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 recent study (BN Limketkai et al. Clin Gastroenterol Hepatol 2020; 18: 1769-76. Levels of Vitamin D Are Low After Crohn’s Disease Is Established But Not Before) takes advantage of stored serum from U.S. military personnel.
Key finding: By examining 240 with Crohn’s disease (CD) along with 240 control patients, the authors show that vitamin D levels prior to CD diagnosis are not associated with the development of CD up to 8 years preceding the diagnosis.
Two other articles on predictive biomarkers for CD and an associated editorial:
- N Nair et al. Gastroenterol 2020; 159: 383-5. Association Between Early-life Exposures and Inflammatory Bowel Diseases, Based on Analyses of Deciduous Teeth
- J Torres, F Petralia et al. Gastroenterol 2020; 159: 96-104. Serum Biomarkers Identify Patients Who Will Develop Inflammatory Bowel Diseases Up to 5 Years Before Diagnosis
- New Biomarkers for Crohn’s Disease (editorial) C Bernstein. Gastroenterol 2020; 159: 30-32. Key points from editorial:
- “In the article by Nair et al, the authors relate the presence of heavy metals in baby teeth to the later development of Crohn’s disease…The finding of metals that can be tracked to the in utero state suggests that the offspring who will ultimately present with IBD and have high values of these metals are likely acquiring these metals from their mothers.”
- “In the study by Torres et al, a serum bank of Department of Defense recruits was accessed to study for microbial antibodies and immune-inflammatory markers for ≤5 years antedating diagnoses of either Crohn’s disease or ulcerative colitis. Anti-Flagellin X and ASCA-IgA were predictive of Crohn’s disease…The authors have convincingly showed that these microbial antibodies and immune-inflammatory mediators are present years before the first clinical manifestation of Crohn’s disease. These phenomena very likely are early biological manifestations of Crohn’s disease. They may not be risk factors that Crohn’s disease is coming, but rather that it is already present.”
My take: Stored tissue/blood eventually may help predict who will develop CD. Given a lack of current treatment options in those at risk, the importance of these predictive markers is unclear.
Briefly noted: E Liu et al. JPGN 2020; 71: 252-6. Routine Screening for Celiac Disease in Children With Down Syndrome Improves Case Finding
- Retrospective chart single center review of children with Down syndrome (2011 to 2017).
- Prevalence of celiac disease in our population of children with Down syndrome ages 3 years or older was 9.8%.
- 90 with celiac disease diagnosis:
- 58 biopsy-confirmed
- 17 with diagnosis via serology threshold in accordance with ESPGHAN
- 9 diagnosis at outside center
- 6 with serology but not meeting definitive criteria
- 82% were identified through screening rather than clinical symptoms
My take: To identify celiac disease in children with Down syndrome, routine screening is needed.
Pictures from Sullivan’s Island, SC -This first picture looks out on Charleston Harbor and Ft Sumter is in the distance
Briefly noted:
Safety of Thiopurine Use in Paediatric Gastrointestinal Disease. E Miele et al. JPGN 2020; 71: 156-62. Useful review of thiopurines for IBD and for autoimmune hepatitis
The Effect of Adalimumab Treatment on Linear Growth in Children With Crohn Disease: A Post-hoc Analysis of the PAILOT Randomized Control Trial. M Matar et al. JPGN 2020; 71: 237-42. This study showed that 66 (of 78) who completed 72 weeks of treatment had improved (but not normalized) linear growth (height z-score at baseline improved from -0.62 to -0.33 (P=0.005) and normalization of weight and BMI. The presence of perianal disease was associated with diminished growth velocity. Overall, this study adds to the literature that anti-TNF agents can reverse growth failure associated with Crohn’s disease.
Full text: Deep Remission at 1 Year Prevents Progression of Early Crohn’s Disease RC Ungaro et al. Gastroenterol 2020; DOI: https://doi.org/10.1053/j.gastro.2020.03.039 Key finding: When we adjusted for potential confounders, deep remission (adjusted hazard ratio, 0.19; 95% confidence interval, 0.07–0.31) was significantly associated with a lower risk of major adverse outcome. This study is reinforced by recent data published at DDW 2020 -Abstract 401: N Plevris et al. “Early Mucosal Healing Key to Long-Term Success.” This was highlighted by Miguel Regueiro in Gastroendonews.com. Among 375 patients, those who achieved a fecal calprotectin (FC) <250 mcg/g within one year of diagnosis, the disease progression was 65% slower than those with FC values that did not normalize within a year. Initiation of a biologic within 3 months of diagnosis, more than quadrupled the likelihood of FC normalization within one year.
Two recent well-controlled studies (D Schnadower et al.N Engl J Med 2018; 379:2002-2014, SB Freedman et al. N Engl J Med 2018; 379:2015-2026) showed that probiotic-treated children with acute gastroenteritis (AGE) did not have better outcomes than placebo-treated children. In addition, a recent AGA practice guideline recommended against the use of probiotics for most GI conditions, including in AGE.
However, a new report (H Szajewska et al. JPGN 2020; 71; 261-69) from an ESPGHAN working group recommends that probiotics should have a role for AGE. Several points about this report:
- Their recommendations are very qualified: “weak recommendation” with “low to very low certainty of evidence” for the following in descending order: S boulardiii, L rhamnosis GG, L reuteri DSM 17938, and L rhamnosus 19070 & L reuteri DSM 12246
- It is noted that this report has a disclaimer from ESPGHAN: “it does not represent ESPGHAN policy and is not endorsed by ESPGHAN”
- The authors have extensive disclosures
- The report notes that “despite large number of identified trials, we could not identify 2 randomized controlled trials of high quality for any strain that provided benefit when used for treating acute gastroenteritis”
Of note, the associated editorial (pg 146-47) also favors probiotics in the setting of AGE. “These recommendations…have clarified that there is a role for probiotics in treating” AGE.
Related article (just published): F Mourney et al. The Pediatric Infectious Disease Journal: August 7, 2020 – Volume Online First – Issue –doi: 10.1097/INF.0000000000002849 A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Saccharomyces boulardii in Infants and Children With Acute Diarrhea (n=100) Key findings: The time of recovery from diarrhea was significantly shorter in the probiotic group compared with the placebo group (65.8 ± 12 hours vs. 95.3 ± 17.6 hours, P = 0.0001).
My take: Overall, probiotic effectiveness is overstated; though, some strains may be helpful for AGE. Still, there are concerns about variation in production and quality standards even in these strains.
Related blog posts:
NR Jones et al. BMJ 2020;370:m3223. Full Text: Two metres or one: what is the evidence for physical distancing in covid-19?
Key messages from article:
- Current rules on safe physical distancing are based on outdated science
- Distribution of viral particles is affected by numerous factors, including air flow
- Evidence suggests SARS-CoV-2 may travel more than 2 m through activities such as coughing and shouting
- Rules on distancing should reflect the multiple factors that affect risk, including ventilation, occupancy, and exposure time
Highlighted article from Eric Topol’s Twitter Feed
A more nuanced approach is recommended by authors -color-coded Figure 3 above –caption: “Risk of SARS-CoV-2 transmission from asymptomatic people in different settings and for different occupation times, venting, and crowding levels (ignoring variation in susceptibility and viral shedding rates). Face covering refers to those for the general population and not high grade respirators. The grades are indicative of qualitative relative risk and do not represent a quantitative measure. Other factors not presented in these tables may also need to be taken into account when considering transmission risk, including viral load of an infected person and people’s susceptibility to infection. Coughing or sneezing, even if these are due to irritation or allergies while asymptomatic, would exacerbate risk of exposure across an indoor space, regardless of ventilation.”
A recent retrospective study (DS Fishman et al. JPGN 2020; 71: 203-207) identified 25 patients who underwent combined Laparascopic cholecystectomy/ERCP in Same Session (=LESS) to more conventional ERCP followed by laparoscopic cholecystectomy (n=42). The center utilized prospectively-collected data from 13 centers and 67 consecutive ERCPs.
Key findings:
- Median hospital stay was shorter for LESS patients, 3 days vs. 4 days (P=.32)
- Total procedure time was similar, though a decrease in total anesthesia time was reported for LESS patients: mean 177 minutes compared to 205 minutes (P=.04)
- No significant adverse events were reported in either group, though both groups had two patients who required repeat care due to suspected retained stones
- The authors note that concerns about gaseous distention following ERCP “is likely unfounded as all cholecystectomies were completed.”
- No local or systemic infections were reported. The authors recommend antibiotic prophylaxis with the LESS approach
My take: Given the recommendation that cholecystectomy should take place during the same hospitalization for patients with choledocholithiasis, this combined approach makes a lot sense and is supported by this study.
Related posts:
Isle of Palms, SC
Media reports that a Hong Kong man was reinfected with SARS-CoV-2. The study reported different strains between the two infections. With the 2nd infection, the patient remained asymptomatic, indicating that prior infection likely prepared adequate immune response.
V Cardenas et al. JPGN 2020; 71: 197-202. Incidence and Sequelae of Liver Injury Among Children Treated for Solid Tumors: Analysis of a Large Single-Center Prospective Cohort
- Of 1136 solid tumor patients, 160 (14%) experienced liver injury, and the overall frequency of DILI was 4%.
- DILI was the leading identified cause of liver injury (31%), followed by infection (17%), metastatic/malignant biliary disease (13%), and perioperative liver injury (13%).
- Most DILI cases (>90%) were mild acute hepatocellular injury episodes that did not result in modification to the chemotherapy plan, and all DILI eventually resolved.
N Kapila et al. Hepatology 2020; 72: 32-41. Full Text Link: Hepatitis C Virus NAT‐Positive Solid Organ Allografts Transplanted Into Hepatitis C Virus–Negative Recipients: A Real‐World Experience
Background: As of April 1, 2019, an estimated 103,000 kidney, 13,500 liver, and 3,800 heart transplant (HT) candidates are awaiting transplantation
Key findings:
- Seventy‐seven patients who were HCV negative underwent solid organ transplantation from a donor who was HCV viremic. Only one has been a HCV-treatment nonresponder (though several have not completed SVR12).
- “Our study is the largest to describe a real‐world experience of the transplantation of HCV‐viremic organs into recipients who are aviremic. In carefully selected patients, the use of HCV‐viremic grafts in the DAA era appears to be efficacious and well tolerated.”
M Martinello et al. Hepatology 2020; 72: 7-18. Short‐Duration Pan‐Genotypic Therapy With Glecaprevir/Pibrentasvir for 6 Weeks Among People With Recent Hepatitis C Viral Infection
- This was an open‐label, single‐arm, multicenter, international pilot study; adults with recent HCV (duration of infection < 12 months) received glecaprevir/pibrentasvir 300/120 mg daily for 6 weeks.
- At baseline, median estimated duration of infection was 29 weeks (range 13, 52) and median HCV RNA was 6.2 log10 IU/mL (range 0.9, 7.7). SVR12 in the intention‐to‐treat and per‐protocol populations was achieved in 90% (27/30) and 96% (27/28), respectively.
H Verkade et al. JPGN 2020; 71: 176-83. Systematic Review and Meta-analysis: Partial External Biliary Diversion in Progressive Familial Intrahepatic Cholestasis
- With regard to pruritus improvement, 104/155 (67%) were responders, 14/155 (9%) had partial response, and 37/155 (24%) were nonresponders.
K Patel et al. Hepatology 2020; 72: 58-71. Cilofexor, a Nonsteroidal FXR Agonist, in Patients With Noncirrhotic NASH: A Phase 2 Randomized Controlled Trial
- “Cilofexor for 24 weeks was well‐tolerated and provided significant reductions in hepatic steatosis, liver biochemistry, and serum bile acids in patients with NASH.”
A recent retrospective study (PE van Beek et al. J Pediatr 2020; 223: 57-63. Increase in Brain Volumes after Implementation of a Nutrition Regimen in Infants Born Extremely Preterm) with 178 infants (median gestational age 26.6 weeks) found that a modification in the nutritional regimen resulted in improved brain volumes.
Key findings:
- In cohort B (new regimen), mean protein and caloric intake were 3.4 g/kg/d & 109 kcal/kg/day which were significantly increased compared to Cohort A: 2.7 g/kg/d and 104 kcal/kg/d for first 28 days of life.
- At 30 weeks gestational age, 22 brain regions were significantly large in cohort B compared with cohort A, though at term age equivalence, only the caudate nucleus remained significantly larger.
- key limitation: brain MRI can only be performed in relatively stable neonates; thus, sicker infants may be underrepresented.
My view: Optimizing nutrition as early as possible is likely to help improve cognitive outcomes.
Related blog posts:
Other nutrition-related articles in this issue:
DL Harris et al. J Pediatr 2020; 223: 34-41. Glucose Profiles in Healthy Term Infants in the First 5 Days: The Glucose in Well Babies (GLOW) Study
- In term infants, plasma glucose concentrations of 47 mg/dL (2.6 mmol/L) approximated the 10th percentile in the first 48 hours, and 39% of infants had ≥1 episode below this threshold.
- The mean glucose concentrations increased over the first 18 hours, remained stable to 48 hours (59 ± 11 mg/dL; 3.3 ± 0.6 mmol/L)] before increasing to a new plateau by the fourth day (89 ± 13 mg/dL; 4.6 ± 0.7 mmol/L).
WG Sharp et al. J Pediatr 2020; 223: 73-80. Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review Congratulations to my colleagues at the Marcus Center for this work, particularly Valerie Volkert who has worked with so many of our kids and Barbara McElhanon who has been so helpful. 83 patients with complex medical-behavioral-developmental problems met study criteria. Key finding: 58 patients (72%) weaned from tube feeding at follow-up.
From Pitt Street Bridge Park, Mount Pleasant, SC
A recent review (T Qazi, M Regueiro. Practical Gastroenterology 2020: June Issue, 10-18. Full PDF Link: Crohn’s Disease Complicated by an Intra-abdominal Abscess: Poke, Prod, or Cut?)
The article is a good review & the algorithm below provides some good guidance -if difficult to visualize, then it may be worthwhile to look at source article.
The authors propose initial management with antibiotics, minimization of steroids, nutritional support and drainage.
Medical treatment is favored after initial management:
- Newly diagnosed Crohn’s disease
- Extensive disease
- No fibrostenoting disease
- Active perianal disease
Surgical treatment is favored after initial management:
- Long-standing disease
- Stricture with dilatation
- Abscess >6 cm in size
- Prior surgical intervention
The authors note that “recent studies have suggested that roughly 30% of patients
treated with PD are able to avoid future surgical resection.”
Related blog posts:
gutsandgrowth 