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.

Pediatric Experience with Infliximab Biosimilar in UK

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Briefly noted: N Chanchlani et al. JPGN 2018; 67: 513-9.  The authors report on the use of infliximab biosimilar (IFX-B), n=82, compared to infliximab originator (IFX-O) in 175.

  • While the authors did not find a difference with the biosimilar in terms of efficacy and adverse effects, this finding is quite limited; only 28 in IFX-O and 19 in IFX-B had a physician global assessment data which was used to determine efficacy.
  • The authors noted that less than 20% of their patients had a baseline and 3-month followup PCDAI recorded.
  • In addition, of those with available data, less than half (44%) had screening for hepatitis B and tuberculosis.
  • The authors estimate that 875,000 pounds would have been saved for a 1-year period with universal adoption of biosimilars

My take: This study, due to incomplete data, does not add much to our knowledge about biosimilars.  It does indicate that better screening prior to infusions for HBV and tuberculosis is needed along with more well-documented experience.

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Peyto Lake, Banff

IBD Shorts -November 2018

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G Horneff et al. J Pediatr 2018; 201: 166-75.  This industry-funded analysis of 577 pediatric patients who received adalimumab (1440 patient-years) identified no new safety signals.  The most common serious infection was pneumonia (0.6 events per 100 patient-years).  The most common adverse events were respiratory tract infections/nasopharyngitis. Serious infections were more common in the subset of patients with Crohn’s disease (CD), (n=189), occurring in 13%.

PS Dulai et al. Gastroenterol 2018; 155: 687-95.  This study, using data from GEMINI 2 phase 3 trial with 814 patients, developed a clinical prediction tool for determining the likelihood of a clinical response to vedolizumab.  Common predictors for response:

  • No prior bowel surgery
  • No prior anti-TNF exposure
  • No prior fistulizing disease
  • Higher baseline albumin
  • Lower baseline CRP

R Matro et al. Gastroenterol 2018; 155: 696-704.  The authors performed a prospective study of women with IBD and their infants (n=72).  They “detected low concentrations of infliximab, adalimumab, certolizumab, natalizumab, and ustekinumab in breast milk samples.  We found breastfed intants of mothers on biologics, immunomodulators, or combination therapies to have similar risks of infection …compared to non-breastfed infants or infants unexposed to these drugs.”

 

Endoscopic Incisional Therapy for Esophageal Strictures

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MA Manfredi et al. JPGN 2018; 464-8. This retrospective chart review describes the use of endoscopic electrocautery incisional therapy as a treatment for refractory benign esophageal anastomotic strictures (n=57) from 2011-2017.

The authors define refractory as inability to achieve an adequate esophageal lumen diameter after 5 dilatations to the following:

  • Age <9 months: at least 8 mm
  • 9-23 months: at least 10 mm
  • 24 months to 5 years: at least 12 mm
  • 6 years or older: at least 14 mm

Key findings:

  • The median number of dilatations prior to EIT was 8 in the refractory group (n=36) and 3 in the nonrefractory group
  • In the 2 years following EIT the median number of dilatations was 2 in the refractory group and 1 in the nonrefractory group
  • Major complications were reported in 3 (2.3%) —>”non-contained” leak. All healed without surgical intervention. There were an additonal 4 cases of contained fluid leaks (total of 5.3% of esophageal leaks)
  • The authors had a 61% treatment success in children with refractory anastomotic strictures.  Their definition of success “no stricture resection, appropriate diameter for age, and fewer than 7 dilatations in the 2 years following the first EIT session.”
  • The authors note that patients were generally referred for stricture resection in the refractory group after the first or second EIT session IF there was not improvement in esophageal diameter.

Role of this therapy/technical aspects:

  • The authors note that this technique is particularly suited to an asymmetric stricture rather than a completely circular stricture.  With a circular stricture, typical balloon or bougie dilatations exert force equally in all directions and “will more likely tear less dense tissue adjacent to the thicker shelf.”
  • Fluoroscopy during a conventional dilatation may facillitate identification of stricture asymmmetry.
  • In the associated editorial (J Mack, MR Narkewicz) note that the technique should be limited to short (<1 cm) refractory strictures
  • In the technique for EIT, the authors note that combining EIT with balloon dilatation frequently allows a more shallow incision and likely lowers the risk of perforation.

My take: This is a promising treatment for a stubborn problem though its use will require advanced therapeutic experience. As an aside, I think their definition of success is at odds with common sense.

Related blog posts:

The first bear I saw in Banff

Big Advance in Cystic Fibrosis –Who Will Benefit?

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Recent studies point to huge advances in cystic fibrosis (CF) therapy. Though as noted in a previous blog (Why Do Canadians with Cystic Fibrosis Live Longer?), medical advances may have limited effect based on a lot of issues including access to care.

Despite that note of caution, it is hard not to be excited about a couple of recent publications which show that triple cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy has great potential to improve outcomes for CF patients.

  • JC Davies et al. NEJM 2018; 379: 1599-611.
  • D Keating et al. NEJM 2018; 379: 1612-20.
  • Editorial: F Holguin, 1671-2

Background: In the editorial, the pathophysiology of the defect of CF is discussed and how the newer medicines either act as a potentiator of the CFTR (ivacaftor) or as corrector (lumacaftor and tezacaftor).  Potentiators increase CFTR channel opening at the cell surface whereas correctors increase the amount of CFTR protein at the cell surface. One caveat has been that these therapies had not been proven effective, individually, for Phe508del CFTR mutation which occurs in “approximately two thirds of patients.”  Combination therapy has helped in most of this group but not in those with Phe508del-minimal function (MF).

The new studies examine triple therapy with the addition of two new-generation small molecule correctors: VX-445 and VX-659. These new correctors target different sites of the CFTR protein.

Key findings:

  • in the Davies (VX-659) trial, “4 weeks of triple therapy …increased the primary end point of predicted percentage of FEV1, in the Phe508del-MF and Phe508del-Phe508del groups by an averae of 13.3% and 9.7% respectively”
  • In the Keating (VX-445) trial, triple therapy “significantly increased FEV1 in patients with those genotypes by 13.8% and 11.0% respectively.”
  • Overall, triple therapy “improved the percentage of predicted FEV1 more than double-combination therapy” in patients with a Phe508del-Phe508del mutation.  And reported efficacy in the patients with Phe508del-MF CFTR mutation.
  • The majority of patients had at least one adverse event. 3 of the 122 in the VX-445 trial discontinue treatment due to severe adverse events.

My take: These reports “represent a major breakthrough…for improving health and possibly survival in all patients who carry the most common CFTR mutation.”  Long-term outcomes will need to be followed to confirm these findings.

Related blog posts:

This is Figure 2 from Davies study showing immunoblot findings, densitometry findings, and chloride transport in bronchial cells. The most robust responses were with triple therapy

 

More on the Flu -5 Reasons for the Flu Shot

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Last year’s deadly flu was likely due in part due to a low rate of vaccination.

From NPR: 5 Reasons Why You Need the Flu Shot

Last year “more than 80,000 people died from flu-related illnesses in the U.S. — the highest death toll in more than 40 years.” So 5 reasons to get your shot:

1. You are vulnerable.

People 65 and older are at higher risk of flu-related complications, but the flu can knock young, healthy people off their feet, too. It does every year.

2. Getting a flu shot is your civic duty.

“Nobody wants to be the dreaded spreader,” says Schaffner. But everybody gets the flu from somebody else.

3. You can still get the flu, but you won’t be as sick.

After last winter’s severe season, some people are skeptical. They say: “I got the flu shot, but I still caught the flu.”

4. Pregnant women who get the flu shot protect their babies from flu.

Women who are pregnant should be vaccinated to protect themselves. The vaccine also offers protection after babies are born

5. You cannot get flu from the flu vaccine.

It’s still a common misperception: the idea that you can get the flu from the flu shot.

Related blog posts:

 

 

 

#NASPGHAN18 Highlights (Part 2)

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I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

My favorite slide from postgraduate course -Dr. Robert Kramer

Slides regarding the topic of Treat-toTarget Dr. Eric Benchimol:

Slides regarding GI symptoms and autism from Dr. Kara Margolis:

Slide regarding the frequency of bariatric surgery: Dr. Rohit Kohli:

Slides regarding intestinal failure population from Dr. Conrad Cole:

From Dr. Miranda van Tilburg regarding psychological therapies for functional GI disorders:

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

#NASPGHAN18 Highlights and Tweets (part 1)

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I did not make it to this year’s meeting but did get a chance to catch up on a lot information via the PG 2018 Syllabus and based on information posted online.

Here are a couple of highlights for me:

Slides from postgraduate course on CVS from Dr. Katja Kovacic

The slide from Dr. Lightdale (pg 22 in Syllabus) below suggests it is OK for scope if platelets >20K and OK for biopsies if platelets >50K. It is worth noting that some adult data indicate that even lower biospy thresholds are reasonable for biopsies (Post: Lower Endoscopic Thresholds for Thrombocytopenia). As always, one needs to consider carefully the risks compared with the benefits.

From Postgraduate Course

 

 

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

New Button Battery Guidelines –with Honey and Vinegar

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Button batteries –definitely more scary than Halloween.  Here is a link to new guidelines from Poison Control: New Button Battery Guidelines 2018

A recent report from Nationwide Childrens, How Sweet It Is: Honey Attenuates Button Battery-Induced Esophageal Damage, highlights two important advances in button battery management that are now incorporated into the new button battery guidelines:

  1. At time of endoscopy,  “a weak acetic acid rinse (sterile vinegar) can help neutralize tissue pH and protect the esophagus from continued tissue breakdown after battery removal. This irrigation concept has now been successfully used in children around the world with good clinical outcomes.”
  2. Prior to endoscopy, “both honey and sucralfate (Carafate®) were able to effectively neutralize the tissue pH and reduce visible injury.”

“More than 3,000 cases occur per year, mostly among children younger than age 6, and severe cases are on the rise. Lodged button batteries can cause rapid injury, including permanent bilateral vocal cord paralysis and even death.”

Guideline recommendations with regard to acetic acid:

After a battery is removed from the esophagus, inspect the area endoscopically for evidence of perforation. If none is evident, irrigate the injured areas with 50 mL to 150 mL of 0.25% sterile acetic acid (obtained from the hospital pharmacy). Irrigate in increments and suction away excess fluid and debris through the endoscope. For decades toxicologists have advised against neutralization for fear of causing a thermal injury. However, a recent study (Jatana, 2016) using piglet esophagus preparations after button battery removal, showed only a minimal increase in temperature (0-3 oC), effective tissue surface pH neutralization, and decrease in the visible injury using this neutralization strategy. The tissue surface pH neutralization may reduce the development of progressive, delayed-onset esophageal injury after battery removal.

From guideline with regard to honey:

Administer honey immediately and while en route to the ER, if:

  1. A lithium coin cell may have been ingested (if you don’t know what kind of button battery was swallowed, assume it is a lithium coin cell unless it is a hearing aid battery);
  2. The child is 12 months of age or older (because honey is not safe in children younger than one year);
  3. The battery was swallowed within the prior 12 hours (because the risk that esophageal perforation is already present increases after 12 hours);
  4. The child is able to swallow; and
  5. Honey is immediately available.

How to dose honey:

      1. Give 10 mL (2 teaspoons) of honey by mouth every 10 minutes for up to 6 doses. Do not worry about the exact dose or timing.
      2. Use commercial honey if available, rather than specialized or artisanal honey (to avoid inadvertent use of large amounts of honey produced from potentially toxic flowers).
      3. Honey is NOT a substitute for immediate removal of a battery lodged in the esophagus. Honey slows the development of battery injury but won’t stop it from occurring. Do not delay going to an ER.

Why give honey?

Honey is administered to coat the battery and prevent local generation of hydroxide, thereby delaying alkaline burns to adjacent tissue. Efficacy is based on a 2018 study (Anfang et al) assessing the in vitro protective effects of various liquids in the cadaveric porcine esophagus and in vivoprotective effects of honey and sucralfate (Carafate®) compared to saline irrigations of batteries placed in the esophagus of live piglets. Both honey and sucralfate (Carafate®) effectively prevented the expected battery-induced pH increase and decreased the depth of the resulting esophageal injury.

References:

  1. Anfang RR, Jatana KR, Linn RL, Rhoades K, Fry J, Jacobs IN. pH-neutralizing esophageal irrigations as a novel mitigation strategy for button battery injury. The Laryngoscope. 2018 Jun 11. [Epub ahead of print]
  2. Jatana KR, Rhoades K, Milkovich S, Jacobs IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. The Laryngoscope. 2017 Jun;127(6):1276-1282.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

 

#NASPGHAN18 Abstract: LR for Pancreatitis & Pumpkin Shot

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At NASPGHAN18, an abstract provided more information that indicates that lactated ringer’s is probably the best intravenous fluid for most children with acute pancreatitis

Related blog posts:

 

2018 Pumpkin for our House