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.
States with unfavorable trends: Arizona, Arkansas, Florida, North Carolina, South Carolina, Tennessee, Texas, and Utah. From Eric Topol Twitter feed:
Also recent modeling indicates that face masks lower transmission rate –from Reuters: Widespread mask-wearing could prevent COVID-19 second waves: study
Related blog posts:
Here is a link to the EPUB draft of AGA clinical report (G Su et al. Gastroenterology DOI: https://doi.org/10.1053/j.gastro.2020.05.059): AGA Clinical Practice Guidelines on the Role of Probiotics in the Management of Gastrointestinal Disorders
Here is a link to the pre-draft technical review by GA Preidis et al. Gastroenterology DOI: https://doi.org/10.1053/j.gastro.2020.05.060 AGA Technical Review on the Role of Probiotics in the Management of Gastrointestinal Disorders
- The report recommends NOT using probiotics outside of clinical trials for irritable bowel syndrome, Clostridium difficile infection treatment, Crohn’s disease, and gastroenteritis.
- It recommends a specific probiotic for pouchitis and for prevention of necrotizing enterocolitis in preterm infants <37 weeks and 3 probiotics for patients who are receiving antibiotics (to prevent Clostridium difficile infection)
CNN summary: Probiotics don’t do much for most people’s gut health despite the hype, review finds
“While our guideline does highlight a few use cases for probiotics, it more importantly underscores that the public’s assumptions about the benefits of probiotics are not well-founded,” said Dr. Grace L. Su, a professor of medicine and chief of gastroenterology at the University of Michigan, Ann Arbor, in a news statement. She was the chair of the panel that issued the new guidance….
“The industry is largely unregulated and marketing of product is often geared directly at consumers without providing direct and consistent proof of effectiveness,” said the new guidelines. “This has led to widespread use of probiotics with confusing evidence for clinical efficacy,” it said…
“Not all probiotics are created equal. Some probiotic strains and mixtures are very effective for some types of diseases and should not be overlooked due to studies that lump all probiotics together as one”
My take: Probiotics are overhyped and underperform for most conditions. This report suggests that most people should NOT be taking probiotics.
Related blog posts:
Wired: When Health Care Moves Online, Many Patients Are Left Behind
An excerpt:
Amid the coronavirus pandemic, more of the nation’s medical care is being delivered by telephone or videoconference, as in-person care becomes a last resort for both doctors and patients. That’s a problem for tens of millions of Americans without smartphones or speedy home internet connections. For them, the digital divide is exacerbating preexisting disparities in access to health care…
Overall, as many as 157.3 million people in the US only have access to substandard download speeds. During the pandemic, roughly half of low-income American say they’re concerned about affording to pay their broadband and smartphone bills, according to April Pew Research data. In rural areas (where Pew figures suggest only 63 percent of residents have home broadband subscriptions), phone calls might be patients’ best option.
Related blog post: #NASPGHAN19 Impact of New Technology
Recently Kipp Ellsworth, with input from members of the nutritional team, developed our first institutional Short Gut Diet.
Per Kipp, this diet is “designed to facilitate digestion while minimizing abdominal pain and ostomy/stool output in our inpatients with truncated intestinal anatomy. Previously, clinicians ordered a regular diet for our short gut patients, with parents and nurses providing oversight of the ordering process based on their knowledge of short gut diet precepts. Obviously this non-standardized approach resulted in significant noncompliance, another onerous daily task for nursing, and a failure of inpatient short gut diet principles reinforcement. I anticipate the new diet serving as an omnipresent education tool, reinforcing short gut diet precepts for patients and parents during their inpatient stays.”
Related blog posts:
NY Times: Is the Secret to Japan’s Virus Success Right in Front of Its Face?
An excerpt:
In America, masks have become a weapon in the culture wars. In Japan, wearing one is no big deal, and deaths have stayed low…
Face coverings are nothing new here….
Yet a feared spike in cases and deaths has not materialized. Japan has reported more than 17,000 infections and just over 900 deaths, while the United States, with a population roughly two and a half times as large, is approaching 1.9 million cases and 110,000 deaths.
“Japan, I think a lot of people agree, kind of did everything wrong, with poor social distancing, karaoke bars still open and public transit packed near the zone where the worst outbreaks were happening,” Jeremy Howard, a researcher at the University of San Francisco who has studied the use of masks, said of the country’s early response. “But the one thing that Japan did right was masks.”…
The scientific evidence on whether a mask protects the wearer from infection is mixed. But experiments show that masks can be effective in blocking the emission of respiratory droplets that may contain the virus, even when someone has no symptoms of illness. And there is some evidence that infected people with no symptoms can still transmit the coronavirus.
Related blog posts:
Huntingdon Lake, Sandy Springs (no image filters used)
B Briggs et al. J Pediatr 2020; 220: 154-8. This study confirmed a high rate of bleeding problems in infants with Noonan syndrome. 9/70 (12.8%) had bleeding complications in those without comprehensive preoperative testing and undergoing major or dental surgery. Hematology evaluation is indicated in these children.
H Christian et al. J Pediatr 2020; 220: 200-6. Using data from the Longitudinal Study of Australian Children with data points at ages 5 (n=4242) and at ages 7 (n=4431). Key finding: Owning pets was associate with improved emotional health for children: odds of abnormal emotional scores on SDQ questionnaire was OR 0.81, peer problems OR 0.71, and prosocial behavior OR 0.70 compared with non-pet owners. Prosocial behavior was most improved for children without any siblings with OR 0.21.
A recent systematic review (IH Jones, NJ Hall. J Pediatr 2020; 220: 86-92) provides contemporary outcomes for infants with necrotizing enterocolitis (NEC). The authors analyzed from 38 articles (from 1375 abstracts); the authors excluded data from developing countries. This review included 21,349 infants with any stage of NEC and 7540 with Bell stage 2a+.
Key findings:
- Overall mortality was 23.5% in all neonates with confirmed NEC (Bell stage 2a+), 34.5% for infants who underwent surgery
- Mortality rates were higher for extremely low birthweight infants (<1000 g) at 40.5%; the rate was 50.9% for surgical NEC in this cohort
- Neurodevelopmental disability was reported in only 4 studies and ranged between 24.8% and 61.1% (n=1209)
- Intestinal failure was reported with an incidence of 15.2% to 35.0% (n=1370)
A limitation with this study is the lack of agreement on definitions/diagnosis for necrotizing enterocolitis and intestinal failure.
My take: This study shows that NEC still carries a high mortality.
Related blog posts:
Sandy Springs
I was keenly interested in a recent study: BP Lee, NA. Terrault. Liver Transplantation in Unauthorized Immigrants in the United States. Hepatology 2020; 71: 1802-12. Given the potential for causing a political firestorm, I was surprised it was published.
Definitions: “Unauthorized immigrants, also termed illegal aliens in US federal statures are…all foreign-born non-citizens who are not legal residents.” Since March 2012, UNOS has required transplant centers to record citizenship…”primarily to better understand transplant tourism.” The authors excluded international transplant tourists in their cohort.
Key findings:
- 116 of 43,192 (0.4%) liver transplant (LT) recipients were unauthorized immigrants
- The majority were from Mexico (52%). Others came from Guatemala (7%), China (6%), El Salvador (5%) and India (5%).
- Unauthorized immigrant recipients had a similar risk of graft failure (sHR 0.74) and death (sHR 0.68), though at time of LT, there was higher disease severity (higher MELD scores and increased need for renal replacement therapy).
- Most LTs for unauthorized immigrants took place in California (47%) and New York (18%). Texas (3%) and Florida (4%) had a lower proportion of LTs for unauthorized immigrants based on population distribution.
- The authors note that unauthorized immigrants are different that transplant tourists –they pay social security tax/other taxes and contribute to organ donation (~3% of donated organs) whereas transplant tourists do not.
- The authors note that unauthorized immigrant LTs were less than half the number of transplant tourist LTs; the later LT recipients are commonly individuals from Persian Gulf countries.
- Current federal law mandates that LT be distributed based on “established medical criteria” which does not suggest a “tiered allocation system by citizenship.” Almost half of the unauthorized immigrant LTs were covered by Medicaid.
My take: Unauthorized immigrants are underrepresented as LT recipients compared to their total population distribution in the U.S. This likely is due to a number of barriers. Interestingly, this population is not underrepresented when it comes to organ donation.
A recent case study (A Adeyemi et al. J Pediatr 2020; 220: 245-8) provides information on 6 infants with a subsequent diagnosis of biliary atresia who had HIDA scans which reported excretion.
Methods: HIDA scans from 1992-2012 were reviewed from CHOP, this included 223 infants up to 4 months of age.
Key findings:
- While there were six cases with HIDA scans that showed excretion into the bowel, none of these infants had truly normal HIDA scans.
- 4 of the 6 patients had excretion qualified as slight, mild, or subtle and faint.
- 5 of the 6 patients did not have the gallbladder visualized on HIDA.
Commentary:
- HIDA scans are well-known to have a high sensitivity but a low specificity for biliary atresia (even with pretreatment choleretic agents). Liver biopsies have a higher diagnostic accuracy.
- Since biliary atresia is a progressive disease, some excretion on HIDA does not exclude the diagnosis. Though, age at HIDA was not a significant variable in this small series.
My takes:
- Don’t rely too much on any test, including HIDA scans. Equivocal findings need to be reported as such.
- Fortunately, MMP-7 has emerged as another quick way with good (not perfect) specificity for biliary atresia.
- Another related caveat is to look carefully at ultrasounds in this age group. Often a small or retracted gallbladder is overlooked and could be an important clue to the diagnosis of biliary atresia.
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Rhododendron Flowers (Spring 2020)
gutsandgrowth 