Use of Neostigmine as Adjunct for Manual Disimpaction

Posted on March 3, 2026 by gutsandgrowth

M Mostavi, S Lee, V Martin. JPGN Reports. 2026;7:55–58. When manual disimpaction isn’t enough: Case report and review of neostigmine’s role in refractory constipation management

This was a case report of a 21 yo with chronic constipation and likely undiagnosed autism spectrum disorder hospitalized for severe fecal retention, unresponsive to nasogastric polyethylene glycol. He underwent a manual disimpaction but due to residual stool in more proximal colon, Neostigmine was administered with good results.

Methods: “The patient underwent manual disimpaction under general anesthesia with a large amount of hard stool removed from the rectum. He was noted to have ongoing abdominal distension with significant palpable stool more proximally. A trial of 1 mg intravenous (IV) neostigmine was given. This was done without anticholinergic co-administration due to his persistent tachycardia (HR ~ 120 s) and with close heart rate monitoring. Passive passage of stool occurred within 5 min of drug administration. Subsequently, neostigmine was titrated in additional 1 mg IV doses every 3–5 min. His heart rate remained above 90bpm. He received a total of four doses of neostigmine over 20 min. Each administration, combined with abdominal massage, produced large amounts of soft stool along with marked reduction in distension and palpable stool burden.

Before NG cleanout and disimpaction:

After NG cleanout and disimpaction/Neostigmine:

Pharmacokinetics:

” Neostigmine has been clinically utilized by anesthesiologists to reverse the effects of non-depolarizing neuromuscular blocking agents…In the gastrointestinal (GI) tract, the accumulation of acetylcholine in the neuromuscular junction of the small intestine and colon results in increased contractility and peristalsis, thus promoting defecation. Neostigmine is predominately administered intravenously with typical dose ranges from 0.03 to 0.07 mg/kg, up to maximum 5 mg. The peak effect typically occurs between 7 and 10 min, while the duration of action lasts approximately 55–75 min in adult patients…

Because of its cholinergic effects on the muscarinic receptors of the cardiac parasympathetic nervous system, neostigmine results in a significant decrease in heart rate. Therefore, when neostigmine is bolused to reverse non-depolarizing paralytics at the clinically appropriate dose (~3–5 mg IV), it is always co-administered with glycopyrrolate or atropine to prevent bradycardia at a 1:1 volume ratio.”

My take (borrowed from authors): “This case demonstrates that intravenous neostigmine can be a safe and effective adjunct to manual disimpaction in severe refractory constipation when administered in a monitored setting.”

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Why Are Kids in U.S. Picky Eaters?

Posted on March 2, 2026 by gutsandgrowth

Helen Zoe Veit, NY Times 2/15/26: There’s a Reason American Kids Are Such Picky Eaters:

An excerpt:

In historical documents of all kinds, from medical treatises to diaries to school records, Americans described children as curious omnivores who appreciated bold flavors and interesting textures…

This was unrelated to socioeconomic status — children at every income level happily ate a diversity of foods. But today, appreciation of sharp and varied flavors can be hard to find among American kids. Parenting message boards are filled with questions about getting reluctant children to eat vegetables, and kids’ menus across the country offer dishes aimed at narrow palates.

Many adults assume that prolonged pickiness is a hard-wired stage and that kids naturally dislike many foods. But mass childhood pickiness is a modern phenomenon created largely by junk food companies that marketed products like sugary cereals as food specifically for children, convincing Americans that kids need different, easily likable foods...widespread pickiness didn’t exist until the 20th century. Before then, kids sometimes disliked individual foods, just as some adults did. But people in earlier eras didn’t think that pickiness was related to age.

All this changed as food companies like General Foods and Nestlé poured money into designing products in laboratories to target humans’ biological instincts and make their foods very hard to refuse. By the mid-20th century, thousands of seductively sweet, salty and crunchy factory foods crowded grocery shelves, and many of them were marketed aggressively to children — from Goldfish crackers to SpaghettiOs…

Junk food companies also started pushing portable, calorie-dense snacks…

As marketers glorified personalized eating, family eating habits fractured. Before the mid-20th century, most family meals centered on communal food. But as kitchens filled with shelf-stable products, many Americans stopped sharing food in the same way. One 1950s mother noted that she ate whole-wheat bread, her husband ate rye bread, and her children ate white bread…Cooking had also transformed. As more food was processed in factories, meal preparation could mean warming up or even just assembling. It suddenly became feasible to “cook” separate meals for different family members...

We’ve been told that urging kids to eat any particular dish can cause lasting aversions and dysfunctional relationships with food...

Parents can warmly encourage children to eat family foods and avoid offering alternatives. They can also counter corporate marketing with their own enthusiastic messages about the foods they love to eat, whether it’s a crunchy salad or slippery green olives.

My take: The advice in this article is not for everyone – especially for patients with ARFID, sensory processing disorders, and autism. Also, this problem is not solely related to ‘big food’ marketing. There are other factors shaping our eating habits. For example, one factor for many households, especially if both parents are working, is less time for meal preparation.

Some books that may be helpful for families working through these issues:

Laura Jana and Jennifer Shu: Food Fights: Winning the Nutritional Challenges of Parenthood
Ellyn Satter: Child of Mine and Secrets of Feeding a Healthy Family
Keith E. Williams and Laura J. Seiverling: Broccoli Boot Camp: Basic Training for Parents of Selective Eaters

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The Lancet Cover: Robert F Kennedy Jr: 1 year of failure

Posted on March 1, 2026 by gutsandgrowth

Here’s link to editorial: Open Access! Robert F Kennedy Jr: 1 year of failure

A lengthy excerpt:

“Kennedy promised a receptive and collaborative relationship, and to the public from whom he claims his mandate, he promised a new era of unbiased science without hidden conflicts of interest, secrecy, or profiteering. Radical transparency, gold-standard science, ethics, compassion, competency, and pride would restore to HHS the unimpeachable authority that the USA needs and deserves. Politicians are known to break promises, but Kennedy’s record, 1 year in, has been a failure by most measures, especially his own.

10 days after his speech about trust and openness, HHS rescinded a 54-year-old policy of soliciting public comments for new rules and regulations, silencing the voices of many of the stakeholders he pledged to serve. Kennedy has summarily dismissed advisers and experts, communicated policy changes on pay-walled media, fired a whistleblower, and overseen the revisions of guidelines and recommendations, contradicting decades of established science, often to the benefit of industries he formerly condemned. Under Kennedy’s leadership, the National Institutes of Health (NIH) shuttered programmes studying the health effects of air pollution, HHS withheld a report linking alcohol consumption to cancer, and the Food and Drug Administration (FDA) withdrew warnings of potential harm from consuming products (such as raw milk and chlorine dioxide) falsely marketed as treatments for autism. His changes at CDC have driven 26 states to reject official guidance on vaccine policy, and in December the CDC awarded an unsolicited $1·6 million grant to conduct a vaccine study in Guinea-Bissau that raised so many ethical concerns—the design would have risked exposing thousands of unvaccinated children to hepatitis B—that it has been compared to the infamous Untreated Syphilis Study at Tuskegee.

HHS under Kennedy has made a habit of throwing good money after bad science. Amid the Trump administration’s cuts to research funding and personnel there has been a harmful shift in priorities. Cutting-edge discoveries and clinical investigations—on subjects ranging from mRNA vaccines to diabetes and dementia—are denied crucial resources while junk science and fringe beliefs are elevated without justifiable explanation. Under Kennedy’s leadership, politicisation at the NIH, FDA, and CDC is imperilling the future of US science and innovation and throttling the public health enterprise that keeps the country safe today.

The mechanisms maintained by the Federal Government to monitor and report health concerns such as drug overdoses, maternal mortality, and food security have been as beleaguered as the doctors and scientists who rely on them; thousands of datasets are no longer publicly available, leaving Americans—and the world—unprepared to respond to future crises. And crises are looming: in November, 2025, the first human infection (and death) from the H5N5 strain of avian flu was recorded in Washington state; pertussis, which killed 13 people in the USA in 2025, continues to spread across the country; and the measles outbreak that began in January of last year now threatens the elimination status of the USA and Mexico.”

Related blog posts:

Worsening Measles Outbreak

Posted on February 28, 2026 by gutsandgrowth

From CNN: The US surpassed 1,100 measles cases in two months. Expect more deaths next

“According to the CDC, out of every 1,000 children who are infected with measles, one may develop encephalitis, which is a dangerous swelling of the brain. Up to 3 out of every 1,000 infected children will die.

The US is on track for another record-breaking year for measles: The number of measles cases reported in the first eight weeks of the year — 1,136 as of February 26, according to CDC data — is already six times more than typical for an entire year. A tracker from the Johns Hopkins University Center for Outbreak Response Innovation has tallied an even higher the annual case total than the CDC…

New measles cases have started to slow in South Carolina in recent weeks…[due to] ublic health groundwork that has helped rapidly identify cases and potential exposures and drive quarantine guidance…Improving vaccination coverage has also helped, she said. The state health department administered nearly 17,000 MMR vaccines in January, which was one of the most successful months for vaccination that the state has had in years.

Related blog post: U.S. Measles Outbreak Is Not Slowing

Long-Term Outcomes in Pediatric Intestinal Lymphangiectasia

Posted on February 27, 2026 by gutsandgrowth

N Goret et al. J Pediatr Gastroenterol Nutr. 2026;82:398–406. Open Access! Clinical presentation, treatment, and outcome of children with primary intestinal lymphangiectasia: A national retrospective study

This French retrospective study included 34 children (2010-2022) and had a median followup of 4.5 years.

Key findings:

Edema (79%), chronic diarrhea (50%), and ascites (35%) were the main symptoms. All of the patients had hypoalbuminemia and decreased IgG
Thirty-one patients received a low long-chain triglycerides dietary therapy and 25 (81%) responded: 15 had a partial response and 10 a complete response. A normal diet could be reintroduced in 14 patients (45%) without relapse during the follow-up
A genetic variant was identified in 5 (33%) of those with a partial response to diet and in none of those with a complete response to diet. Similarly, 6 (40%) of those with a partial response had lymphedema and none in those with a complete response. Both of these were statistically significant (p < 0.05)
Seven patients (21%) received parenteral nutrition for a median duration of 4 weeks (1.5–14) due to profuse diarrhea accompanied by malnutrition
Second-line treatment with either sirolimus or octreotide were ineffective

Discussion/Introduction Points:

Regular monitoring of fat-soluble vitamin levels and essential fatty acids … is crucial during this diet to detect potential deficiencies associated with a fat-free diet.
The current definition is based on the presence of peripheral lymphatic malformations associated in some cases with genetic defects affecting endothelial, connective tissue, immune, or metabolic functions.²⁴

My take: In this cohort, the diagnosis seems uncertain in those with a mild presentation and/or ability to tolerate reintroduction of a normal diet. A few patients that I have seen with this disorder continued with very low albumin and required albumin infusions and electrolyte supplements. More stringent diagnostic criteria/genetic testing are needed for children with presumptive primary intestinal lymphangiectasia.

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Does Liver Histology Still Help with Risk Stratification in Advanced Liver Disease Due to MASLD?

Posted on February 26, 2026 by gutsandgrowth

L Aceituno, J Banares et al. Gastroenterol 2026; 170: 385-394. Open Access! The ANTICIPATE-NASH Models Stratify Better the Risk of Clinical Events Than Histology in Metabolic Dysfunction-Associated Steatotic Liver Disease Patients With Advanced Chronic Liver Disease
L Castera. Gastroenterol 2026; 170: 257-259. Editorial. Open Access! Refining Risk Stratification in Metabolic Dysfunction–Associated Steatotic Liver Disease: Moving Beyond Histology With Individualized Noninvasive Predictive Models for Clinical Events

The editorial provide a succinct critique and summary of this retrospective study. An excerpt:

For many decades, liver biopsy specimens and HVPG measurements have served as the cornerstone for risk stratification of patients with cirrhosis. Fibrosis staging, particularly the distinction between F3 and F4, as well as HVPG measurements, have informed prognoses and patient enrollment in therapeutic trials…

Noninvasive tests, particularly liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE), are increasingly used for risk stratification in MASLD patients with cirrhosis and may inform treatment decisions.³ The ANTICIPATE–nonalcoholic steatohepatitis (NASH) models, which combine LSM, platelet count, and body mass index, have been proposed to predict the risk of CSPH [clinically significant portal hypertension] progression and liver-related events (LRE) in patients with MASLD.^4–6 …

First, the authors examined a multicenter cohort of 699 biopsy specimen–proven MASLD patients with LRE (hepatic decompensation, hepatocellular carcinoma, transplantation, or liver-related death) as the end point. Second, they examined a validation cohort of 1396 F3 or F4 patients from 4 clinical trials…

The results can be summarized as follows: In the first cohort, 56 LREs (8%) occurred during a 3-year follow-up, mostly in F4 patients. The second cohort had 33 composite end points (2.3%) during a median follow-up of 16 months. The ANTICIPATE-NASH model showed excellent discrimination for LRE (C statistic, 0.93), which was higher than that for histology (C statistic, 0.67). However, adding histology to the model did not improve prediction… These findings highlight the limitations of biopsy specimens and underscore the ability of noninvasive models to capture the dynamic and continuous nature of disease progression…

The clinical and research implications are substantial. In daily clinical practice, the widespread adoption of the ANTICIPATE-NASH model could allow hepatologists to identify high-risk patients who require closer monitoring or early therapeutic intervention while sparing low-risk patients from invasive biopsies and unnecessary procedures. For clinical trials, model-based enrichment could increase event rates, reduce required sample sizes, and shorten follow-up duration.

My take: This study, while limited by its retrospective design, indicates that histology is no longer the “gold” standard for prognostication in adults with MASLD and advanced fibrosis.

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New Option For Severe Hypertriglyceridemia

Posted on February 25, 2026 by gutsandgrowth

NA Marston et al. NEJM 2026; 394: 429-441. Olezarsen for Managing Severe Hypertriglyceridemia and Pancreatitis Risk

Background: “Severe hypertriglyceridemia, defined as a serum triglyceride level of 500 mg per deciliter or higher (≥5.65 mmol per liter), affects approximately 1 in 100 persons and can have clinical consequences, including an increased risk of life-threatening acute pancreatitis. Conventional triglyceride-lowering therapies, such as fibrates and n–3 fatty acids, often have modest effects on the triglyceride level and have not been shown to reduce the risk of acute pancreatitis.³“

This study examined the efficacy and safety of olezarsen, an antisense oligonucleotide targeting apolipoprotein C-III messenger RNA. Olezararsen has already been shown to be effective in genetically identified familial chylomicronemia syndrome. This study targeted individuals with less extreme forms of hypertriglyceridemia (mean baseline triglyceride level of 793 mg/dL).

Key findings:

Incidence of Acute Pancreatitis

Adverse Effects:

The incidence of any adverse events appeared to be similar across trial groups. Elevations in liver-enzyme levels and thrombocytopenia (platelet count, <100,000 per microliter) were more common with the 80-mg dose of olezarsen, and a dose-dependent increase in the hepatic fat fraction was noted.
During the 1-year trial, major adverse cardiovascular events occurred in 2.0% of the pooled olezarsen group and 2.5% of patients receiving placebo.

My take: It is likely that olezarsen will have cardiovascular benefits as well as reducing the risk of pancreatitis in those with severe hypertriglyceridemia; though, these potential benefits await long-term studies.

Related blog posts:

Methotrexate Tolerance and Toxicity in Pediatric Inflammatory Bowel Disease

Posted on February 24, 2026 by gutsandgrowth

E Vermeer et al. J Pediatr Gastroenterol Nutr. 2026;82:477–486. Open Access! Methotrexate toxicity and intolerance in paediatric inflammatory bowel disease: A retrospective cohort study

This was a a retrospective single-center cohort study, including pediatric IBD patients (n=207) initiating MTX between 2010 and 2023. The median follow-up time was 303 days.

Key findings:

Methotrexate was used in combination with a biologic medication in 114 patients (55%)
157 patients (75.8%) experienced at least one MTX-induced AE, with hepatotoxicity occurring in 84 patients (53.5%), myelotoxicity in 43 patients (27.4%), and nausea in 95 patients (60.5%). Most hepato- and myelotoxicity cases were categorized as grade 1 or mild (60.7% and 81.4%, respectively). 10 patients had grade 3 hepatotoxicity (ALT 195-780 U/L)
Nausea was reported in 46%. Fatigue was identified in 13, Headache in 6, and Alopecia in 6
MTX was discontinued in 60 out of 157 cases with an AE (38%), including 27 following nausea, 27 and 4 following hepatotoxicity
Sixty-five (43.0%) of all biochemical toxicities occurred within the first 3 months of MTX initiation
Strategies to manage AEs included reduced dosage, use of antiemetics or PPIs, and change in route of administration

Discussion:

The authors recommend biochemical testing after initiation “at 2, 4, 8, and 12 weeks, as most actionable toxicities occurred during this period. After 3 months, laboratory assessments could potentially be spaced out to every 4–6 months instead of every 3 months for stable patients, aligning with the new Dutch guideline for monitoring MTX toxicity in rheumatology.⁴¹ More frequent testing should be reserved for patients with risk factors such as renal dysfunction, hepatotoxic co-medications, or prior toxicity.⁴²“
A study limitation was “the frequent use of combination therapy, leading to a heterogeneous study population and possible overestimation of AE rates”

My take: Methotrexate remains an important part of treatment, especially combination treatment to prevent or overcome immunogenicity. Careful monitoring and prophylactic treatments of nausea may improve durability.

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Health Advice From AI Chatbots Frequently Wrong

Posted on February 23, 2026 by gutsandgrowth

T Rosenbluth, NY Times 2/9/26: Health Advice From A.I. Chatbots Is Frequently Wrong, Study Shows

An excerpt:

A new study published Monday provided a sobering look at whether A.I. chatbots, which have fast become a major source of health information…

The experiment found that the chatbots were no better than Google — already a flawed source of health information — at guiding users toward the correct diagnoses or helping them determine what they should do next. And the technology posed unique risks, sometimes presenting false information or dramatically changing its advice depending on slight changes in the wording of the questions…

The models have passed medical licensing exams and have outperformed doctors on challenging diagnostic problems.

But Adam Mahdi, a professor at the Oxford Internet Institute and senior author of the new Nature Medicine study, suspected that these clean, straightforward medical questions were not a good proxy for how well they worked for real patients…

So he and his colleagues set up an experiment. More than 1,200 British participants, most of whom had no medical training, were given a detailed medical scenario, complete with symptoms, general lifestyle details and medical history. The researchers told the participants to chat with the bot to figure out the appropriate next steps, like whether to call an ambulance or self-treat at home. They tested commercially available chatbots like OpenAI’s ChatGPT and Meta’s Llama.

The researchers found that participants chose the “right” course of action — predetermined by a panel of doctors — less than half of the time…They were no better than the control group, who were told to perform the same task using any research method they would normally use at home, mainly Googling…

Participants didn’t enter enough information or the most relevant symptoms, and the chatbots were left to give advice with an incomplete picture of the problem…By contrast, when researchers entered the full medical scenario directly into the chatbots, they correctly diagnosed the problem 94 percent of the time…

Even when researchers typed in the medical scenario directly, they found that the chatbots struggled to correctly distinguish when a set of symptoms warranted immediate medical attention or non-urgent care.

My take: AI and chatbots can be quite helpful and continue to improve. This study and the summary by NY Times show some of the limitations. Even small changes in wording/prompts can alter the advice from chatbots considerably.

Related blog posts:

Taking Away the Keys from Older Clinicians

Posted on February 22, 2026 by gutsandgrowth

DB Kramer et al. NEJM 2026; 394: 402-407. Promoting Fairness in Screening Programs for Late-Career Practitioners

This is an interesting article regarding screening late-career physicians (LCPs) to assure competency.

An excerpt:

Late-career physicians (LCPs) are an integral part of the U.S. medical workforce. Nearly a quarter of practicing physicians in the United States are over 65 years of age, and they are serving at a time of overall physician scarcity.^1,2 Older physicians bring valuable wisdom and expertise to patient care, but many will experience cognitive and physical decline that may affect their clinical skills.^3,4 Interest has grown among hospitals in mandatory screening programs that could proactively identify physicians whose ability to deliver safe care may be compromised, before patient harm occurs.⁵…

Yet physicians also have interests related to being screened that deserve respect, and LCP programs can and should protect these interests by ensuring procedural fairness…

Evidence that LCPs can pose risk to patients has motivated health care institutional leaders to develop mandatory screening programs.^5,12 LCP policies may require testing of the aspects of physicians’ cognitive and physical functioning that are relevant to clinical activities; such testing is usually triggered when a physician reaches an age threshold (commonly 70 years) and is tied to renewal of privileges….Among physicians’ objections are that tests have imperfect predictive accuracy and that erroneous results could threaten their reputation and livelihood…

Fair assessment requires that the screening tests and processes employed provide an accurate, impartial assessment of relevant skills. An appeals process should be developed that gives physicians a meaningful opportunity to contest any restrictions on their privileges based on test results. Physicians who participate in LCP programs, like employees in other industries, retain recourse to the Equal Employment Opportunity Commission and the courts to contest wrongful termination, age discrimination, and disability discrimination…

The other key component considered by courts evaluating individual burden is known as least infringement. In the context of LCP programs, such an inquiry would center on whether an adverse action taken on the basis of test results is the least-restrictive option that is commensurate with the goal of protecting patient safety…

Care should be taken not to mistakenly hold LCPs to a higher standard than younger physicians simply by applying greater scrutiny to their practice.²⁶

My take: In theory, screening of late-career physicians makes a lot of sense to protect patient welfare. In practice, it may be difficult to design tests that have adequate sensitivity and specificity with regard to physician capability. This is true for both older and younger physicians.

Related blog post: “You Still Going to be Doing This?”