Author Archives: gutsandgrowth

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About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

Coding Correctly in 2023

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The following information was provided by our coding advisor, Mary Suhr.

Key points:

  1. Time codes (when used) for inpatient visits have changed (see below). In 2023, when you share a service with an APP, you may bill on patient medical decision making or time spent.  You can add the time together and whoever spends more total time on that date of service (including face to face and non-face to-face) gets to be the service provider for that charge. 
  2. Extra time code: 99418 for every 15 minutes increments above average inpatient code.
  3. Observation codes are obsolete.
  4. Specific requirements for documentation of History and Physical exam are NOT needed for coding. Good documentation is still important part of medical practice and for liability; patient still needs to be examined.
  5. ALL outpatient and inpatient E/M visits will be leveled using the same methodology.
  6. Coding is based on medical decision making or time code (whichever has higher complexity). When selecting a level of service for Medical Decision Making, there is still the concept of having three components/tables and the requirement that two of the three components are met.  Tables 1, 2, and 3 outline the requirements.
  7. CPT 99251 (Straightforward Inpatient Consult) and CPT 99241 (Straightforward Outpatient Consult) are going away because the history and exam requirements for consults no longer apply and history/exam was the only difference between level 1 and level 2 consultation codes.
  8. For consultations, you still need a requesting provider, a reason for the consult and a report back to the provider.  CMS was explicit this year that assuming care of the problem is not considered a consult.
  9. Consultations cannot be shared between two providers (e.g. physicians and APPs).  If a consultation is shared between an APP and a MD, our advisor recommends the use admission codes for those.  This is true for inpatient consultations as well as office-based consultations.

Related blog posts:

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.

FDA Approves Pharmaceutical Fecal Transplant Product

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FDA News Release (11/30/22): FDA Approves First Fecal Microbiota Product

“Rebyota is approved for the prevention of recurrence of Clostridioides difficile infection (CDI) in individuals 18 years of age and older. It is for use after an individual has completed antibiotic treatment for recurrent CDI.”

“Rebyota is administered rectally as a single dose [150 mL]. Rebyota is prepared from stool donated by qualified individuals….The effectiveness of Rebyota was evaluated in an analysis of data from a randomized, double-blind, placebo-controlled, multicenter study….the overall estimated rate of success in preventing recurrent CDI through 8 weeks was significantly higher in the Rebyota group (70.6%) than in the placebo group (57.5%).”

My take: As pharmaceutical companies gain approval for fecal transplant products, I would anticipate a significant increase in costs. This product seemed to have a fairly low success rate compared to placebo.

Related blog posts:

White Sands National Park. New Mexico.

Vancomycin for Chronic Pouchitis & ASPEN Infant Formula Resources

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G Lupu et al. Inflamm Bowel Dis 2022; 28: 1610-1613. Vancomycin Is Effective in the Treatment of Chronic Inflammatory Conditions of the Pouch

In this retrospective study of 41 adults with history of ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), the authors evaluated the clinical response (subjective judgement of provider) to chronic vancomycin therapy (125 mg twice a day).

Key findings:

  • At 4 weeks, 21 (51%) of patients had a clinical response. 16 of these patients maintained a clinical response at 3 and 6 months (remained on treatment).
  • 6 additional patients demonstrated a later response. In total 22 (54%) were considered clinical responders at 3 and 6 months.
  • The mean number of antibiotics utilized prior to vancomycin was 4, including ciprofloxacin, metronidazole, levofloxacin, rifaximin, sulamethoxazole-trimetoprim, amoxicillin, and amoxicillin-clavulanic acid

My take: Since vancomycin has poor enteral absorption, it’s side effect profile is very favorable. More prospective and objective data is needed; however, vancomycin’s high cost will likely limit frequent use.

Related blog posts:

Link: ASPEN Formula Resource Practice Tool (sponsored by ByHeart)

Improving Reflux While You Sleep

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JM Schuitenmaker et al. Clin Gastroenterol Hepatol 2022; 20: 2753-2762. Open Access! Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial

Methods: This was a double-blind, randomized, sham-controlled trial in patients (n=100) with nocturnal symptoms of gastroesophageal reflux. Patients were advised to sleep in the left lateral decubitus position and were assigned randomly (1:1) to an electronic sleep positional therapy wearable device (applied with an adhesive sticker), programmed to either produce a vibration when in the right lateral position (intervention) or only during the first 20 minutes (sham).

Key findings:

  • In the intention-to-treat analysis, the rate of treatment success (defined as a 50% or more reduction in the nocturnal reflux score) was 44% in the intervention group (22 of 50) vs 24% in the sham group (12 of 50) 
  • There was increased time sleeping in the left lateral decubitus position (intervention 60.9% vs sham 38.5%)

My take: In those with nocturnal heartburn, this appears to be a helpful nonpharmacological tool.

Website for the company (side sleep technologies) that makes the device: The Left ” Your body will be conditioned to sleep at least 80% on your left within a week.” (I do not have any financial relationship with this company).

Related blog posts:

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.

Short Bowel Syndrome is a Full Time Job

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C Belza et al. J Pediatr 2022; 250: 75-82. Carrying the Burden: Informal Care Requirements by Caregivers of Children with Intestinal Failure Receiving Home Parenteral Nutrition

This was a cross-sectional study of caregivers of children (n=34) with intestinal failure receiving long-term parenteral nutrition. 97% of caregivers were the child’s mother and median duration of providing care among respondents was 3.4 years.

Key findings:

  • Caregivers reported a median of 29.2 hours per week (IQR, 20.8-45.7 hours per week) of direct medical care. 6.1 hours was spent on providing PN and care of the central venous catheter. 6.3 hours was spent on enteral nutrition and enteral tube care.

In the associated editorial (pgs 10-12 by S Mauskar, JG Berry. Open Access! “Failing to Support Families’ Burden of Care for Children with Intestinal Failure“), the authors note that in the U.S. there has been a growing population of children at home with greater medical complexity and reliance on medical technology and that the need for home nursing support “greatly exceeds the supply, leaving many families on their own to care for their children.”

They also note that the medical literature (over the last 25 years) on caregiver burden for children notes it is associated with “marital discord, loss of employment, and financial struggle…In the U.S. a substantial portion of children with medical complexity assisted with technology live in single-parent households, in poverty, and are exposed to adverse childhood events…very vulnerable to the effects of high caregiving burden.”

My take: This study shows that while we have an effective treatment for intestinal failure, the burden of this treatment is very high even with care coordination and social worker help. Understanding this burden could help medical providers be more empathetic for the family who is struggling with home medical care (eg. child with recurrent admissions for central line infections).

Related blog posts:

Island Ford National Recreational Area. Sandy Springs, GA

Which Diet is Best for Irritable Bowel Syndrome? A Randomized Trial

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A Rej et al. Clin Gastroenterol Hepatol 2022; 20: 2876-2887. Open Access! Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet, and the Gluten-Free Diet

Methods: In patients (n=99) with Rome IV–defined non-constipated IBS, outcomes after randomization to one of three diets were compared. The “traditional dietary advice” group: “Its principles include adopting healthy, sensible eating patterns such as having regular meals, never eating too little/too much, maintaining adequate hydration, and reducing the intake of (1) alcohol/caffeine/fizzy drinks, (2) fatty/spicy/processed foods, (3) fresh fruit to a maximum of 3 per day, (4) fiber and other commonly consumed gas-producing foods (eg, beans, bread, sweeteners, etc), and (5) addressing any perceived food intolerances (eg, dairy).” (Link: National Institute for Health and Care Excellence advice on IBS mgt). The Gluten-Free diet allowed for cross-contamination. All patients had specialist dietary counseling.

Key findings:

  • All three diets resulted in improvement. The primary end point of ≥50-point reduction in IBS-SSS was met by 42% (n = 14/33) undertaking TDA, 55% (n = 18/33) for LFD, and 58% (n = 19/33) for GFD (P = .43)
  • Alterations in stool dysbiosis index were similar across the diets, with 22%–29% showing reduced dysbiosis
  • “The pragmatic study design, whereby the responsibility was left on patients to undertake the diets following appropriate education, means our findings can be generalized”

My take: All three diet approaches would be appropriate to reduce IBS symptoms, thought the TDA is the easiest for patients.

Related blog posts:

Why Are Immunization Levels Falling? It is not just due to COVID-19 and Anti-Vax Attitudes

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EJ Emmanual, M Guido. NY Times (12/28/22): Covid Isn’t the Only Reason Children’s Vaccination Rates Are Falling

Why does Mississippi have the best childhood immunization rates (99%)? This is due to state policies. This article reviews the small but significant drops in childhood immunizations which is opening the door for highly contagious diseases like measles.

Some excerpts:

U.S. routine childhood vaccination rates have historically been among the world’s best. But within the first year of the pandemic, the nation’s children missed nine million vaccine doses for diseases like polio and measles. Rates for the three major childhood immunizations — for measles, mumps and rubella; chickenpox; and diphtheria, tetanus and pertussis — fell by an average of 1.3 percentage points, with the rates in seven states and many cities falling under 90 percent…

Measles should not be taken lightly. The virus is highly contagious; according to the C.D.C., if one person has it, up to 90 percent of the people close to that person who are not immune will also become infected. It can live up to two hours in the air. One to three of every 1,000 children who contract measles die of respiratory and neurological complications…

Covid vaccine acceptance and anti-vax attitudes do not fully explain differences among states. Neither do red-blue partisan affiliations or the strength of a state’s public health system. Instead, the decline is rooted in longstanding policies among some states that allow, for instance, for nonmedical exemptions, failures to rigorously enforce vaccination requirements and inadequate public health campaigns…

Vaccines are one of the few true cost savers in medicine. The routine immunizations of children born from 1994 to 2018 are projected to prevent nearly one million early deaths and save nearly $1.9 trillion in economic costs — more than $5,700 for each American, according to the C.D.C. For measles, a state might spend more than $2 million responding to a single outbreak, with each case costing nearly $50,000 on average, according to an analysis of a recent outbreak in Washington State.

To avoid dangerous and costly outbreaks, states should introduce enforceable solutions that give their children and communities the best protections against vaccine-preventable infectious diseases.

Related blog posts:

Unrelated issue -improving numbers of physcians being trained in psychiatry:

When Are UGI Polyps Important for Familial Adenomatous Polyposis?

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According to ESPGHAN guidelines -see blog: What I Like About ESPGHAN Familial Adenomatous Polyposis Position Paper

  • Recommendation 5: Despite the presence of gastric polyps in children, and the
    later risk of duodenal polyposis and ampullary cancer in adult practice, there is no justification to commence routine UGI surveillance until the age of 25 years.
    (weak recommendation, low-quality evidence, consensus agreement 90%)

A recent study questions this recommendation: T Middleton, I Sugarman. JPGN Reports Feb 2023: doi: 10.1097/PG9.0000000000000269. Open Access: Upper Gastrointestinal Screening of Polyp Load in Children With Familial Adenomatous Polyposis: Is It Required?

Methods: A prospective record of all upper GI endoscopies in children (aged 9 to 17) with FAP was kept across a 12-year period

Key finding:

  • Thirty-eight esophagogastroduodenoscopies (79%) identified at least 1 gastric or duodenal polyp in 22 (79%) patients; 10 (36%) patients had gastric adenomas
  • Eight (29%) patients showed very high numbers of polyps
  • All 21 patients who had duodenal polyps had adenomas
  • No patients had malignancy

My take: This is a provocative study. Is there a benefit for the patient in identifying gastric/duodenal polyps at a younger age?

Figure 1

U.S. News & World Report’s Flawed Rankings Plus One

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HJ Humphrey, D Levinson. Stat. 11/22/22. Deans: Dump that USNWR ‘best medical school’ survey Thanks to John Barnard’s twitter feed for this article.

This article recommends medical schools stop participating in U.S. News & World Report’s (USNWR) ‘best medical school’ survey. I would advocate for eliminating USNWR’s reports more broadly including their ranking of hospitals and medical specialties.

The medical school rankings rely on the following:

  • Federal research dollars
  • Reputation – “assessed by a survey (with an abysmal response rate) of medical school deans, department chairs, and residency program directors”
  • Ratio of full-time faculty to students
  • Students’ median scores on the Medical College Admission Test and their undergraduate grade-point averages
  • Acceptance rate 

Some excerpts:

  • “Yale and Harvard Law Schools recently announced they would no longer participate in U.S. News & World Report’s (USNWR) flawed ranking system, followed closely by additional schools. The nation’s medical schools need to follow their lead. Why? The USNWR ranking system is in direct opposition to medical schools’ goal of educating a well-trained, diverse, and culturally competent medical workforce..”
  • “It is hardly a secret among medical school deans that the USNWR rankings are based on data not directly related to educational process, quality, and outcomes. Nor can they trust the veracity of the data that are provided, given the recent scandals reported in other professional schools and colleges that manipulate the formula to their own advantage.”
  • “Comprehensive analyses of USNWR rankings have long demonstrated that the methodology is ill-conceived, that the response rate of those completing the questionnaires that feed into the ranking formula would not meet the standards of a peer-reviewed publication, and that the most important aspects of educational quality are largely ignored.”
  • “There is peer pressure to stay within the system and to compete for the top prize because it feels good to see your school on top, no matter how flawed the measuring stick.”

My take: It is difficult to measure quality. I do not trust USNWR’s rankings with regard to “best” medical school, “best” hospital or “best” subspecialty. I think medical care would be better off without these reports. Another option would be to focus on reporting hard data, rather than the current aggregate format. This data could include federal research dollars and reputational surveys; the latter would need to be transparent with regard to methodology.

From The Washington Post, 11/23/22. Opinion  Americans are choosing to be alone. Here’s why we should reverse that. “Spending less time with friends is not a best practice by most standards, and it might contribute to other troubling social trends — isolation, worsening mental health (particularly among adolescents), rising aggressive behavior and violent crime. “

Treatments for “Bad” Inflammatory Bowel Disease (Part 3)

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D Tarabar et al. Inflamm Bowel Dis 2022; 28: 1549-1554. A Prospective Trial with Long Term Follow-up of Patients With Severe, Steroid-Resistant Ulcerative Colitis Who Received Induction Therapy With Cyclosporine and Were Maintained With Vedolizumab

As noted previously, in my view, “bad” inflammatory bowel disease (IBD) occurs when treatments are not working; though, many would argue that any IBD is bad IBD. Today’s post concludes several reviewed articles that focus on the problem of IBD that is not responding well to treatment.

Methods: Seventeen steroid-resistant adult UC patients were treated with cyclosporine in combination with vedolizumab, with a follow up of 52 weeks. Only 2 patients in this chort had failed infliximab therapy. The authors administered IV cyclosporine at a dose of “2 to 4 mg/kg/d IV for 7 days, titrated to a goal trough level of 300 to 400 ng/mL.” In those with a response, patients were started on oral therapy along with IV vedolizumab. During oral therapy (for 8 weeks), goal trough levels were 150 to 250 ng/mL (measured weekly).

Key findings:

  • Fifteen (88%) of 17 patients initially responded to cyclosporine and were started on vedolizumab
  • At week 10, 11 (73%) of 15 patients had achieved endoscopic remission with a Mayo score of ≤1. 
  • At week 26, 14 (93%) of 15 of the patients were in clinical remission and 11 (73%) were in endoscopic remission.
  • At week 52 of follow-up, 10 (71%) of 14 of these patients continued to be in endoscopic remission and 11 (79%) of 14 were in clinical remission.
  • Colectomy-free survival rate was 82% (n = 14 of 17) at 1 year and mean C-reactive protein, erythrocyte sedimentation rate, and fecal calprotectin levels were 3.2 mg/L, 16.1 mm/h, and 168.3 µg/g, respectively

My take: Cyclosporine is a fast-acting medication and thus appropriate as a salvage therapy in those with severe disease. Concerns for adverse effects have led most pediatric GIs to favor infliximab for refractory severe UC. However, in selected patients, it could be a useful “bridge” to slower-acting long-term treatments. It is possible (likely) that insurance issues would be less with cyclosporine than tofacitinib as a bridge therapy.

**An alternative agent to cyclosporine is tacrolimus. Hamel B, Wu M, Hamel EO, Bass DM, Park KT. Outcome of tacrolimus and vedolizumab after corticosteroid and anti-TNF failure in paediatric severe colitis. BMJ Open Gastroenterol. 2018;5(1):e000195 (“Positioning Biologic Therapies in the Management of Pediatric Inflammatory Bowel Disease” & 14% of U.S. Infected with COVID-19)

Related blog posts:

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.

Island Ford National Recreational Area, Sandy Springs GA