Author Archives: gutsandgrowth

Unknown's avatar

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.

NEJM: Competing Visions for U.S. Health Policy, Evolocumab for Pediatric Familial Hypercholesterolemia, and the Cervical Cancer Vaccine

Posted on by

A recent commentary (M Fiedler. NEJM 2020; 383: 1197-99. Competing Visions for the Future of Health Policy) describes two competing approaches to U.S. healthcare policy.

  • The current administration has supported legislation which would repeal or sharply curtail many of the Affordable Care Act’s (ACA’s) coverage provisions and is “asking the U.S. Supreme Court to strike down the entire ACA.”  Their approach views “existing federal coverage programs, particularly those serving lower-income people, [as] too expansive.”
  • The main alternative approach aims for expanded insurance coverage and deep subsidies to cover low- and moderate-income individuals.
  • Areas of potential agreement include encouraging competition to lower costs as well as making prices more transparent to encourage patients to seek out lower-priced alternatives.

My take: Overall, I favor more expansive health care coverage.

RD Santos et al. NEJM 2020; 383: 1317-1327. Evolocumab in Pediatric Heterozygous Familial Hypercholesterolemia

Methods: In this 24-week, randomized, double-blind, placebo-controlled trial with pediatric patients (n=157) with heterozygous familial hypercholesterolemia, patients 10 to 17 years of age were treated with evolocumab.  All had been receiving lipid-lowering treatment before screening and had LDL cholesterol level of 130 mg/dL.

Key finding: At week 24, the mean percent change from baseline in LDL cholesterol level was −44.5% in the evolocumab group and −6.2% in the placebo group.

My take: Long-term data are needed.  However, in high risk patients who have not responded to other intensive treatment, evolocumab may be worthwhile.

J Lei et al. NEJM 2020; 383: 1340-1348. HPV Vaccination and the Risk of Invasive Cervical Cancer

Methods: We used nationwide Swedish demographic and health registers to follow an open population of 1,672,983 girls and women who were 10 to 30 years of age from 2006 through 2017.

Key findings:

  • After adjustment for all covariates, the incidence rate ratio was 0.12 (95% CI, 0.00 to 0.34) among women who had been vaccinated before the age of 17 years and 0.47 (95% CI, 0.27 to 0.75) among women who had been vaccinated at the age of 17 to 30 years.

My take: HPV vaccine (aka ‘Cervical Cancer Vaccine’) may lower the risk of cancer by 88% in those vaccinated before the age of 17 years.

From The Onion

Should We Be Worried About Phthalates?

Posted on by

Short answer -you should always be worried about words that are so difficult to spell.

Two years ago, this blog highlighted recommendations from the AAP regarding food additives (Food Additives and Child Health).

More information of phthalates is available from the Cincinnati Children’s website: Phthalates and Your Health. The backdrop to this article is in relation to a recently published study Pubertal Growth, IGF-1, and Windows of Susceptibility: Puberty and Future Breast Cancer Risk (F Biro et al. Journal of Adolescent Health 2020).

Key points from Cincinnati Children’s website:

  • Phthalates have been used for many years to make plastics softer and more flexible. These plastics are so common that more than 95 percent of all people have detectible levels of phthalates in their urine. They can be found in everything from perfumes and shampoos to food packaging, detergents, vinyl flooring and shower-curtains.
  • These chemicals act like hormones, which in turn can disrupt the function of natural hormones, which can increase diabetes risk and interfere with male genital development.
  • These chemicals also are considered “obesogens,” which means they contribute to the risk of obesity. For these reasons, several types of phthalates have been banned from use in baby toys and teething rings since 2009, but they can still be found in many consumer products.
  • To avoid exposures, some tips include the following:
    • Minimize plastics used for food storage and avoid heating food in plastic. Use glass, ceramic and stainless steel containers when possible.
    • Minimize use of other plastic products with the recycling code numbers 3 and 7. Those coded 1, 2 or 5 are phthalate-free.
  • Increase consumption of fruits and vegetables, foods more frequently that are known to contain “phytoestrogens”.
  • The National Institute of Environmental Sciences offers this document: “Phthalates: the everywhere chemical.”

My take: Environmental research is quite difficult.  Yet, we know that changes in our environmental exposures are directly related to many adverse health outcomes since changes in disease frequencies related to genetics is a much slower process.

Outcomes Associated with Delayed Diagnosis in Pediatric Crohn’s Disease

Posted on by

A Ricciuto et al. Journal of Crohn’s and Colitis; 2020. jjaa197, https://doi.org/10.1093/ecco-jcc/jjaa197 Link: Diagnostic Delay Is Associated with Complicated Disease and Growth Impairment in Paediatric Crohn’s Disease

Methods: “We conducted a national, prospective multi-centre IBD inception cohort study, including 1399 children. Diagnostic delay was defined as time from symptom onset to diagnosis >75 th percentile.”

Key findings:

  • In CD, diagnostic delay was associated with a 2.5-times higher rate of strictures/internal fistulae (HR 2.53, 95% CI 1.41-4.56)
  • Every additional month of diagnostic delay was associated with a decrease in height-for-age z-score of 0.13 standard deviations
  • Diagnostic delay was more common in CD, particularly small bowel CD

My take: Delays in diagnosis in this study were associated with stricturing/internal fistulising complications and growth impairment in paediatric CD.  It is likely that inadequate treatment would increase the risk of these problems as well.

Related blog posts:

Insight Into Alpha-1 Antitrypsin Heterozygosity

Posted on by

CV Schneider, K Hamesch et al. Gastroenterol 2020; 159: 534-548. Liver Phenotypes of European Adults Heterozygous or Homozygous for Pi∗Z Variant of AAT (Pi∗MZ vs Pi∗ZZ genotype) and Noncarriers)

Key findings:

  • Ten percent of subjects with the Pi∗MZ genotype vs 4% of noncarriers had LSMs (liver stiffness measurements) of 7.1 kPa or more (adjusted odds ratio, 4.8; 95% confidence interval, 2.0–11.8)
  • Obesity and diabetes were the most important factors associated with LSMs ≥7.1 kPa in subjects with the Pi∗MZ genotype.
  • AAT inclusions were detected in liver biopsies of 63% of subjects with the Pi∗MZ genotype, vs 97% of subjects with the Pi∗ZZ genotype, and increased with liver fibrosis stages.

The associated editorial (pg 433-34) noted that Pi∗MZ genotype is a disease modifier in cystic fibrosis, alcoholic liver disease, and nonalcoholic liver disease.

My take: This study indicates that Pi∗MZ genotype for alpha-one antitrypsin are more likely to develop liver fibrosis in the presence of other risk factors like obesity and diabetes mellitus.

Related blog posts:

IBD Briefs -October 2020

Posted on by

EV Loftus et al.  AP&T  2020; 52: 1343-1365. Full text: Long‐term safety of vedolizumab for inflammatory bowel disease

GEMINI long‐term safety (LTS) study results –initiated 2009:

  • Enrolled patients (UC, n = 894; CD, n = 1349) received vedolizumab 300 mg IV every 4 weeks. Total of 7999 patient years of vedolizumab exposure.
  • Vedolizumab discontinuation due to AEs occurred in 15% (UC) and 17% (CD) of patients.
  • There were no new trends for infections, malignancies, infusion‐related reactions, or hepatic events, and no cases of progressive multifocal leukoencephalopathy
  • Conclusion from authors: “The safety profile of vedolizumab remains favourable with no unexpected or new safety concerns.”

Related blog posts:

AS Faye et al. Inflamm Bowel Dis 2020; 26: 1368-1376. Fertility Impact of Initial Operation Type for Female Ulcerative Colitis Patients (link includes video abstract)

Surgical options include Ileal pouch–anal anastomosis (IPAA), rectal-sparing colectomy with end ileostomy (RCEI), and ileorectal anastomosis (IRA). Conclusions based on “a patient-level state transition microsimulation in TreeAge Pro:”… “Despite an increased risk of infertility, our model results suggest that IPAA may be the optimal surgical strategy for female UC patients aged 20–30 years who desire children. For patients aged 35 years, RCEI should additionally be considered, as QALYs for RCEI and IPAA were similar.”   In older age group, RCEI’s increase rate of childbirth (28%), decrease time to childbirth (14 months) and 77% reduction in IVF are important factors.

Related blog posts:

R Tariq et al. Inflamm Bowel Dis 2020; 26: 1415-1422. Efficacy of Fecal Microbiota Transplantation for Recurrent C. Difficile Infection in Inflammatory Bowel Disease

In this retrospective study with 145 patients,  the overall cure rate of CDI after FMT was 80.0%, without CDI recurrence at median follow-up of 9.3 (range, 0.1–51) months. The authors concluded that “fecal microbiota transplantation effectively treats recurrent CDI in IBD patients but has no apparent beneficial effect on the IBD course.”

Related blog posts:

Isle of Palms (July 2020)

 

What’s Missing In Pediatric IBD Care

Posted on by

A recent single-site cross-sectional survey (HK Michel et al. J Pediatr 2020; 224: 94-101. Gaps Exist in the Comprehensive Care of Children with Inflammatory Bowel Diseases) of parents (n=161) and adolescents(n=84)  identified gaps in the comprehensive care of pediatric patients with inflammatory bowel disease (IBD).

Key points:

  • Discussions about family/peer relationships, school/extracurricular activities, and mood were not addressed in 30%-40% of participants.
  • Adolescents frequently reported that no one had talked to them about substance use (40%), sexual health (50%), or body image (60%)
  • 75% of adolescents and 76% of their parents reported that no one had discussed transitioning to an adult provider.

There is likely a wide variability in addressing psychosocial issues among providers and centers.  Limitations for this type of study includes recall bias and selection bias.

The associated editorial (MJ Ladinsky, MB Cohen, pg 20-22) urge us to ‘Mind the Gap.’  This likely means allowing sufficient time and arranging opportunities for teens to speak directly (& alone) with care provider.  Like other aspects of care, establishing a standardized approach is likely to be helpful.

My take: As noted on this blog previously, emotional health issues are likely more important than other aspects of IBD care that attract more consistent attention (eg. vaccination); the message is clear that these needs need to be addressed.

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

Why We Are Not Making Progress with Probiotics

Posted on by

A recent commentary A Khoruts et al. Gastroenterol 2020; 159: 409-413. Full text: Probiotics: Promise, Evidence, and Hope

Despite the fact that the probiotic industry has ample money which is projected to reach $70 billion yearly, there is very little high quality research.

Key points:

  • Probiotics are regulated by the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC). The FDA, unlike the FTC, regulates products by category (eg, foods, drugs, dietary supplements, medical devices, and cosmetics)…Foods and dietary supplements, unlike drugs, do not require FDA premarket approval. By law, probiotic foods and dietary supplements must be safe. However, food manufacturers are permitted to make a self-determination of whether their product meets the “generally recognized as safe” (GRAS) designation, typically based on history of prior use”
  • Probiotic food and dietary supplement manufacturers do not have to specify on their product labels the strains they use in probiotic products or specify the number of live microbes of each strain that the product delivers through the end of its shelf life; and, although they are required to have validation of label claims, they are not required to submit it to the FDA
  • Dietary supplements can make structure/function claims, even though they cannot claim to treat any specific disease. These claims can sound very promising and consumers may be hard pressed to distinguish between a statement that a product “improves digestion,” a structure/function claim that is so vague that it is literally untestable
  • Rational selection of donor microbiota should be possible based on microbiome-based diagnostics, as well as in vitro technologies that interrogate the functional potential of complex microbial communities. There are parallel, intensive efforts to develop defined microbial communities. A common theme among these different approaches is deployment of complex assemblages of microorganisms rather than single strains. Such complex consortia are likely to have more consistent and predictable effects.
  • The emergence of microbial therapeutics requires development of a new branch of pharmacology. The challenges of formulation, pharmacokinetics, and pharmacodynamics are very distinct from those of small molecule therapeutics or protein biologics.

My take: “These next-generation probiotics will need to be tested for safety and efficacy in well-designed and properly powered clinical trials.”  Probably the only way that will happen is to empower regulatory agencies to insist that these products are treated like medications.  Given the fact that probiotics are so profitable now with little evidence of efficacy for most strains, I am not optimistic about any changes in the near future.

Related blog posts:

Best Screening For Celiac At All Ages

Posted on by

Another study (MR Khan et al. J Pediatr 2020; 224: 158-61. The Utility of IgA-Based Serologic Markers in Diagnosing Celiac Disease in Children 24 Months of Age or Younger) shows that tissue transglutaminase (TTG) IgA is the best first test, even in children less than 2 years of age.

This was a multicenter retrospective study with 150 children, mean age was 18 months.

Key findings:

  • ~98% of children <2 years of age with celiac disease had an elevated TTG IgA
  • “These findings are consistent with recently published European guidelines, which endorse TTG IgA…as the initial screening test regardless of age.”
  • IgG-based test should be reserved for IgA-deficient children, which was noted in 5.5% of this cohort.
  • Endomysial antibody (EMA) had excellent specificity in this study but was less sensitive; it was negative in 13 of 66 (19.7%) of children with celiac disease (positive in 80%).

My take: TTG IgA is a good first step; based on clinical presentation, further testing (eg. endoscopy) could be warranted in highly-selected cases with negative results.

Related blog posts:

Leading Medical Journals Condemn U.S. Pandemic Response

Posted on by

Multiple prestigious journals have weighed in on the U.S. pandemic response.

 

From Science Editor-in-Chief
From Nature
Also, from Nature

From The Lancet:

“If logic and justice prevail in the next presidential
administration, universal health coverage, a fairer society,
stronger health institutions, more energetic global
engagement, and a robust research agenda will be the
foundations for America’s renewal. We all have a stake in
America’s success.”

Transanal Irrigation Device -Pediatric Experience

Posted on by

A recent retrospective study (S Patel et al. JPGN 2020; 71: 292-297. Impact of Transanal Irrigation Device in the Management of Children With Fecal Incontinence and Constipation) provides some useful experience in the management of constipation related to bowel dysfunction (n=147), including patients with neurogenic bowel dysfunction (NBD) related to spinal cord defects (NBD, n=85), refractory constipation (RC, n=43), or anorectal malformations (ARMs, n=19).

The authors elaborate on their protocol which includes flushing with warm tap water (on average) 15 mL/kg, generally once a day.  They note that the device is contraindicated in patients <2 years of age and/or within 3 months of anal/colorectal surgery.  The Peristeen device has been FDA approved since 2012.

Key findings:

  • For all patient groups, there was significant improvement in symptoms of fecal incontinence and constipation (P ≤ 0.001).
  • Abdominal pain was improved in the NBD and RC group, but not significantly in the ARM group.

My take: As with other treatment options for these problems, the key to success is adequate upfront training.  The authors note that their training sessions typically last 1-2 hours. A limiting factor with this treatment can be cost.

Useful link: Peristeen Bowel Management

Related blog entries:

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