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.

Year in Review: My Favorite 2019 Posts

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Yesterday, I listed the posts with the most views.  The posts below were the ones I like the most.

General/General Health:

Nutrition:

Liver:

Endoscopy:

Intestinal Disorders:

 

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.

 

Most Popular Posts of 2019

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The following are the most viewed posts from the past year:

Wishing friends, family and colleagues a healthy and happy New Year.

Morning in Sandy Springs, GA

 

Primary Prevention of Cow’s Milk Allergy

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A recent randomized clinical study (M Urashima et al. JAMA Pediatr. 2019;173(12):1137-1145) indicates that avoiding cow’s milk formula in the first 3 days of life may prevent the development of cow’s milk allergy. Thanks to Ben Gold for this reference.

Link to full Abstract (article behind paywall): Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth

The Atopy Induced by Breastfeeding or Cow’s Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. The primary outcome was sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant’s second birthday.

Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid–based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).

If the mother, allocated to the BF/EF group, added more than 150 mL/d of EF to BF for 3 consecutive days, EF was switched to CMF after the fourth day. Thus, offspring allocated to BF/EF could avoid CMF for at least the first 3 days of life.

Key Finding:

  • “In this randomized clinical trial involving 312 newborns, risks of sensitization to cow’s milk and immediate-type food allergy, including cow’s milk allergy and anaphylaxis, were decreased by avoiding supplementation with cow’s milk formula for at least the first 3 days of life.”
  • “The primary outcome occurred in 24 infants (16.8%) in the BF/EF group, which was significantly fewer than the 46 infants (32.2%) in the BF plus CMF group (relative risk [RR], 0.52; 95% CI, 0.34-0.81).”
  • “The prevalence of food allergy at the second birthday was significantly lower in the BF/EF than in the BF plus CMF groups for immediate (4 [2.6%] vs 20 [13.2%]; RR, 0.20; 95% CI, 0.07-0.57) and anaphylactic (1 [0.7%] vs 13 [8.6%]; RR, 0.08; 95% CI, 0.01-0.58) types.”

This study is interesting in that it suggests that exposure to cow’s milk in the first three days of life potentially increases the risk of CMA, whereas a previous study (*see below) showed showed that early exposure to CMF within 14 days after birth reduces the risk of CMA.  In this previous study, exposure to small quantities of CMF for the first 3 days of life was not monitored. “Thus, the results of that observational study are not necessarily in contrast to those of the present trial.”

My take: This type of study is difficult to complete.  It is difficult to understand why exposure to cow’s milk in the first two weeks of life is helpful and why exposure in the first three days of life is detrimental with regard to the development of cow’s milk allergy.

*Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020)

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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.

Promoting Poorly-Equipped Medical Students

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An interesting commentary (SA Santen et al. NEJM 2019; 381: 2287-9): “Kicking the Can Down the Road –When Medical Schools Fail to Self-Regulate”

Key points:

  • Medical schools have only a ~3% attrition rate
  • Some students, perhaps 1 or 2 per class, matriculate even though the dean(s) “would not allow [them] to care for their family” due to either academic limitations or unprofessional behavior
  • The authors note that there is a low likelihood of legal liability of dismissal as long as there is adequate documentation and as long as schools do not deviate from due-process

My take: This concern of advancing the medical careers of problematic individuals is limited to a small number.  However, it is NOT limited to medical school but applies as well to residency & fellowship programs.  In addition, of course, promoting suboptimal individuals is not limited to the field of medicine.

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Briefly noted: Mortality in Acute Severe Ulcerative Colitis

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C Dong et al. AP&T 2019 https://doi.org/10.1111/apt.15592

Link: Systematic review with meta‐analysis: mortality in acute severe ulcerative colitis

Key point:

  • “Six population‐based studies with 741,743 patients and 47 referral centre‐based studies with 2556 patients were included. The pooled 3‐month and 12‐month mortalities were respectively 0.84% and 1.01%”

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Preserving the Patient-Physician Relationship

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A recent commentary (J Noseworthy. NEJM 2019; 2265-9) discussed the need to preserve the patient-physician relationship.  The author, who previously led the Mayo Clinic, makes a number of useful points.  Though, at the outset it is important to recognize that the care at the Mayo clinic is not representative of the care elsewhere.  In this institution, there is a selection bias both of patients and physicians.  Based on my knowledge of patients evaluated there (a small sample), patients are much more likely to undergo extensive evaluations.

Key points:

  • “Physicians in the United States are increasingly caught between the conflicting concepts of medicine as a humanitarian profession and health care as a competitive business.”
  • “Medicine’s most fundamental element remains the relationship between patient and physician…I believe it must remain central to medical practice even as medicine evolves.”
  • Principles include the following:
    • spending adequate time -to deal with uncertainty, treatment plans that are failing, and comfort those at the end of life
    • support the work of a coordinating physician -to address comprehensive care for patients with complex health issues

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Do Button Battery Guidelines Need To Be Revised?

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A recent abstract presented at DDW (R Khalaf et al. abstract Sa2046) with 68 patients identified mucosal findings in the stomach and questioned whether the current guidelines are sufficient.  Generally, guidelines call for the immediate removal of button batteries in the esophagus but in asymptomatic children older than 5 years, most gastric batteries can be observed (see links to previous blog posts below which highlight expert recommendations).

Link: Sa2046 GASTRIC INJURY SECONDARY TO BUTTON BATTERY INGESTIONS IN CHILDREN: A RETROSPECTIVE MULTICENTER REVIEW

This study was reviewed in Gastroenterology & Endoscopy News: Retrieving Swallowed Batteries in Children: Don’t Watch and Wait  This link also highlights an abstract from the Emory pediatric GI group, NASPGHAN 2019 (#24), which found that only 5% of esophageal button batteries were removed within two hours.

An excerpt:

According to the National Poison Data System, between 1985 and 2017, roughly 3,500 button batteries were swallowed in the United States each year (www.poison.org/ battery/ stats). ..

The researchers reviewed 68 cases of children who underwent endoscopy after having swallowed button batteries, which are used in a variety of devices, such as cameras and watches. Eighteen of the patients (26%) were asymptomatic, but 41 (60%) had visible mucosal damage…

Some injuries were more severe. A 9-year-old child with a battery lodged in the antrum experienced a gastric perforation that led to pneumoperitoneum, Dr. Khalaf reported. Although only one other injury was as serious, the researchers identified no risk factors that predicted significant complications.

My take: There are a lot of button battery ingestions.  More data is needed to determine whether more button batteries from the stomach should be retrieved.

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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 The IRS Proved That Health Insurance Saves Lives

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NY Times: The I.R.S. Sent a Letter to 3.9 Million People, It Saved Some of Their Lives

Recently, economists have shown that an I.R.S. letter encouraging people to sign up for health insurance saved lives.  This letter was an inadvertent randomized trial as 600,000 people who were eligible for the letter did not receive it due to a budget shortfall.

An excerpt:

Three years ago, 3.9 million Americans received a plain-looking envelope from the Internal Revenue Service. Inside was a letter stating that they had recently paid a fine for not carrying health insurance and suggesting possible ways to enroll in coverage…

Obtaining insurance… reduced premature deaths by an amount that exceeded any of their expectations. Americans between 45 and 64 benefited the most: For every 1,648 who received a letter, one fewer death occurred than among those who hadn’t received a letter.

In all, the researchers estimated that the letters may have wound up saving 700 lives…

The results also provide belated vindication for the much-despised individual mandate that was part of Obamacare until December 2017, when Congress did away with the fine for people who don’t carry health insurance…

The uninsured rate for Americans is rising for the first time in a decade, as states tighten eligibility rules for Medicaid, and as the Trump administration cuts back on health care outreach…

Previous research has found a link between expanded health insurance access and fewer deaths. Multiple studies showed a decline in mortality rates after states expanded Medicaid, but none could tie the outcome directly to the policy change, since states typically cannot randomly pick which residents do and don’t receive Medicaid. That makes the Treasury experiment, an unintended result of a budget shortfall, distinctively useful.

My take: This analysis shows that prompting health care coverage by sending a single letter can save lives.  It is unfortunate that we are currently heading in the opposite direction.

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Our Study: Provider Level Variability in Colonoscopy Yield

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Most readers of this blog will recognize that one focus has been on delivering high value medical care.  In pediatric gastroenterology, there is a great deal of variability in the use of endoscopy as a tool.  When there are individuals with high-use/low-value endoscopy, some might question whether this is due to training, expediency, financial motivation, or a lack of clinical confidence.

There have been a number of studies looking at diagnostic yield with pediatric colonoscopy but none on individual provider variation.   To look into this issue, we examined our outpatient experience with colonoscopy among 16 providers.  This work has now been published:

Digestive Diseases (Full Text): Diagnostic Yield Variation with Colonoscopy among Pediatric Endoscopists

Key points:

  • This study found high variability in diagnostic yield among the 16 clinicians ranging from as low as 22% to as high as 86% (p = 0.11) with an overall diagnostic yield of 48% for colonoscopy; excluding follow-up colonoscopies, the diagnostic yield was 42%.
  • Abnormal calprotectin and abnormal blood tests were associated with higher diagnostic yields of 83 and 65%, respectively, compared with symptoms such as diarrhea, and rectal bleeding which had yields of 43, and 61%.
  • Ileal intubation rates averaged 90% (range ­63–100%, p = 0.06). Ileal intubation is important because, among our patients with a normal colon, there were 21 (6%) with a grossly abnormal ileum and an additional 16 (4%) with abnormal histology in the ileum.  Thus, about 10% of patients with a normal endoscopic and histologic evaluation of the colon had abnormalities in the terminal ileum. A NASPGHAN report (JPGN 2017; 65: 125-31) on quality improvement recommended an ileal intubation rate of 90% as a goal.

Comments:

  • Our group’s overall diagnostic yield is similar to previous studies which ranged from 33-64%.
  • Among physicians with the lowest and highest yield, there was not a specialized focus in IBD or functional GI disorders.  Thus, the driving factor for the variation in diagnostic yield is related to the threshold for performing an endoscopy in patients with probable functional disorders and the response to parental pressures.
  • A negative endoscopic study has not been shown to improve outcomes in patients with functional abdominal pain; though a normal colonoscopy would provide reassurance in some situations (eg. familial polyposis).

My take: Goals for pediatric endoscopy to provide high-value care could include ileal intubation rates of >90% and provider diagnostic yields of >40%.  High-value also includes the actual cost of the procedure; most of our outpatient endoscopies are performed in a pediatric ambulatory center with much lower costs than hospital-based endoscopy.

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