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.

A Definite Maybe: Antibiotics for Acute Severe Colitis

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D Turner et al. Inflamm Bowel Dis 2020; 26: 1733-1742. Antibiotic Cocktail for Pediatric Acute Severe Colitis and the Microbiome: The PRASCO Randomized Controlled Trial

This randomized study with 28 children with acute severe ulcerative colitis (ASUC) (PUCAI > /= 65) tried to determine if antibiotics with IV corticosteroids resulted in improved outcomes compared to IV corticosteroids alone. Most in the antibiotic group received the following for 3 weeks:

  • Vancomycin 250 mg 4/day (if less than 8 years, then 125 mg 4/day)
  • Amoxicillin 50 mg/kg/day divided into 3/day dosing (max 500 mg/dose)
  • Metronidazole 5 mg/kg/dose 3/day (max 250 mg/dose)
  • Doxycycline 2 mg/kg/dose 2/day (children less than 7 years rec’d ciprofloxacin 10 mg/kg 2/day -max 250 mg/dose)

Key findings:

  • The mean day-5 PUCAI was 25 ± 16.7 in the abx/steroid combination group vs 40.4 ± 20.4 in the steroid monotherapy group (P = 0.037)
  • Median calprotectin values were lower in the abx combination group at day 5 (1202 vs. 2170, P=0.24) and at discharge (1210 vs 1840, P=0.695)
  • The need for 2nd line rescue therapy was low in both groups: 19% in abx group and 17% in the steroid group
  • Within 1 year, 3/16 (19%) in the abx combination group had had a colectomy compared with 2/12 (17%) in the steroid monotherapy.
  • The authors found no correlation between microbial features/microbiome at admissioin and clinical response 5 days later

In their discussion, the authors note that if antibiotics had a treatment benefit as high as 30% in avoiding second-line treatment (ie, 14% in intervention arm), “randomization of 1228 children would be required to show such a difference with a power of 80%.”

My take: I agree with the authors who state that “antibiotics cannot be routinely recommended until larger studies demonstrate a reduced need for second-line treatment or colectomy.”

Related blog posts:

Ravenel Bridge, Charleston, SC

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

How Helpful Are School-Based BMI Measurements?

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KA Madsen et al. JAMA Pediatr. Published online November 16, 2020. doi:10.1001/jamapediatrics.2020.4768.Full text link: Effect of School-Based Body Mass Index Reporting in California Public Schools

Methods:  Cluster randomized clinical trial. The Fit Study (2014-2017) randomized 79 California schools (n=28 641 students) to BMI screening and reporting (group 1), BMI screening only (group 2), or control (no BMI screening or reporting [group 3]) in grades 3 to 8. The setting was California elementary and middle school

Key findings:

  • Among 6534 of 16 622 students with a baseline BMI in the 85th percentile or higher (39.3%), BMI reporting had no effect on BMI z score change (−0.003; 95% CI, −0.02 to 0.01 at 1 year and 0.01; 95% CI, −0.02 to 0.03 at 2 years)
  • Weight dissatisfaction increased more among students having BMI screened at school (8694 students in groups 1 and 2) than among control participants (5674 students in group 3).

My take: Tackling obesity will require a lot more than measuring BMIs. An interesting follow-up study would be to see if schools who reported BMIs were more likely to take other measures, such as providing nutritional counseling, improving school lunch selection, and providing opportunity for more activity/exercise.

Related blog posts:

Help Wanted in Hepatology

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MW Russo et al. Hepatology 2020; 72: 1444-1454. Modeling the Hepatology Workforce in the United States: A Predicted Critical Shortage

Overall, this article details the estimated shortage of hepatologists in the coming years.

Key points:

  • One of the more interesting suggestions in this article is the need to change the name of specialty training from “transplant hepatology” to “advanced hepatology” to more accurately reflect the type of liver conditions managed by hepatologists.
  •  In 2018, the adult and pediatric workforce included 7,296 and 824 hepatology providers, respectively, composed of hepatologists, gastroenterologists, and advanced practice providers whose practice was ≥50% hepatology
  • The modeling analysis projects that in 2023, 2028, and 2033, there will be shortages of 10%, 23%, and 35% adult hepatology providers, respectively, and 19%, 20%, and 16% pediatric hepatology providers, respectively

The authors note that there are many challenges when predicting workforce needs. The main reasons for the predicted shortfall with hepatology include the following:

  • Older age of current clinicians
  • Increasing amount of liver disease (~34% increase from 2018 to 2033), particularly fatty liver disease. This is happening among adults and children.

Related blog post: Sad Truth: Job Security in Hepatology

From The Onion

What about Combination Therapy with Adalimumab?

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M Matar et al. Inflamm Bowel Dis 2020; 26: 1627-1635. Free full text link: Combination Therapy of Adalimumab With an Immunomodulator Is Not More Effective Than Adalimumab Monotherapy in Children With Crohn’s Disease: A Post Hoc Analysis of the PAILOT Randomized Controlled Trial

Methods: Participants (n=78, ages 6-17 years) in this study were part of the PAILOT trial; they were naïve to biologic therapy with moderate to severe Crohn’s disease. This was a randomized controlled trial aimed to evaluate proactive vs reactive therapeutic drug monitoring in children with Crohn’s disease (CD) treated with adalimumab. 

Key findings:

  • There was no significant difference in the rates of sustained corticosteroid-free clinical remission (25/34, 73%, vs 28/44, 63%; P = 0.35) or sustained composite outcome of clinical remission, C-reactive protein ≤0.5 mg/dL, and calprotectin ≤150 µg/g (10/34, 29%, vs 14/44, 32%; P = 0.77) between the combination group and the monotherapy group, respectively.
  • Adalimumab trough concentrations and immunogenicity were not significantly different between groups. The rate of serious adverse events was not significantly different between groups but was numerically higher in the monotherapy group. The monotherapy group had three patients undergo ileo-cecal resection.

The discussion reviews a number of studies that have compared combination and monotherapy. One key point is that this study enrolled children who were naïve to biologic therapy; thus, combination therapy may be more useful in those who have failed a previous biologic, particularly if the loss of response was immune-mediated.

My take: This study indicates that combination therapy is likely not routinely needed in children who start adalimumab and who are naïve to biologic therapy. Another finding of interest is the relatively low sustained composite outcome of clinical remission, approximately 30; this outcome combined clinical remission with biological markers. ~30%

Pitt Street Bridge Park, Mt Pleasant SC

Get Ready for 2021 Coding Changes (Part 2)

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Earlier in the year, I summarized the upcoming changes for 2021: Link Get Ready for 2021 Coding Changes (with links to AMA resources and tables). Subsequently, I went to a coding seminar led by Jan Rasmusen and wanted to share some additional observations.

  1. One of the most important changes is the need for “medically appropriate history and/or examination” rather than focusing on specific elements. This helps eliminate scoring the history and physical exam and should allow more time to document critical thinking. Besides billing, H&P is still key for helping with continuity of care and for liability.

2. When using time codes and not using medical decision-making, the total time –face-to-face and non face-to-face –is what is used. Total time does not include clinical staff time.

3. A lot of the terms have more specific definitions

4. Medical Decision-Making is Similar to Current Guidelines

5. Creation of a new code for additional time

My take: The intent of these changes is logical.  The goal of coding is to align the reimbursement with the degree of effort and not simply allow pre-formatted templates to justify upcoding.  These changes could lead to simplification of documentation and allow more documentation time for medical decision-making part of the visit.

Resources:

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

Liver Shorts -November 2020 and Georgia’s ACA Waiver

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E Zuckerman et al. Clin Gastroenterol Hepatol 2020; 18: 2544-53. Full text link: Eight Weeks of Treatment With Glecaprevir/Pibrentasvir Is Safe and Efficacious in an Integrated Analysis of Treatment-Naïve Patients With Hepatitis C Virus Infection

  • “We pooled data from 8 phase 2 or phase 3 trials of treatment-naïve patients with HCV genotype 1 to 6 infections, without cirrhosis or with compensated cirrhosis, who received 8 weeks of glecaprevir/pibrentasvir.” (n=1248) Key finding:  Overall rates of sustained virologic response at post-treatment week 12 were 97.6% (1218 of 1248) in the intention to treat (ITT) and 99.3% (1218 of 1226) in the modified ITT populations.

JA Silverman et al. JPGN 2020; 71: 283-287. Composite Lipid Emulsion for the Infant at Risk of Intestinal Failure–associated Liver Disease: The Canadian Perspective

This review discussed the use of SMOFlipid that includes soybean, medium-chain triglycerides, olive and fish oils. Key points:

  • “Lipid minimization strategies have also been shown to reverse IFALD [intestinal failure associated liver disease]. There are, however, considerable concerns regarding adequate weight gain, compromise to neurodevelopment, and EFAD [essential fatty acid deficiency]”
  • “Thee is actually considerable safety data for CLE [composite lipid emulsion] in neonates, albeit over the short term.”
  • “In Canada, CLE is currently the lipid emulsion of choice for all infants at risk of IFLAD.”

T Mitchell et al. Clin Gastroenterol Hepatol 2020; 18: 1584-1591. Decreased Physical Working Capacity in Adolescents With Nonalcoholic Fatty Liver Disease Associates With Reduced Iron Availability

  • Methods: “We collected information on weight-adjusted, submaximal physical work capacity (PWC), ultrasound-determined hepatic steatosis, iron indices, and hematologic and metabolic parameters from 390 female and 458 male participants of the Raine Study—a longitudinal study of disease development … in Western Australia”
  • Key finding: “Fourteen percent of the cohort had NAFLD. PWC was significantly reduced in adolescents with NAFLD compared to adolescents without NAFLD (reduction of 0.17 W/kg, P = .0003, adjusted for sex and body mass index [BMI])… we found NAFLD to be associated with decreased cardiorespiratory fitness, independent of BMI. The relationship between transferrin saturation and PWC in adolescents with NAFLD indicates that functional iron deficiency might contribute to reductions in cardiorespiratory fitness.”

In other news, Georgia has received approval for an affordable care act waiver. From the AJC (October 15, 2020): Kemp’s health care waivers win federal approval Two key points:

  • “Thousands of Georgia’s poor and uninsured adults who meet a work or activity requirement will soon be eligible for Medicaid, with perhaps 50,000 added to the rolls within two years…And more than 350,000 very poor, uninsured Georgia adults still won’t meet Georgia’s requirements for Medicaid”
  • “At the same time, the 400,000 Georgians who bought individual health insurance plans on the federal healthcare.gov Affordable Care Act shopping website will find they can’t do that anymore. Instead they will be directed to contact information for private brokers or insurance companies”
These tweets were posted on 11/2/20.

Intracranial Hypertension & Papilledema with Alagille Syndrome

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NM Rock et al. JPGN 2020; 71: 655-662. Intracranial Hypertension and Papilledema in a Large Cohort of Pediatric Patients With Alagille Syndrome

Key findings:

  • In this retrospective cohort of 69 patients, Nine (13.0%) had papilledema and Five (7.2%) had confirmed or probable intracranial hypertension. All five had undergone liver transplantation.
  • Age (in months) when intracranial hypertension was diagnosed: 35, 43, 55, 62, and 103.

Discussion Points:

  • “Cerbrovascular abnormalities, including moyamoya disease, are increasingly describe in patients with” Alagille syndrome.
  • “Opthalmic complications in relation with papilledema seem to appear mostly after” liver transplantation. This could indicate that LT/immunosuppression exaccerbate underlying disorder, that those who need LT have more severe phenotype or could be related to closer scrutiny (‘follow-up bias”).
  • First line treatment for intracranial hypertension in this group is generally acetazolamide.

My take: I agree with the authors who propose regular eye exams for patients with Alagille syndrome, especially if needing liver transplantation. Further evaluation is recommended for patients who have greater than mild papilledema. This includes MRI and lumbar opening pressure.

Related blog posts:

Sunrise -Isle of Palms

Potential Efficacy of Ondansetron for Irritable Bowel -More Studies Needed

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A recent correspondence letter (CJ Black, AC Ford. AJG 2020; doi: 10.14309/ajg.0000000000000932. Full text: Efficacy of Ondansetron for Irritable Bowel Syndrome With Diarrhea) shows that ondansetron could be an effective option for irritable bowel syndrome with diarrhea. Thanks to Ben Gold for this reference.

Kansas’ Mask Mandates for COVID-19

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Link to full report:  Van Dyke ME, Rogers TM, Pevzner E, et al. Trends in County-Level COVID-19 Incidence in Counties With and Without a Mask Mandate — Kansas, June 1–August 23, 2020. MMWR Morb Mortal Wkly Rep. ePub: 20 November 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6947e2.

“Kansas counties that had mask mandates in place appear to have mitigated the transmission of COVID-19, whereas counties that did not have mask mandates continued to experience increases in cases.”