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.
In this representative sample (2706 adults, median 37.9 years) from 2017-2018 NHANES, subjects without any known chronic disease had tow 24-hr dietary recalls collected and had liver stiffness measurements (LSM) and controlled attenuation parameters (CAP); LSM <7 kPa (using vibration-controlled transient elastography) was considered low risk for advanced fibrosis and CAP >248 dB/m were at risk for heaptosteatosis. Key findings:
11% (n=305) had LSM >7.0 kPa and 46% (n=1254) had CAP >248 dB/m
Sugar-sweetened beverage (SSB) >2/day was associated with greater LSM (OR 2.30)
In mutlivariate analysis, consuming >1-2 sugar-sweetened servings per day was associated with elevated CAP (OR 1.51 compared to adults with SSB consumption
Limitations: this cross-sectional study cannot prove causality
My take: Even in healthy adults, SSB consumption is associated with detrimental changes in the liver.
100 adults enrolled in a multisite prospective observational study in which 55 underwent dilatation. Key findings:
In nondilated patients, the association between eos/hpf and symptoms was moderate (ρ = 0.49; P < .001) based on the symptom-based EoE activity index (EEsAI); for a 10-eos/hpf increase, the predicted EEsAI increased by 2.69 (P = .002)
In patients dilated 1 or less and more than 1 year before index endoscopy, this association was abolished (ρ = -0.38; P = .157 for ≤1 y and ρ = 0.02; P = .883 >1 y)
Limitations: sample size (only 25% subset of total cohort due to missing data), cross-sectional study design
My take: This finding is a double-edge sword. The good part is that dilatation improves dysphagia despite ongoing inflammation which may be refractory to current medical treatments. The bad part is this dissociation in symptoms makes it less likely for patients to be adherent to therapy.
Design: Patients completed 1 week of observation prior to randomization to 1 of 2 counterbalanced groups: OLP for 3 weeks followed by a 3-week control period or control period for 3 weeks followed by OLP for 3 weeks. During the OLP period, participants took 1.5 mL of an inert liquid placebo twice a day.
Key findings:
The mean (SD) pain scores were significantly lower during open label placebo (OLP) treatment compared with the control period (39.9 [18.9] vs 45.0 [14.7]; difference, 5.2; 95% CI, 0.2-10.1; P = .03)
Patients took nearly twice as many hyoscyamine pills during the control period compared with during the OLP period (mean [SD] number, 3.8 [5.1] pills vs 2.0 [3.0] pills; difference, 1.8 pills; 95% CI, 0.5-3.1 pills)
My take: It is a mistake to consider placebo as a treatment for functional abdominal pain. In many children, pain fluctuates and may improve with reassurance, distraction, healthier diets, and physical activity. However, we also need more effective therapies including pain psychology, dietary approaches and medications. The idea that placebo helps is misleading and undermines the fact that patients with functional disorders need effective treatment.
“Let me say at the outset that in my primary care clinic I practice low-value care. Not every day, but often enough. Probably every week”
“Choosing Wisely was an immediate public relations win for the medical profession in 2012, demonstrating that doctors were stepping up to address low value and high costs in medicine. Ten years later, however, it’s clear that making lists and publicizing them are not sufficient to reduce low-value care.1 “
“In the years since Choosing Wisely lists were first released, researchers have noted that specialty societies rarely select income-generating treatments provided by their members for inclusion on the lists.4“
“In short, Choosing Wisely has allowed doctors (and medical societies) to look like they are addressing low-value care without actually being forced to make any substantive changes.”
“My experience mirrors the findings of a 2015 study that used surveys, interviews, and focus groups to assess how patients understood low-value care. The study found ‘quite powerfully” that patients favored “replacing excessive tests with time for clinicians to talk, listen and personalize'”
“If Choosing Wisely is to continue, the specialty societies that have participated in it should celebrate its 10th anniversary by coming together to rethink and reinvent it.”
My take: While there are many factors that make it hard to eliminate low-value care, much is related to Upton Sinclair’s maxim: “It is difficult to get a man to understand something when his salary depends on his not understanding it.”
“The C.D.C. study covered the period from mid-December to late February, during which about 400 children were hospitalized with Covid at the select hospitals participating in the study.”
“Among the children who tested positive for the virus before or during their hospitalization, three-quarters of them were admitted primarily for Covid, rather than other illnesses, the C.D.C. said.”
Case: A 4 yo developed abdominal distention and crepitus after gastrostomy tube (GT) placement. An AXR (see below) showed subcutaneous emphysema (especially in left abdomen). There was no pneumoperitoneum or extravasation of contrast with fluoroscopy. Due to persistent distention, a CT scan was obtained three days after tube placement. The CT scan confirmed appropriate intragastric location of GT and nonspecific dilatation of bowel loops without pneumoperitoneum; the dilated bowel was attributed to an ileus and improved over the next few days. Thanks to colleague for sharing information.
My take: Isolated subcutaneous emphysema is rarely identified after GT placement and requires careful evaluation to assure appropriate insertion site (1,2).
In this retrospective study, among those who developed skin reactions to anti-TNF agents, 71 (64%) continued anti-TNF and 40 (36%) switched to ustekinumab (UST). Key findings:
Switching to UST had a higher rate and odds of resolution of skin findings (29/40 (73%) vs. 24/71 (34%); p <0.0001) and combined remission (21 (52%) vs. 22 (31%); p=0.03) vs. continuing anti-TNF at 6 months
Patients (n=181) on established maintenance IV infliximab who switched to SC CT-P13 were included in this retrospective multi-centre cohort study. Key findings:
Treatment persistence rate was high (N=167, 92.3%) and only 14 patients (7.7%) stopped treatment during the follow-up period. There were low rates of immunogenicity with no change in clinical disease activity indices or biomarkers
This NIDDK-funded Hepatitis B Research Network (HBRN) was established in 2009 and enrolled 362 patients. 97% of participants were born in countries where HBV is endemic or in North America to mothers born from these countries.
Key points:
Due to revised criteria for ALT values, most pediatric patients have elevated ALT and do not meet the definition of immune-tolerant
Spontaneous flares (ALT >400 in males and >350 in females) in untreated children…did not lead to hepatic decompensation
Hepatocellular carcinoma was not identified in this cohort, though HBRN centers reported historical experiences. Only one patient developed cirrhosis over 4 years of followup.
Clinical Recommendations from Authors:
Screen for HBV in children with unexplained serum aminotransferases regardless of immunization history
Screen for HBV in children with normal aminotransferases if they or their parents are from an area where HBV is endemic or other risk factors
In those with HBV, monitor aminotransferases and HBV levels every 6 months
Obtain genotype in children with HBV
Consider treatment if ALT >2 x ULN over 3-6 mo. Treatment should follow AASLD guideline
Recommend AGAINST treatment at the start of a flare
Recommend counseling to promote healthy weight and avoidance of at-risk alcohol use
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.
This prospective study (n=80) expands on previous observations regarding the use of a transanal irrigation device for neurogenic bowel management.
Key points:
The neurogenic bowel dysfunction (NBD) score improved at both time points (<6 months, >6 months) by 14 and 13 points respectively. 94% and 98% had improved NBD score at time 1 and time 2 respectively
Patient satisfaction was high, though 8 patients discontinued device early on due to either discomfort or poor results
NBD score can used to monitor treatment effectiveness
This article describes a retrospective review of seven patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). In their cohort 4 of 6 were receiving anti-TNF therapy at the time of CRMO diagnosis. Misleading statements from this article:
The triad of IBD, CRMO and psoriasis has not been reported previously to their knowledge
“It seems unlikely that anti-TNF-alpha therapy would promote its [CRMO] development”
In JPGN Reports (not available on pubmed), Cordesse et al (JPGN Reports; November 2020 – Volume 1 – Issue 2 – p e007) identified the association of IBD, CRMO and psoriasis; in addition, they identified a paradoxical reaction to anti-TNF-alpha therapy; in this case series of three patients, anti-TNF-alpha therapy triggered CRMO and stopping anti-TNF-alpha therapy led to resolution of CRMO in two of the cases.
In a response to a letter to the editor (Hochman JA. JPGN 2022; DOI: 10.1097/MPG.0000000000003407. Faulty Information Regarding CRMO and IBD), Dushnicky et al (DOI: 10.1097/MPG.0000000000003433) note that JPGN Reports is not available on Pubmed; however, the articles that have described this association are near the top of a google search if one looks for “IBD, CRMO and Psoriasis.” Interestingly, in their response to the letter to the editor, the authors did not amend their claim that anti-TNF therapy is unlikely to promote CRMO despite being furnished with information showing that it can. In my view, the situation with CRMO is similar to psoriasis which can be treated with anti-TNF therapy and can paradoxically be caused by anti-TNF agents as well.
My take:
CRMO is important to recognize due to its association with IBD and to realize that antibiotics are not an effective treatment.
Anti-TNF-alpha agents can cause CRMO in some patients.
In 2022, a web browser search (eg Google), in addition to Pubmed, is probably worthwhile when claiming that this is the first case of xyz ‘to our knowledge.’
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