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 randomized control trial (BP Chumpitazi et al. Clin Gastroenterol Hepatol 2018; 16: 219-25) evaluated 23 children in a double-blind placebo (maltodextrin) cross-over design (2014-2016) to determine whether fructans (0.5 g/kg/day with max 19 g divided over 3 meals) worsen symptoms in children with irritable bowel syndrome (IBS). Fructans are a commonly ingested FODMAP carbohydrate (oligosaccharides). All subjects were 7-18 years (median 12.4 years) and met Rome III IBS criteria.
Key findings:
- Subjects had more episodes of abdominal pain/day while receiving fructan-containing diet (3.4 ± 2.6) compared with placebo-group (2.4 ± 1.7) (P<.01).
- The fructan group had more severe bloating (P<.05) and flatulence (P=.01). This was associated with higher hydrogen production (617 ppm/h compared with 136 pph/h) (P<.001)
- 18/23 (78%) had more frequent abdominal pain with fructan-containing diet and 12 (52%) had fructan sensitivity which the authors defined as having an increase of ≥30% in abdominal pain frequency following fructan ingestion.
My take: While the number of participants in this study is limited, the implications are clear: in children with irritable bowel, fructans frequently exacerbate symptoms. At this time, though, it is not possible to predict which patients with IBS will benefit.
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Chattahoochee River
A grand rounds report (CK McLean et al. J Pediatr 2018; 193: 245-48) focuses on the presentation of a rare tumor in a neonate, angiosarcoma. A few pointers from the discussion:
- The most common benign hepatic vascular tumors are congenital hemangiomas and infantile intrahepatic hemangiomas (IHH)
- The AAP dermatology section recommends assessing for hepatic lesions when there are 5 or more cutaneous hemangiomas. The risk of a hepatic hemangioma may be 23%, according to one study, when there are >5 cutaneous hemangiomas or one large cutaneous hemangiomas.
- “Consumptive hypothyroidism is a unique characteristic in some IHH.” This is due to tumor expression of a type 3 iodothyronine deiodinase enzyme which inactivates thyroid hormone.
Related blog post:
Bright Angel Trail, Grand Canyon
A recent story in the NY Times (Patients Eagerly Awaited a Generic Drug. Then They Saw The Price. ) shows that the availability of a generic drug does not guarantee that exorbitant pricing will be remedied.
An excerpt:
Syprine, which treats a rare condition known as Wilson disease, gained notoriety after Valeant Pharmaceuticals International raised the price of the drug to $21,267 in 2015 from $652 just five years earlier…
In promoting its “lower-cost” alternative to Syprine, a Teva executive boasted in a news release that the product “illustrates Teva’s commitment to serving patient populations in need.”
What the release didn’t mention was the price: Teva’s new generic will cost $18,375 for a bottle of 100 pills, according to Elsevier’s Gold Standard Drug Database. That’s 28 times what Syprine cost in 2010, and hardly the discount many patients were waiting for.
Nearly three years after Valeant’s egregious price increases ignited public outrage, the story of Syprine highlights just how hard it can be to bring down drug prices once they’ve been set at stratospheric levels.
My take: This type of excessive drug cost is why critics demand additional regulation be placed over the entire pharmaceutical industry; it can occur only in a system which has limited competition and indirectly shares the cost across the entire system by having insurance companies foot most of the bill.
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Bright Angel Trail
A recent systematic review and meta-analysis (NE Rich et al. Clin Gastroenterol Hepatol 2018 16: 198: 210) provides a more comprehensive description of how ethnicity impacts the epidemiology of nonalcoholic fatty liver disease (NAFLD) in the U.S. This study identified 34 previous publications with 368,569 unique patients.
Key points:
- NAFLD prevalence in hispanic persons is higher than white persons with a pooled relative risk of 1.47; whereas compared to white persons, black persons have a pooled relative risk of 0.74
- Presence of NASH also had an ethnic predilection with a relative risk of 1.09 for hispanic persons, and 0.72 for black persons in comparison to white persons
- Approximately one in 6 of all Americans have NAFLD
My take: While hispanic persons have a higher rate of NAFLD/NASH, it is still quite high among white persons and even in black persons who have the lowest rates.
Bright Angel Trail
A recent commentary (J Avorn. NEJM 2018; 378: 689-91) addresses a huge problem in medicine: “medicine’s ongoing assumption that clinicians and patients are, in general, rational decision makers.”
He points out that just as Albert Einstein upended Newtonian physics with the much more complex theory of relativity, Richard Thaler’s work in economics “explained that people often don’t make choices by acting as the rational balancers of risk and reward assumed by classic economics.” (More information about his work at Wikipedia post on Nudge).
Key points:
- “We are disproportionately influenced by the most salient and digestible information” rather than the totality of information. This “helps explain the power of simplistic pharmaceutical promotional materials, often delivered..with a tasty lunch.”
- “Our beliefs are shaped by recent experiences…(Last-case bias).”
- “We often overestimate small probabilities (such as uncommon drug risks).” Another example would be fear of dying in a plane crash which is far less likely than dying in an auto accident.
The potential remedies to flawed decision-making include the following:
- “Academic detailing” which is a process attempting to integrate more information to counter biases
- Nudge concept. This is a strategy of “making a preferred alternative the default choice when several options exist.” Order entry systems in computers could default to preferred drugs (ie. best drug in class)
- Cost constraints can affect decision-making which could include targeting copayments for payments. For physicians/administrators, looking at what drives revenue is crucial. “As Upton Sinclair once noted, ‘It is difficult to get a man to understand something when his salary depends on his not understanding it.'”
My take: Addressing these ideas could help reduce unnecessary surgeries, increase high value care, and improve outcomes. This is why Richard Thaler’s work is important for medicine.
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A recent article (P Collin et al. AP&T 2018; 47: 563-72) reviews the presentation of celiac disease in later years (Thanks to Ben Gold for this reference).
Key findings:
- Approximately 25% of celiac diagnoses are made at age ≥60 years
- ~4% of celiac diagnoses are made at age ≥80 years
- About 60% of individuals with celiac disease remain undetected
- Adherence with gluten free diet results in “resolution of symptoms and improvement in laboratory indices…in over 90% of patients”
This review also focuses on specific related problems besides epidemiology: malabsorption, dermatitis herpetifromis, bone mineral density and fractures, autoimmune disease, heart disease, neurological disturbances, and malignancy.
Bright Angel Trail
Tsugawa Y, Newhouse JP, MacArthur JD, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017;357 doi: https://doi.org/10.1136/bmj.j1797
Thanks to Ben Gold for this reference. Slides from Patient Care newsletter.
Background:
Researchers used nationally representative data on Medicare beneficiaries admitted to hospital with a medical condition during 2011-14. They wanted to find out the association between age of the treating physician and 30 day patient mortality after admission; whether this association varied with the volume of patients a physician treats; and whether physician age is associated with readmissions and costs of care. Their study included 736 537 admissions managed by 18 854 hospitalist physicians (median age 41).
Key findings
BG Feagan et al. Gastroenterol 2018; 154: 61-4. In this study of GED-0301 (Mongersen), an antisense oligodeoxynucleotide affecting Smad7, was randomly assigned to 63 patients with Crohn’s disease (160 mg/day). Endoscopic improvement was observed in 37% at week 12. Clinical remission (CDAI<150) was noted in 32% (4 weeks of Rx), 35% (8 weeks of Rx) and 48% (12 weeks of Rx). No new safety signals were noted.
Related blog posts:
PJ Pasricha et al. Gastroenterol 2018; 154: 65-76. First of all, I have to say that I like the visual abstracts in many Gastro studies. In this randomized, double-masked “APRON” study of 126 patients with chronic nausea or gastroparesis receiving Aprepitant, a neurokinin-1 receptor antagonist, or placebo, the key findings were the following:
- Aprepitant did not reduce symptoms of nausea significantly compared to placebo
- Apreptiant-treated patients had improvements in secondary outcomes of symptom severity for nausea (1.8 vs 1.0, P=.005 on Gastroparesis Clinical Symptom Index) and overall symptoms (1.3 vs. 0.7, P=.001)
Related blog post:
B Bielawska et al. Gastroenterol 2018; 154: 77-85. Using data (administrative databases) and propensity matching from more than 3 million outpatient colonoscopies (2005-2012), the authors noted that the use of anesthesia assistance (AA) was associated with an increased risk of aspiration pneumonia (OR 1.63) but not perforation (OR 0.99). Though this study is limited by its retrospective design and reliance on administrative data, the authors state “the potential for residual confounding by indication for AA [is] extremely unlikely, especially because AA use in Ontario appears to be driven by institutional policy or business model rather than by patient factors.”
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