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.

How Many Times Have You Done This?

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Two recent studies illustrate the need for better endoscopic training for fellows:

  • AM Banc-Husu et al. JPGN 2017; 64: e88-e91.
  • EA Mezoff et al. JPGN 2017; 64: e96-e99.

In the first study from CHOP, the authors performed a retrospective review of their endosocpic database from 2009-2014.  Out of 12,737 upper endoscopies, 15 patients underwent 17 upper endoscopies which required a therapeutic intervention to control nonvariceal bleeding (1:750 procedures).  therefore, among their 24 fellows, this resulted in less than 1 therapeutic endoscopy per fellow.

In the second study, “a recent study suggests that fellows are largely unable to achieve the prescribed case volume recommended to achieve competence.”  The authors found that control of nonvariceal bleeding [and other advanced endoscopy cases] “were performed exclusively but relatively infrequently by members of this advanced endoscopy service. Fellows…participated in relatively few.”

My take: Fortunately, life-threatening nonvariceal bleeding cases are infrequent.  The downside of the rarity of these cases is the lack of subspecialty expertise, particularly in recently trained physicians.  My recommendations:

  1. Work with experience physicians (adult and pediatric) until sufficient expertise is developed.
  2. Even experienced physicians should collaborate on these difficult cases
  3. Efforts to improve simulation would be welcome –similar to aviation pilots.

Related blog posts:

Arc de Triomph

Rural Health: “And How Long Will You Be Staying, Doctor?”

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A recent short commentary, (Full Text Link:“And How Long Will You Be Staying, Doctor?”) (H Kovich, NEJM 2017; 376: 1307-9), provides a great deal of insight into rural medicine.

  • “Twenty percent of the U.S. population is rural, but only 11% of physicians practice in rural settings, even though residents of rural areas are older and have worse health indicators.”
  • “Physician supply is driven by where physicians want to live, not by the health needs of the community.”
  • “The nearest tertiary care hospital is another 3 hours away. We don’t refer often.”
  • “Caring for entire families helps me understand my community.”
  • Physicians leaving:  “there is guilt for the person who left, insecurity for the one left behind…Should I leave too? It sounds nice to live in a neighborhood with Trader Joe’s, high-speed internet, and babysitting grandparents.”
  • Patients still ask me [after 7 years] “The Question at least twice a day. “You’re not leaving soon, are you?” …I tell them honestly, I have no plan. I don’t tell them that I’m undecided about buying a new dining-room table…I’m torn between buying a nice one that fits this space and getting a cheap one.  If I move, I might want something different in a new house….[my friend] “Buy a nice one for this space,” she says.”

My take: Currently there are not enough primary care physicians.  Rural settings suffer this deficit disproportionately and it increases inequities.

Related blog post: Zip Code vs. Genetic Code

Notre Dame

FDA Approves Plecanatide (Trulance) for Adults with Idiopathic Constipation

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Here’s the link: FDA approves Trulance for Chronic Idiopathic Constipation (Jan 19.2017).  Plecanatide is a guanylate cyclase-C agonist.

An excerpt:

Trulance, taken orally once daily, works locally in the upper GI tract to stimulate secretion of intestinal fluid and support regular bowel function.

The safety and efficacy of Trulance were established in two 12-week, placebo-controlled trials including 1,775 adult participants. Participants were randomly assigned to receive a placebo or Trulance, once daily. Participants in the trials were required to have been diagnosed with constipation at least six months prior to the study onset and to have less than three defecations per week in the previous three months, as well as other symptoms associated with constipation. Participants receiving Trulance were more likely to experience improvement in the frequency of complete spontaneous bowel movements than those receiving placebo, and also had improvements in stool frequency and consistency and straining.

Trulance should not be used in children less than six years of age due to the risk of serious dehydration… The safety and effectiveness of Trulance have not been established in patients less than 18 years of age.

The most common and serious side effects of Trulance was diarrhea.

Related posts:

Achalasia -Updated Epidemiology

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In this new era of high resolution manometry, there is an increasing incidence of achalasia.

Briefly noted:

JA Duffield et al. Clin Gastroenterol Hepatol 2017; 15: 360-5. In this study from South Australia, using a large database (2004-2013), the annual incidence of achalasia was between 2.3 and 2.8 per 100,000 persons. Mean age at diagnosis was 62 years.

S Samo et al. Clin Gastroenterol Hepatol 2017; 15: 366-73. In a similar study from Chicago, the authors estimated that the yearly city-wide incidence averaged 1.07 per 100,000; however the average in the neighborhood closest to the hospital (and possibly with better case capture) was 2.92 per 100,000.

My take: These studies identified incidence rates that are about double the rates that were reported prior to the availability of high resolution manometry.

Related blog posts:

Breastfeeding and IQ -the Latest Data

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A recent study (JY Bernard et al J Pediatr 2017; 183: 43-50) takes a look at the relationship between breastfeeding, specific polyunsaturated fatty acid (PUFA) levels and intelligence quotient at age 5-6 years.

The authors used the French EDEN cohort with 1080 children.

Key findings:

  • Breastfed children had higher IQs by 4.5 points on Wechsler Scales –though this dropped to 1.3 (not significant) when adjusted for confounders
  • DHA was positively associated with higher IQ.  Children exposed to colostrum high in linoleic acid (LA)/ow in docosahexaenoic acid (DHA) had lower IQs than those exposed to colostrum high in DHA/low LA

The authors speculate that one reason that supplemental DHA has not been shown to be effective could be related to a high intake of LA.

Related article: CT Collins et al. NEJM 2017; 376: 1245-55.  In this study, the authors showed that enteral supplemental of DHA (60 mg/kg) did not result in a lower risk of physiological bronchopulmonary dysplasia in a randomized trial of 1273 born before 29 weeks gestation.

Related blog posts:

With a new ballpark in town, there are a lot of firsts: first HR, first hit, etc. And now this

 

A Better Budesonide for Eosinophilic Esophagitis (Part 2)

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A recent study (ES Dellon et al Gastroenterol 2017; 152: 776-86) provides more data indicating that a premixed solution of budesonide improves eosinophilic esophagitis (EoE). This study complements a recent report highlighted in a blog post earlier this year:

A Better Budesonide for Eosinophilic Esophagitis

In the present study by Dellon et al, the authors performed a multicenter, randomized, double-blind, placebo-controlled, parallel-group trial of 93 EoE patients (ages 11-40).  All patients had dysphagia and active EoE. The active treatment group received 2 mg twice daily.

Key findings:

  • Dysphagia symptom questionnnaire (DSQ) scores improved more in the active treatment group compared to placebo.  At baseline, the DSQ scores were 29.3 and 29.0 respectively.  After 12 weeks, the the scores were 15.0 and 21.5 respectively.
  • Similarly, the active treatment group peak eosinophil counts improved more.  At baseline, the treatment group had a count (per hpf) of 156 and this dropped to 39; in contrast, the placebo group started at 130 and dropped to 113.
  • The overall histologic response (≤6 eos/hpf) was 39% for the treatment group and 3% for the placebo group.
  • No significant adverse effects could be attributed to budesonide.  There was 1 case of esohageal candidiasis.  “There were no notable differences between the groups in cortisol levels.”

My take: Budesonide suspension is useful for EoE but not effective in all patients. A reliable composition from a manufacturer, if not too expensive, would be a big improvement for many kids with EoE. Higher doses of budesonide may be warranted in some cases of EoE.

Related blog posts:

Statue outside the Louvre

Better to Do a Coin Toss than an ENT Examination to Determine Reflux

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A recent study (R Rosen et al. J Pediatr 2017; 183: 127-31) adds additional data to the literature which has shown that ENT doctors are NOT able to tell if there is reflux by examining the airway.

Prior post on this topic: Accuracy of ENT diagnosis of Reflux Changes

This prospective, cross-sectional cohort study of 77 children correlated ENT examinations with “reflux finding score” (RFS) by three blinded otolaryngologists with objective measures of reflux: pH-metry and impedance.  All children had chronic cough and underwent bronchoscopy and esophagogastroduodenoscopy.

Key findings:

  • “There was no correlation between pH-MII variables and mean RFS”
  • The concordance correlation for RFS between ENT doctors was low (intraclass correlation coefficient =0.32)
  • Using pH-metry as a gold standard, the positive predictive value for the RFS was 29% whereas with MII as the gold standard, the positive predictive value for the RFS was 40%.

My take: ENT doctors are unable to tell if a patient has reflux.  The finding of a red or swollen airway has poor predictive value in determining the presence of reflux –a coin toss is more reliable.  Based on this study and others, starting a PPI because of an abnormal airway exam does not make sense.

Related blog posts:

Monet, Musee de l’Orangerie

How Much Do We Really Know About Fecal Microbiota Transplantation?

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A recent study (SJ Ott et al. Gastroenterol 2017; 152: 799-811) followed 5 patients who were treated with a sterile fecal filtrate (via nasojejunal tube) for recurrent Clostridium difficile infection (CDI) for a minimum of 6 months.  This open-label study noted that this fecal filtrate transfer eliminated the symptoms of CDI in all 5 patients.

A summary of this important study is available in the AGA blog:

Here’s an excerpt: What is the Active Ingredient in FMT for CDI?

Stool was collected from 5 donors selected by the patients and fully characterized according to FMT standards. The stool was then sterile filtered to remove small particles and bacteria, and the filtrate was transferred to patients in a single administration via nasojejunal tube.

Fecal samples were collected from patients before and at 1 week and 6 weeks after FFT. Microbiome, virome, and proteome profiles of donors and patients were compared….

They identified about 300 different proteins in each of the filtrates they analyzed—most proteins were of human origin, but the filtrates also contained 20–60 bacterial and fungal proteins. The major human proteins in the filtrate proteome were human enzymes such as intestinal-type alkaline phosphatase, chymotrypsin-like elastases, and α amylases. Bacterial proteins included metabolic enzymes and redox proteins without obvious microbiome-modifying properties, such as glyceraldehyde-3-phosphate dehydrogenase, phosphoenolpyruvate carboxykinase, glutaredoxin-1, or thioredoxin-1…

Ott et al propose that the active component of FMT therapy might not be living bacteria, but bacterial components, antimicrobial compounds of bacterial origin (bacteriocins), or bacteriophages that contribute to a healthy intestinal microenvironment. These could be common to all successful FMT therapies and even rather unspecific regarding the bacterial strain(s) used for therapies. They propose that bacteriophages affect community dynamics of gut microbiota to resolve dysbiosis.

My take: This is a provocative study that challenges us to rethink how FMT works. Ultimately, treating CDI needs to be more precise.

Related blog posts:

 

NY Times: Do DHA Supplements Make Babies Smarter?

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Do DHA Supplements Make Babies Smarter?

Excerpt:

A systematic review of studies published this month by the Cochrane Collaboration concluded there was no clear evidence that formula supplementation with DHA, or docosahexaenoic acid, a nutrient found mainly in fish and fish oil, improves infant brain development. At the same time, it found no harm from adding the nutrient. The findings are consistent with a review of the effects of omega-3 supplements in pregnancy and infancy published by the Agency for Healthcare Research and Quality last fall that found little evidence of benefit.

Still, many experts believe there is value in including DHA in formula. “Even if you can’t easily prove it, because it’s hard to prove developmental outcomes, it makes sense to use it,” said Dr. Steven Abrams, a professor of pediatrics at Dell Medical School at the University of Texas at Austin. “It’s probably a good idea to keep it in there, and it’s certainly safe.”..

The review combined data from 15 randomized controlled trials into a meta-analysis including nearly 1,900 children, many tracked from infancy into mid-childhood. Some studies found small improvements in vision or cognition, but many did not, and when the results were pooled, there was no clear pattern of benefit from DHA added to formula…

 “If you don’t have a deficient population, then it probably doesn’t matter” if people take a supplement, said Dr. Susan Carlson, professor of nutrition at the University of Kansas Medical Center.

But in the United States, many women don’t seem to be getting enough DHA. Women of childbearing age consume an average of 60 milligrams of DHA per day, but many experts recommend at least 200 milligrams per day during pregnancy and breast-feeding.

Quick Take: New Rotavirus Vaccine Stable without Refridgeration.

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A recent study (S Isanaka et al. NEJM 2017; 376: 1121-30) shows that a new low-cost oral rotavirus vaccine is effective and importantly, it does not require refridgeration.

Here is a link to a 1:35 min quick take video summary: Efficacy of a Low-Cost, Heat-Stable Oral Rotavirus Vaccine in Niger