The link I provided earlier in the day was not correct. I will have to find a better production editor!
This link should work: Art Metrano is Wonderful
Or can look up “Art Metrano is Wonderful YouTube”
Author Archives: gutsandgrowth
Comedy Magic -Art Metrano
This is an old video (picture quality not that great) that I only saw recently. This is true genius:
YouTube Link (2:47 min): Art Metrano is Wonderful
This work was referenced on (24 seconds) The Family Guy: Jesus doing Art Metrano
Understanding the Laxative Effects of Coffee
V Mehta et al. JPGN 2023; 76: 20-24. Open Access! Effect of Caffeine on Colonic Manometry in Children
Methods: A prospective study of pediatric patients (N=16) undergoing standard colonic motility testing that were able to consume caffeinated coffee, decaffeinated coffee, and caffeine tablet during colonic manometry (with normal response to bisacodyl)
Key findings:
- Caffeinated coffee resulted in a higher AUC, motility index (MI), and time to HAPC compared with decaffeinated coffee (P < 0.05).
- Urge to defecate, or actual bowel movement in 100% (n = 16) of patients after intraluminal bisacodyl (IB), compared to 81% (n = 13) after caffeinated coffee (CC), 56% (n= 9) after caffeine tablet (CT), and 50% (n = 8) after decaffeinated coffee (DC)
- Based on AUC between T = 1 and T = 60 minutes after each agent, the response of the colon to IB was more robust, relative to other agents (P < 0.05). Both CC and DC had resulted in a higher AUC compared to CT (P < 0.05), but no significant difference between CC and DC
- Caffeine is indeed a colonic stimulant; however, other components of caffeinated and non-caffeinated beverages likely induce colonic response as well
- Limitation: Study population: patients required motility testing for refractory chronic constipation Therefore, they do not represent a normal population
My take: As with adult patients, coffee (both caffeinated and decaffeinated) acts as a colonic stimulant. Though, it is relatively weak compared to bisacodyl
Related blog posts:
Weight Gain If Semaglutide Stopped
- NPR (Jan 30, 2023: Wegovy works. But here’s what happens if you can’t afford to keep taking the drug A study found that most people gain back most of the weight within a year of stopping the medicine…The rebound weight gain is not a surprise given how the medication works. Wegovy’s active ingredient — semaglutide — is a GLP-1, or glucagon-like peptide-1, which mimics the GLP-1 satiety hormone in our bodies. When we eat, GLP-1 is released from our intestines and sends signals to our brain centers that control appetite.
- JPH Wilding et al. Diabetes, Obesity and Metabolism 2022. https://doi.org/10.1111/dom.14725 Open access! Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension “One year after withdrawal of once-weekly subcutaneous semaglutide 2.4 mg and lifestyle intervention, participants regained two-thirds of their prior weight loss, with similar changes in cardiometabolic variables. Findings confirm the chronicity of obesity and suggest ongoing treatment is required to maintain improvements in weight and health.”
- J Belluz. NY Times Jan 31, 2023: What New Weight Loss Drugs Teach Us About Fat and Free Will
This article discusses several conditions like Prader-Willi and pregnancy that can result in increase hunger and then elaborates on genetic tendency towards obesity in an age of abundant ultra-processed high calorie foods. Excerpts:
A famous 1990 study of identical twins born in Sweden showed that pairs who were separated at birth and adopted had weights more similar to each other than to their adoptive families…The ability to sense such fullness — and hunger — varies, the result of genetic differences in brain circuits that control appetite.
The new drugs are the first to manipulate the hormonal regulatory systems governing energy balance. The drugs simulate the action of our native GLP-1 but with longer-lasting effects, amplifying the fullness signal inside the body…At the very least, though, the way the drugs work can teach us that people who are larger did not necessarily choose to be, just as people who are smaller did not — and are not morally superior. This “isn’t a free pass, either to individuals who do have the capacity to choose better, nor does it take the heat off of food industries,” said a University of Sydney nutritional biologist, Stephen Simpson, but it’s “evidence that obesity isn’t a personal lifestyle choice.”
My take: For those who benefit from GLP-1 medications, it is important to recognize that weight gain is likely when the medications are discontinued; this indicates once treatment is started, the goal would be to use indefinitely –until something better comes along.
Related blog posts:
- What Really Causes Obesity and Weight Bias
- Semaglutide in Adolescent Obesity
- AGA Guidelines for Adults with Obesity
- Does Motivational Interviewing Help Long-Term Outcomes for Obesity?
- Time to Change the Medical Treatment and Attitudes Directed at Obesity?
- How to Talk About Childhood Obesity
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
Briefly Noted: Kiwi for IBS-C
R Gearry et al. AJG 2022. DOI: 10.14309/ajg.0000000000002124.Open Access! Consumption of 2 Green Kiwifruits Daily Improves Constipation and Abdominal Comfort—Results of an International Multicenter Randomized Controlled Trial
Participants included healthy controls (n = 63), patients with functional constipation (FC, n = 60), and patients with constipation-predominant irritable bowel syndrome (IBS-C, n = 61). Mean age 35 years.
Key findings: Consumption of green kiwifruit was associated with a clinically relevant increase of ≥ 1.5 CSBM (complete spontaneous bowel movement) per week (Functional constipation; 1.53, P < 0.0001, IBS-C; 1.73, P = 0.0003) and significantly improved measures of GI comfort (GI symptom rating scale total score) in constipated participants (FC, P < 0.0001; IBS-C, P < 0.0001)
Related blog post: Small Study: Kiwi For Constipation
What I Don’t Want to See: Catastrophic Antiphospholipid Syndrome
SA Kahn et al. NEJM 2023; 388: 358-368. Case 3-2023: A 16-Year-Old Girl with Abdominal Pain and Bloody Diarrhea
This case report of a girl presenting with abdominal pain and diarrhea identifies a rare etiology, catastrophic antiphospholipid syndrome (CAPS). CAPS can result in ischemic colitis. This patient underwent a colonoscopy which was normal in rectum but then became abnormal in the sigmoid colon:
“CAPS is thought to result from the binding of antiphospholipid antibodies to cell surfaces, which activates endothelial cells, monocytes, and platelets and leads to inflammation, complement activation, and thrombosis. The formation of thrombi in patients with antiphospholipid antibodies is thought to be a multihit process.7 The presence of antiphospholipid antibodies in the blood is the first event, but the antibodies typically do not cause disease until another event occurs.”
Management of antiphospholipid antibodies: “Thrombotic disease manifestations are important in guiding therapy. For patients with antiphospholipid antibodies and no history of clotting, anticoagulation for primary thromboprophylaxis is generally not recommended…For patients with antiphospholipid antibodies and a history of unprovoked thrombosis (e.g., patients with APS), long-term thromboprophylaxis is recommended…For patients with more severe presentations — such as this patient, who had CAPS with thrombosis in multiple organs — treatment is more aggressive and involves targeting multiple steps within the CAPS cascade.”
From ChatGPT
My take: This 16 yo had a severe presentation and the case is a reminder that there are multiple reasons besides IBD for a teenager to have bloody diarrhea and abdominal pain.
Related blog posts:
How Low Can You Go with Split Livers?
Z Wang et al. Liver Transplantation 2023; 29: 58-66. Outcome of split-liver transplantation from pediatric donors weighing 25 kg or less
DJ Stoltz et al. Liver Transplantation 2023; 29: 3-4.(Editorial) Open Access! Exploring the lower weight limit of splitable liver grafts for pediatric recipients
From the editorial:
“In this issue of Liver Transplantation, Wang et al.7 describe the results of an innovative strategy to increase organ availability, particularly for low‐weight pediatric recipients, by utilizing a low‐weight donor population (≤25 kg) that historically has been avoided in pediatric split‐liver transplantation (SLT)…They found no significant differences in perioperative data, postoperative complications, patient survival, or graft survival between SLTs from donors ≤25 kg and the other three groups.”
Implications of study findings:
- Splitting livers from donors weighing less than 25 kg will increase the pediatric donor pool and could improve waitlist mortality
- Split smaller livers may mitigate “the clinical consequences of large‐for‐size syndrome and subsequent graft dysfunction”
- “This approach requires a substantial level of surgical expertise to achieve comparable outcomes with more conventional operative techniques”
- “1‐year graft survival for pediatric recipients receiving technical variant grafts was significantly worse at low‐volume centers performing an average of <5 pediatric liver transplantations per year” compared with high‐volume centers (89.9% vs. 95.3%; p < 0.001)
- Limitations: Retrospective study. Also, only 22 of the split livers were from <25 kg donors
My take: Making the best use of this precious resource is a solemn responsibility. This study provides another reason for more transplants to be done in centers with a high level of expertise and more reasons to continue to use split livers. In those with sufficient expertise, even smaller livers can save two lives instead of one.
Related blog posts:
- Liver Update: Past Time to Split (2022) & Graft Fibrosis -Will the Liver Last?
- Improved Outcomes with Living Donor Livers for Vulnerable Recipients
- Pediatric Liver Transplantation: Past Time to Split (2017)
- Liver Transplant Outcomes in Children: Two Studies
- Online Aspen Webinar (Part 7) -Liver Organ Allocation
- Projected 20-Year and 30-Year Survival Rates for Pediatric Liver Transplant Recipients (U.S.)
New Information on Neonatal Liver Failure
WS Thompson et al. Liver Transplantation 2023; 29: 118-121. Ultra-rapid whole genome sequencing: A paradigm shift in the pre-transplant evaluation of neonatal acute liver failure
In this case series, three patients had ultra-rapid whole genome sequencing (WGS). Case 1 identified PRF1 mutation consistent with familial HLH, Case 2 identified variants in FDXR implicated in a mitochondrial disorder and Case 3, found pathogenic mutations in ASL associated with agrininosuccinic aciduria.
The authors argue that ultra-rapid WGS which can provide information in as little as 12 hours and typically provides actionable results within 3 days. should be a first-line approach and would identify nearly all causative genetic reasons for neonatal acute liver failure. While GALD and viral etiologies would not be found, if there are no genetic causes, this would support the “initiation of empiric therapy.”
S Antala et al. Liver Transplantation 2023; 29: 5-14. Open Access! Neonates with acute liver failure have higher overall mortality but similar posttransplant outcomes as older infants
In this retrospective study with 1807 neonates and 890 infants (31-120 days) with ALF (identified in two large databases between 2004-2018), the key findings:
- Neonates had higher death rates (46% alive without liver transplant, compared to 53% of infants who were alive without liver transplant)
- Both groups had low liver transplant rates, with neonates less likely to be transplanted: 2% vs 6.4% (P<0.001)
- Infants had higher rates of “unidentified” as etiology whereas neonates had higher rates of GALD and viral infections. Cardiac etiologies causing ALF were common in both groups, 24% of neonates and 18% of infants.
My take: Rapid genomic testing is very useful in infants/neonates with ALF. This population has a high mortality rate and a low rate of receiving liver transplants. Reducing the size for split liver donation could help with organ availability (see next post).
Related blog posts:
Why Telehealth Will Not Solve Health Care Disparities: Liver Care Experience
JB Henson et al. Hepatology 2023; 77: 176-185. Access to technology to support telehealth in areas without specialty care for liver disease
Key finding: Technology access was lowest in areas with low access to care and the highest burden of liver‐related mortality.
Editorial: S Wadhwani, JC Lai. Hepatology 2023; 77: 13-14. Open Access! The digital determinants of liver disease
An excerpt:
The authors found that counties with decreased access to gastroenterologists and liver transplant centers had increased county‐level liver‐related mortality. These counties tended to have residents who were more likely to be living in poverty, have lower educational attainment, have less access to primary care, and be living in a rural location. These same counties were less likely to have access to the high‐quality connectivity necessary to engage in telehealth appointments, demonstrating that telehealth in its current iteration will be unable to overcome health inequities in liver disease. For telehealth to be a viable solution to overcoming disparities in liver‐related mortality, the United States will need to tackle the “digital divide.”
My take: The same patients who have trouble seeing a liver specialist due to distance, transportation issues, and poverty are much less likely to have a good internet connection. Without this digital access, telehealth cannot help solve the disparity in care.
Related blog posts:
Pediatric Fatty Liver Disease is a Reversible Disease
S Lefere et al. Clin Gastroenterol Hepatol 2022; 20: 2317-2326. Open Access! Intensive Lifestyle Management Improves Steatosis and Fibrosis in Pediatric Nonalcoholic Fatty Liver Disease
In this prospective study with 204 children with severe obesity, intensive lifestyle changes were implemented. Key findings:
- After 6 months, the median body weight loss was 16.0% in the 167 patients evaluated
- Fibrosis improved in 75.0% (P < .001) (33% had F2 or higher fibrosis at baseline per elastography)
- Fasting serum alanine aminotransferase and homeostasis model assessment of insulin resistance decreased significantly over the 1-year period (P < .001)
T Khurana et al. J Pediatr 2022; 250: 61-66. Clinically Meaningful Body Mass Index Change Impacts Pediatric Nonalcoholic Fatty Liver Disease
In this retrospective study with 784 children, Key findings:
- Of these children, 168 (31%) had a BMIz (BMI z-score) change of >−.25 from baseline over a median of 367 days (IQR, 201-678 days). Thus, ~1/3rd of children achieved a drop in BMIz with lifestyle advice
- A BMIz reduction of >.25 was associated with significant improvements in serum aminotransferase levels.
My take: These pediatric studies replicate similar findings from adult studies showing that modest reductions in weight are associated with improvement in NAFLD. However, most patients are not successful with lifestyle advice which underscores the need for pharmacotherapy.
Related blog posts:
- Aspen Webinar 2021 Part 2 -Nonalcoholic Steatohepatitis | gutsandgrowth
- Online Aspen Webinar (Part 6) -NAFLD and NASH
- The Paramount Health Challenge for Humans in the 21st Century
- How Often Do Children with Obesity Have a Fatty Liver?
- Pediatric NAFLD: You Don’t Have to be Obese/Overweight to have Fatty Liver Disease (but it helps)
- Should Teenagers with Severe NAFLD Undergo Bariatric Surgery?
Siesta Key, FL
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