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.
It is recognized that there is often a delay in the diagnosis of biliary atresia (BA). A recent study (MR Townsend et al. J Pediatr 2018; 199: 237-42) indicates that hepatoportoenterostomy (HPE) or Kasai procedure is performed in only 37.7% of patients with BA prior to 60 days of age. The data was obtained from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample files from 2000-2011.
Risk factors for delayed HPE: This study of 1243 patients with BA found that those with delayed HPE were more often uninsured–all self-pay patients had HPE after 60 days, more often black (aOR 4.22), and less likely at a teaching hospital (aOR 0.27).
Delayed HPE was associated with increased adverse perioperative outcomes and increased cost.
My take: We have a long way to go if we are going to consistently identify and treat BA in a timely manner.
A recent study (S Litleskare et al. Clin Gastroenterol Hepatol 2018; 16: 1064-72) involved prospective follow-up of 1252 laboratory-confirmed cases of giardiasis from a 2004 outbreak in Norway.
Key findings:
Prevalence of irritable bowel syndrome (IBS) was 43% 10 years after the outbreak among 576 exposed individuals compared with 14% among 685 controls. Thus, the odds ration of developing IBS was 4.74 following Giardia exposure.
Chronic fatigue at 10 years was higher as well, reported in 26% in the exposed group compared with 11% in the control group.
The authors note that the change in IBS between 6 years and 10 years following the infection was 40% and 43% respectively and the change in chronic fatigue was 31% at 6 years and 26% at 10 years.
My take: Don’t get Giardia!! It may cause chronic fatigue and IBS 10 years after acquisition of an infection. This study reinforces other studies which have shown that numerous enteric pathogens can increase the risk of IBS. These other studies reported lower rates of IBS following infections, between 7-36%.
Reslizumab, a monoclonal recombinant antibody to interleukin-5 did not receive FDA approval for eosinophilic esophagitis. However, a recent report (J Markowitz et al. Journal of Pediatric Gastroenterology and Nutrition: June 2018 – Volume 66 – Issue 6 – p 893–897)describes the outcomes of patients who entered the randomized control trial and continued to receive subsequently via open label extension (OLE, n=6) or through compassionate use (CU, n=4. This study provides data over 9 years of treatment.
Key findings:
Median eosinophil count dropped from 35 to 3
No serious adverse events were noted
Clinical features improved. For example, dysphagia dropped from 42% to 0% and vomiting dropped from 67% to 17%
My take: Though this is a small study, it shows that in selected patients disruption of the inflammatory pathways can result in significant clinical improvement.
Pics from Ameila Island and thereabouts -Not sure whose dog (not ours)
An interesting study ( CL Cummings et al. J Pediatr 2018; 199: 57-64) examined performance levels on a reliable ethics knowledge questionnaire (TEK-Neo). They found that out of 36 questions:
While the overall take-home from this study is that the TEK-Neo provides a reliable gauge of neonatal ethic knowledge, I was more interested in some of the specific questions. Here are three true-or-false questions:
#20. “Medically provided fluids and nutrition constitute a medical intervention that may be withheld or withdrawn for the same reasons that justify the medical withholding of other medical treatments.”
#21. “Parents of a critically ill 3-day old infant in the NICU born at 26 weeks on noninvasive positive pressure ventilation decline reintubation in the setting of respiratory failure and new grade 3 IVH B/L. Their informed decision to refuse further life-sustaining medical treatment ought to be respected.”
#24. “A 14 day-old full-term boy has sustained severe anoxia perinatally and has severe hypoxic-ischemic encephalopathy confirmed on continuous electroencephalogram by persistently low -voltage isoelectric activity. He is unresponsive to his environment. In this situation, the patient’s enteral nutrition (administered via oral gavage tube) may be ethically withdrawn.”
Though the correct answer to these three questions is true, my experience is that parents rarely are interested in withholding or withdrawing care in these type of scenarios.
A recent retrospective study (W El-Matary et al. JPGN 2018; 67: 221-24) examined the practice of looking for Cytomegalovirus (CMV) in children with a flareup of their inflammatory bowel disease (IBD) which is currently recommended by expert consensus (JPGN 2018; 67: 292-310 –recommendation #3).
Key findings:
“Four of 61 patients encounters (6.6%) with UC/IBD-U, two with corticosteroid refractory disease, had positive biopsies for CMV by PCR but negative H&E and IHC. They responded to escalated medical therapy, without needing anti-viral therapy.”
All children who had colectomy during the study did not have CMV detected in colonic mucosa.
The authors note that the rationale for looking for CMV is derived mainly from adult populations. Since age is a known risk factor for CMV reactivation, the risk of CMV causing refractory IBD in children is less.
My take (borrowed in part from authors): “The low frequency of CMV in our study challenges current guidelines that recommend assessment for CMV in all pediatric patients with acute severe UC refractory to corticosteroids.” This issue would be another that would benefit by collecting the experience of a large cohort (eg. ICN).
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. 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.
Briefly noted: MA Lowry et al. JPGN 2018; 67: 198-203. This study showed that active eosinophilic esophagitis (EoE) was associated with much lower impedance values that inactive EoE, NERD, and controls. At 2, 5 and 10 cm above the squamo-columnar junction, median values of impedance with active EoE were 1069, 1368, and 1707 respectively. In comparison, inactive EoE had median values were 3663, 3657, and 4494, respectively. My take: Since impedance was also performed during endoscopy with sedation, this does not represent a significant advance in current management.
A prospective pediatric eosinophilic esophagitis (EoE) study (C Gutierrez-Junquera et al. JPGN 2018; 67: 210-6) examines the use of proton pump inhibitors (PPIs) for long-term management for this disorder.
After diagnosis of EoE, children received esomeproazole (1 mg/kg/dose BID). For those with a response (<15 eos/hpf), they were maintained on 1 mg/kg/day for one year.
Key findings:
Of the initial cohort of 109, 72 (66%) had response to esomeprazole.
57 of these responders were subsequently followed in this study. At the lower daily esomeprazole dose, 70.1% (n=40) continued with <15 eos/hpf and 29.9% (n=17) had relapse.
Maintaining response was more common among those who achieved an initial response (with BID esomeprazole) of <5 eos/hpf compared to those who had achieved an initial response of 6-14 eos/hpf. At 1 year, in those with who had a more complete response, 81% maintained eosinophil count <15/hpf compared with only 50% in those with a lesser initial response.
Adverse events with prolonged treatment were uncommon and included self-resolving diarrhea in three, headache in one and urticaria in one; the latter two adverse effects responded to change to lansoprazole
My takes:
PPI treatment is effective in probably 40-50% of individuals with EoE (though higher response in this study)
Some individuals need higher doses of PPIs
Due to the high response rate, this underscores the need to diagnose EoE prior to using PPIs or after they have been discontinued.
What this latest study suggests, in the context of other studies, is that if people can’t shop for elective M.R.I.s, there’s hardly a chance they are going to do so with other health care procedures that are more complicated and variable.
Even if 40 percent of health care is shoppable, people are not shopping. What seems likelier to work is doing more to influence what doctors advise.
For example, we could provide physicians with price, quality and distance information for the services they recommend. Further, with financial bonuses, we could give physicians (instead of, or in addition to, patients) some incentive to identify and suggest lower-cost care.
Leaving decisions to patients, and making them spend more of their own money, doesn’t work.
Briefly noted: A Muntaner-Mas et al. J Pediatr 2018; 198: 90-7. This cross-sectional study with 250 Spanish children (10-12 year olds) examined obesity measures, physical fitness measures and academic performance. Key finding: “Children considered fit had better academic performance than their unfit peers…the association between body mass index and GPA was mediated by cardiorespiratory fitness and speed-agility.” The design of this study precludes establishing this association as a causal relationship.
gutsandgrowth 