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.

Selected Slides from NASPGHAN 2022 Postgraduate Course (Part 1)

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Pediatric Foreign Body Ingestions
Esophageal Strictures
Esophageal Strictures
Imaging for Acute Pancreatitis
Imaging for Acute Pancreatitis
For Acute Liver Failure
For Acute Liver Failure
For Acute Liver Failure

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.

What’s in Your Gut and How to Change It

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W Turpin et al. Gastroenterol 2022; 163: 685-698. Open access! Mediterranean-Like Dietary Pattern Associations With Gut Microbiome Composition and Subclinical Gastrointestinal Inflammation

As part of the Genetic, Environmental, Microbial (GEM) Project, the researchers recruited a cohort of 2289 healthy first-degree relatives of patients with Crohn’s disease. Diet was assessed with a food frequency questionnaire. Key finding: A Mediterranean-like dietary pattern is associated with microbiome (increased Ruminococcus, as well as taxa such as Faecalibacterium) and lower intestinal inflammation.

L Zhao et al. Gastroenterol 2022; 163: 699-711. Open Access! Uncovering 1058 Novel Human Enteric DNA Viruses Through Deep Long-Read Third-Generation Sequencing and Their Clinical Impact This study discovered 1058 novel human gut viruses, and these findings can contribute to current viral reference genome, future virome investigation, and colorectal cancer diagnosis. From the editorial: “Previous literature also identified virome signatures associated with certain diseases, such as colorectal cancer14 or inflammatory bowel disease,15 such that a better understanding of the viral dark matter may be used to develop biomarkers to identify individuals at risk or even to influence gut physiology.”

Related blog posts:

“Gaming” U.S. Patent System by Big Pharma

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NBC News: ‘Gaming’ of U.S. patent system is keeping drug prices sky high, report says 

Excerpts:

Drugmakers are able to extend the patents on their drugs, keeping generics off the market, through a process known as “evergreening”… The excessive use of the patent system — by drugmakers Bristol-Myers Squibb, AbbVie, Regeneron and Bayer — keeps the prices of the medications at exorbitant levels, often at the expense of American consumers, according to the report from the Initiative for Medicines, Access & Knowledge, or I-MAK, a nonprofit organization that advocates drug patent reform.

“They get the power, they get the monopoly and they start hiking their prices,” said Priti Krishtel, a health justice lawyer and a co-founder of I-MAK…

The U.S. patent system is meant to reward innovation by permitting drug companies to sell new medications on the market and barring other manufacturers from making generic versions for a set period of time — usually 20 years. Once the patent expires, generics are allowed on the market, often at a lower list price than the brand-name drug.

But drugmakers often extend their patents by making small tweaks to the drugs, sustaining their monopolies for several years...

Humira, a rheumatoid arthritis drug from the Chicago-based biotech firm AbbVie, generated $17.3 billion in annual sales in 2021. There are 311 patent applications for the drug, 94% of which were sought after FDA approval. AbbVie’s original patent on the drug expired in 2016, but it won’t face competition until 2023...

The practice of extending patents doesn’t always go unchallenged. In some cases, generic manufacturers sue the drugmakers to get their drugs on the market, Lemley said. However, he added, those lawsuits often end in settlements between the companies.

My take: As bioethicist Arthur Caplan states, this is an unethical practice and “we need to be rethinking the rules of patenting.” There is no good reason why patients in the U.S. need to be paying 5 times as much for adalimumab as patients in Europe.

Related blog posts:

Knik River, AK

Repetition of Misleading Information: “Illusory Truth” Effect

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A Hassan, SJ Barber. Cogn Res Princ Implic. 2021 Dec; 6: 38. Open Access! The effects of repetition frequency on the illusory truth effect. doi: 10.1186/s41235-021-00301-5

“Repeated information is often perceived as more truthful than new information. This finding is known as the illusory truth effect, and it is typically thought to occur because repetition increases processing fluency…In Experiment 1, we showed participants trivia statements up to 9 times and in Experiment 2 statements were shown up to 27 times…In both experiments, we found that perceived truthfulness increased as the number of repetitions increased. However, these truth rating increases were logarithmic in shape. The largest increase in perceived truth came from encountering a statement for the second time, and beyond this were incrementally smaller increases in perceived truth for each additional repetition.”

My take (from authors): “Although believing repeated information to be true is evolutionarily efficient in a context where most of the information encountered is correct, it can be detrimental to believe information that is incorrect.”

Related blog posts:

Eklutna Lake, AK

How Useful Are 3-site Esophageal Biopsies for Eosinophilic Esophagitis

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JB Wechsler et al. Clin Gastroenterol Hepatol 2022; 20: 1971-1976. Defining the Patchy Landscape of Esophageal Eosinophilia in Children With Eosinophilic Esophagitis

Design: The authors prospectively obtained 3-site esophageal biopsies based on rigorous endoscopic measurements of the proximal, mid, and distal esophagus and gastroesophageal junction. Biopsies were reviewed by a pathologist, and those with at least 15 eosinophils per high-power field were considered active EoE.  

Key findings:

  • 304 endoscopies in 167 patients had active EoE. The entire cohort was 217 patients (n=596 endoscopies)
  • Among the 304 endoscopies with active EoE, 9 had focal eosinophilia restricted to the mid esophagus, and 8 were restricted to the proximal esophagus
  • Distal + proximal biopsies had the highest diagnostic sensitivity for a 2-site combination (~98% sensitivity)

Based on this study, the authors recommend “3-site biopsies for optimal disease assessment of active EoE in children.”

My take: I think recommendations to add more and more biopsies is premature until we have evidence that identifying “focal” inflammation in the mid-esophagus has some clinical usefulness/improves outcomes. To me, a 2% increase in sensitivity over 2-site biopsies is negligible & in all likelihood, a 4-site biopsy protocol would increase the yield even further.

Related blog posts:

Stream near Byron Glacier

Does Budesonide Work for Collagenous Gastritis?

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Congratulations to NASPGHAN Elected Leaders and especially to Vicky Ng (who I met while completing my fellowship in Cincinnati).

Briefly noted:

RS Choung et al. Clin Gastroenterol Hepatol 2022; 20(9):1977-1985. Collagenous Gastritis: Characteristics and Response to Topical Budesonide

This was an open-label, retrospective study with 64 patients with collagenous gastritis (CG) (50 adults, 14 children). Budesonide was administered in 2 formulations: open-capsule budesonide or compounded immediate-release budesonide capsule.  Key finding: Of the patients treated with topically targeted budesonide (TTB), 89% had a clinical response (42% complete, 46% partial), and 88% had a histologic response (53% complete, 33% partial).

Related blog posts:

At the top of Crow’s Pass Trail, Girdwood AK

Unfortunate or Unfair Disparities in Liver Transplantation

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In medical school, I took additional courses in bioethics and one of the influential lecturers was Tristramm Engelhardt (Right to Health Care).  “According to him, injuries, disabilities, and diseases arising from natural causes are considered unfortunate. On the other hand, those situations become unfair when brought about by the doing of others. Engelhardt also notes that the result of someone’s unfair action should not be attributed to the society as a whole.”

Two recent articles detail the link between socioeconomics and outcomes in liver transplantation. Are these problems unfair or just unfortunate?

NH Ebel et al. Liver Transplantation 2022; 28: 1521-1529. A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation

Key points:

  • Disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes
  • Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children.
  • Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes.
  • Children living farther from a transplant center have higher waitlist mortality

KA Mohamed et al. Liver Transplantation 2022; 28: 1441-1453. Open access! Neighborhood poverty is associated with failure to be waitlisted and death during liver transplantation evaluation

Key points:

  • Based on retrospective analysis of 3454 patients (2011-2018), neighborhood poverty was independently associated with waitlisting (odds ratio 0.56, 95% confidence interval [CI] 0.38–0.82) and death during LT evaluation (hazard ratio 1.49, 95% CI 1.09–2.09)
  • Despite use of the objective prioritization with MELD scores in the allocation of organs, disparities in access for LT continues for vulnerable populations

My take: It is unfortunate but not surprising that poverty and socioeconomic factors adversely affect liver transplantation; the outcomes show stark differences. These issues, however, affect every aspect of health care (& beyond). Though they are not easily addressed, efforts to try to level the playing field are important especially with regard to transplantation to assure optimal use of this life-saving resource.

Related blog posts:

Portage Pass Trail (near Whittier AK) with views of Portage glacier

Will a SQUIRT Score Be Helpful?

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A recent letter to the editor: J Rauh et al. Stool Quality for Intestinal Rehabilitation Therapy (SQUIRT) Score, JPS 2022. doi: https://doi.org/10.1016/j.jpedsurg.2022.08.025

The authors have devised a SQUIRT score for short bowel syndrome. The higher score indicates better enteral tolerance with a highest score of 13 and a lowest score is 3. It is a composite score based on composition, frequency and volume/blowouts. The authors define a blow-out to be a stool loose enough and large enough for the child to require a change of clothes.

How to Score:

Consistency (choose best stool of the day)
Playdough, Formed 5
Peanut Butter, Pasty 4
Pudding, Seedy 3
Pea Soup, Loose 2
Water 1

Occurrences (over 24 hours)
1 to 3 4
4 to 6 3
7 to 9 2
Greater Than 10 1
Ostomy Present 0

Volume
With Ostomy Without Ostomy
(mL/kg) (# of blowouts)

  • < 10 mL/kg 8 0 =4
  • 10 -14 mL/kg 7
    15-19 mL/kg 6 1 =3
  • 20-24 mL/kg 5 2 =2
    25-29 mL/kg 4
  • 30-34 mL/kg 3
  • 35 mL/kg 2
  • >35 mL/kg 1 >3 =1

The authors state that this scoring system has been used in their institution. “This tool can provide objective information to guide clinical decision making. Even patients with ostomies, for whom we can measure stool volume, benefit from SQUIRT scores because including the variable of stool consistency provides a more nuanced assessment than relying on volume.”

My take:This type of scoring system would be useful, primarily in patients in which the volume of stool is difficult to measure. It would benefit from trials to validate its utility.

Related blog posts for Short Bowel Syndrome:

American Windows by Marc Chagall, at the Art Institute of Chicage

A$$inine Pricing of Indomethacin Suppositories

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K McKee et al. Gastroenterol 2022; 163: 543-546. Open access! Rectal Nonsteroidal Anti-inflammatory Drugs for Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Prophylaxis: A Case Study in a Price-Escalation Era

During the pandemic, several of the pharmaceutical companies have helped improve the reputation of the industry by expeditiously developing life-saving therapies and vaccines. At the same time, many have continued with outrageous price increases of generic medications. An example of this is rectal indomethacin which is used for the prevention of pancreatitis after ERCP. In this commentary, the key points:

  • The current price in the U.S. for this previously inexpensive medication is now $429 (in 2021) (previously $17). For patients, this charge is often multiplied by hospital billing departments and is frequently NOT covered by insurance as the manufacturer has not filed a new drug application with the FDA (new indication).
  • The authors note that rectal diclofenac would be a suitable alternative with similar (?better) effectiveness but is currently not available in U.S.
  • The government could allow importation of either diclofenac or indomethacin (see Table below for costs of these medications in other countries). “If the government used the powers granted in the Medicare Modernization Act of 2003, the price gouging problem caused by rectal NSAIDs could be swiftly solved without the need for expanding the US manufacturing market.” This would drop the “price of this potentially lifesaving prophylaxis by 99.24%.”

My take: I am still grateful to Mark Cuban (Why I No Longer Need to Be A Billionaire | gutsandgrowth) who is much more likely to fix the generic drug pricing problem than our government which has been reluctant to take measures against big pharma.

Related blog posts:

Thank You Larry

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One of the difficult aspects at this point in my career is saying goodbye as physicians retire.  Larry Saripkin, who is an amazing person, is retiring (last day yesterday). 

I first met Larry when I was working at Egleston Hospital. Larry, along with Jeff Lewis, provided coverage for me when I had become the single physician in my group.  This allowed me to be off when our youngest son was born.  Then, later, Larry helped convince me to join the merging GI groups at Scottish Rite (23 years ago).  This has been one of my best decisions.  Of course, I feel that our group delivers very good care for our patients.  Yet, the main reason why it has been a good choice is working alongside some terrific individuals. 

Larry has a keen intellect and a wonderful ability to connect with everyone, even families with very stressful medical conditions. He is very generous with his time.  I remember one night when he was on-call, the parents of one of my patients called. They were upset because they could not get the feeding pump to work.  They told me that Larry insisted on driving out to their house (around 11 pm).  He and his wife showed the family how to work the pump.

For about 15 years, he has spent a week every summer at Camp Oasis as the medical director.  At heart, Larry is still a kid.  For years, he would take some of the younger staff (or kids of other physicians) with him when he went to Bonaroo.

He has served as a mentor to many of us in our group and to about a dozen scribes who have moved on to become physician assistants or to medical school/physicians.

Countless families have told me how important Larry has been to them. He has attended many of his patients’ celebrations (eg. weddings).

It will be bittersweet going forward when I walk by Larry’s office & missing out on some great story or some new music.

In this picture with Melissa and Cassie (from 2011), Larry is dressed up
as a cheeseburger (with a fake mustache) at Camp Oasis.