr. López continued. “We look forward to working with CMS on developing, piloting, and evaluating approaches that recognize the value of complex, cognitive care.”

ACP is encouraged to see CMS incorporate several of our recommendations in the physician fee schedule final rule; however, ACP also expresses continued reservations about some of the final provisions. ACP’s recommendations include:

  • ACP is strongly supportive of provisions that would reduce documentation requirements for physicians, reducing unnecessary administrative burdens. ACP thanks CMS for eliminating redundancies and only requiring physicians to document changed information since the last visit for established patients-starting right away in 2019. Additionally, ACP is glad to see that the documentation changes would eventually allow physicians to choose between different options to best fit their practice needs, including enabling them to document based solely on medical decision making. However, these options will not be available until 2021—we would support CMS allowing them to be implemented sooner.
  • ACP is pleased to see that, effective in 2021, CMS has allowed for add-on codes for level 2-4 visits in primary care and certain specialties and for extended visits to account for the value of cognitive work in treating more complex patients. ACP especially appreciates that the changes to the add-on codes equalize primary care payments to specialty payments.
  • ACP is grateful that CMS is not moving forward with proposals to implement the Multiple Procedure Payment Reduction (MPPR).
  • ACP is strongly supportive of payments for new codes for non-face-to-face visits that will be implemented in 2019. Virtual check-ins, e-consultations, and remote evaluation of patient images and videos will improve patient access to care and help control costs.
  • ACP has long advocated for changes to the Physician Practice Information Survey (PPIS) and is extremely encouraged that CMS is considering updating the data source used to calculate indirect practice expenses to improve payment accuracy for physicians.

“ACP is thankful to see that CMS is moving forward, in 2019, with changes to reduce documentation burdens on these same codes. This effort is aligned with ACP goals in the Patients Before Paperwork initiative,” said Dr. López.

Additionally, ACP recognizes that CMS was responsive to feedback provided on the proposed QPP rule. Concerns on some provisions remain:

  • ACP appreciates seeing CMS respond to our request for a Merit-based Incentive Payment System (MIPS) opt-in option for practices previously excluded under the low-volume threshold. This will expand participation without increasing burden.
  • ACP supports CMS’ ongoing work to identify and remove low-priority, low-value quality measures and to continue working with stakeholders to focus on measures that offer the most promise for improving patient care while minimizing reporting burden on clinicians.
  • ACP supports the 2015 Certified Electronic Health Record Technology (CEHRT) requirement and agrees that using updated standards and functionality can help improve interoperability; however, ACP is disappointed that CMS did not call out the need to provide physicians flexibility as they implement these upgrades over the course of 2019. Rushing implementation of these upgrades to meet a reporting deadline can have serious patient safety risks and is a major expense and burden, particularly to small practices.
  • ACP is encouraged to see CMS continue the consistent risk threshold for Alternative Payment Models (APMs), which will provide consistency and predictability for model developers and will help APMs continue to grow. APMs are vital to the success of the transition to value.
  • ACP is concerned that CMS’ finalized changes to the Cost Category, including adding several new episode-based measures despite concerns over low reliability ratings while simultaneously increasing the weight of the Cost Category from 10 percent to 15 percent, despite objections from ACP and other stakeholders. Clinicians should not have their MIPS scores negatively impacted by inaccurate measures.

ACP was pleased to see that the Hospital Outpatient Perspective Payment System (HOPPS) rule, released this morning, finalized site-neutral payments for clinic visits. Equalizing payments across facility types is a longstanding goal of ACP.

“Currently, CMS often pays more for the same type of office visit in the hospital outpatient setting than in the physician office setting, resulting in higher out-of-pocket costs to patients and unnecessary spending by Medicare. ACP agrees with CMS that there is no justification for patients and the Medicare program paying more for a visit to a doctor when the service is provided in an office owned by a hospital than it would for the same type of visit in an independent physician practice,” said Dr. López. “This will increase the sustainability of the Medicare program and improve quality of care for seniors.”

ACP recognizes that these are promising steps in the right direction, and is encouraged that CMS expressed interest in working with ACP and other physician organizations on these issues, in particular, the E/M changes.

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