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.

Prevent HPV

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The CDC currently recommends HPV vaccine at 11-12 years of age.  HPV Vaccine Information

Here’s why: NY Times: Close to Half of Americans with HPV

An excerpt:

More than 42 percent of Americans between the ages of 18 and 59 are infected with genital human papillomavirus, according to the first survey to look at the prevalence of the virus in the adult population.

The report, published on Thursday by the National Center for Health Statistics, found that high-risk strains of the virus — a cause of cervical and vaginal cancers, and cancer of the penis, as well as cancers of the anus and throat in both sexes — infect 25.1 percent of men and 20.4 percent of women.

The virus is transmitted by skin to skin contact; people who are infected may pass the virus to sexual partners…

“If we can get 11- and 12-year-olds to get the vaccine, we’ll make some progress,” Dr. McQuillan said. “You need to give it before kids become sexually active, before they get infected. By the time they’re in their mid-twenties, people are infected and it’s too late. This is a vaccine against cancer — that’s the message.”

Related blog post: Latest Vaccine Recommendations

Image Only: Candida Esopagitis

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In a patient who presented with trouble swallowing, his endoscopy showed candida esophagitis.  “Oral antifungal therapy was initiated in the patient, and within 2 weeks after starting therapy, his pain on swallowing was reduced. A repeat endoscopy performed 12 weeks after the initiation of antifungal therapy showed a marked reduction in the number and severity of esophageal lesion.”

Immigrant Doctors Blocked by New Rules Too

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With the U.S. government’s heightened emphasis on stopping immigration into the U.S., there have been noted declines in border crossings; however, it is anticipated that there will be billions in lost income in reduced tourism coincident with the implementation of these policies.

Along with the efforts to curb illegal immigration, new related policies may result in a significant decline in foreign medical graduates allowed to stay in the U.S. through expedited processing of H-1B visas.  This is likely to further strain the care available in rural communities.

From CNN Money: What Trump’s latest H-1B Move Means for Workers and Business

An excerpt:

Thousands of doctors from abroad need H-1B visas to continue working in the U.S. after the expiration of their J-1 visas — which permit them to complete a residency program…

Once they complete their residency, physicians can either return to their home country for two years before becoming eligible to reenter the U.S. through a different immigration pathway, such as an H-1B visa, or they can apply for a J-1 visa waiver.

In the last 15 years, H-1B visas have allowed 15,000 foreign doctors to come to American to work in underserved communities.

“The lack of premium processing would mean that there would be a delay for the doctors to start working in the communities they wish to serve, which have a lack of physicians in the first place,” said Ahsan Hafeez, a doctor who is in Pakistan awaiting approval of his H-1B so he can begin working in Arkansas.

From Internal Medicine News: Foreign doctors may lose US jobs after visa program suspension

An excerpt:

Starting April 3, U.S. Citizenship and Immigration Services (USCIS) is temporarily suspending its expedited processing of H-1B visas, a primary route used by highly skilled foreign physicians and students to practice and train in the United States…

In the meantime, many foreign medical students and physicians will lose top training spots and jobs as their H-1B applications linger in the system, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.

“As a practical matter, the percentages of physicians coming into the U.S. who are accepted into residencies or fellowships, those are the top of the top for medical graduates around the world,” Ms. Minear said in an interview. “Most of them who stay afterward wind up working in underserved areas of the United States. It really doesn’t make much sense as a policy matter to create obstacles to attracting those people to the United States that would prevent them from getting here, obtaining U.S. education, and then remaining in the U.S. and providing urgently needed care to populations that would otherwise go without.”

Related blog posts:

Liver Problems with Inflammatory Bowel Disease

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A recent review (Full text: LJ Saubermann et al. JPGN 2017; 64: 639-52)  discusses the hepatic issues and complications associated with inflammatory bowel disease.

Key topics:

  • Primary Sclerosing Cholangitis (PSC)
  • Autoimmune Hepatitis (AIH)
  • Autoimmune Sclerosing Cholangitis (ASC)
  • Portal Venous Thrombosis/hypercoagulability
  • Cholelithiasis (more common in Crohn’s disease if diseased terminal ileum)
  • Viral hepatitis
  • Drug-Induced Liver Disease
  • Fatty Liver disease

Many of these topics have been discussed previously on this blog.  A couple of pointers in this review:

PSC:

  • Greater risk of colorectal carcinoma
  • IBD-PSC patients are at higher risk for pouchitis
  • GGT of >252 U/L “was highly sensitive (99%) and had good specificity (71%) for PSC” [or ASC]
  • The authors recommend “screening all newly diagnosed patients with IBD with ALT and GGT
  • Immunosuppressive therapy is NOT effective
  • Vancomycin therapy is currently being tested (clinical trials: NCT02137668 & NCT01802073)

AIH:

  • Less frequent in IBD patients than PSC
  • Most common treatment is prednisone/azathioprine
  • 40-80% of children have cirrhosis at AIH diagnosis, but “progression to end-stage liver disease is rare and …with appropriate treatment, 80% of patients achieve remission.”

ASC:

  • ASC is an overlap syndrome between AIH and PSC
  • “It is important that children with IBD and apparent AIH are routinely investigated for evidence of biliary disease with MRCP”
  • “ASC responds to the same immunosuppressive combination therapy used for AIH”

HAV/HBV Immunization:

  • HAV vaccination is effective in patients with IBD…although the rate [seroconversion] was significantly lower” in patients receiving anti-TNF therapy (92.4% vs 99.1% in one study).
  • In those needing HBV immunization: “One strategy evaluated to improve HBV immunity in adults with IBD is an accelerated course with double vaccine doses at 0, 1, and 2 months.”

Methotrexate (MTX):

  • “The extent of histological features of hepatotoxicity secondary to long-term MTX use in IBD has been infrequently described; however, the inicdence of significant abnormal histological findings appears to be rather low.”

My take: This article is a good starting point for liver-related issues in IBD.  For concerns regarding medications, the NIH livertox website is more useful and much more comprehensive.

Related blog entries:

DILI:

PSC:

AIH:

 

 

Increasing Incidence of Hepatocellular Carcinoma in the U.S.

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A recent study (DL White et al. Gastroenterol 2017; 152: 812-20) provide data showing a striking increase in the incidence of hepatocellular carcinoma (HCC). Using data from the US Cancer Statistics Registry which covers 97% of U.S. population, the authors found the following:

  • HCC incidence rose from 4.4 per 100,000 in 2000 to 6.7 per 100,000 in 2012
  • The annual rate of increase was 4.5% from 2000-2009, but then 0.7% annually from 2010-2012
  • The greatest increase occurred in 55-59 year olds (8.9% annually) and 60-64 year olds (6.4% annually)

The main HCC risk factors are HCV, HBV, and alcoholic liver disease, though obesity-associated HCC is emerging as an important risk factor as well.  The highest rates of HCC are seen in southern and western states, with Texas having the highest rates overall.  The high rate in Texas is in part due to the higher rates of HCC in Hispanics.

Overall, the authors indicate that the rising HCC rates are most closely tied to the peak HCV cohort (1945-65) and speculate that the arrival of direct-acting antivirals may help. At the same time, this HCV cohort is composed “disproportionately [of] minorities and of lower socioeconomic status” and may have less access to these advances in treatment.  Furthermore, in states like Texas which did not adopt Medicaid expansion as part of the Affordable Care Act, there are more uninsured patients who will be less likely to identify preceding risk factors for HCC.

My take: Perhaps in 20 years, we will see HCC incidence maps that are improving as HCV treatments become more widely available.  This presumes that other HCC risk factors, including obesity and alcohol, do not worsen significantly.

Related blog posts:

Safety of Long-term Adalimumab in Pediatrics; Weighted PCDAI

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A recent study (W Faubion et al. Inflamm Bowel Dis 2017; 23: 453-60) reports on the long-term safety/effectiveness of Adalimumab in pediatric patients entering the IMAgINE 2 trial (& who completed the 52 week IMAgINE 1 trial).

Patients with a PCDAI <10 were considered to be in remission and those who had a drop in PCDAI of 15 or more were considered to have had a treatment response.

Key findings:

  • Of the 100 patients enrolled in IMAgINE 2, 41% achieved remission and 48% had a treatment response at week 240.
  • >80% of patients were “able to discontinue use of corticosteroids.”
  • Adalimumab treatment was associated with growth normalization.
  • No new safety signals were identified.

While this study provides some reassurance regarding long-term adalimumab use, it should be noted that the instruments used to assess efficacy in this trial (& many others) are suboptimal.

A recent study (D Turner et al. JPGN 2017; 64: 254-60) showed that PCDAI (and several similar versions) had “poor correlation with calprotectin” and none of the PCDAI versions “can give a valid assessment of mucosal healing.”  This study had used prospectively collected data from the ImageKids study of 100 children with Crohn’s disease.  For the weighted PCDAI, the “best cut-off to identify endoscopic mucosal healing was <12.5 points” with a sensitivity of 58% and specificity of 84%.\

wPCDAI:

History: (recall 1 week):

  • Abdominal Pain  0=None, 10=Mild (does not interfere with activities, brief), 20=Moderate/Severe
  • Patient functioning 0=No limitations, 10=Occn difficulty with activities (below par), 20=frequent limitations
  • Stools per day 0=0-1 liquid stools, no blood, 7.5=up to 2 semiformed stools with blood or 2-5 liquid nonblood, 15=Gross bleeding or ≥6 liquid stools or nocturnal diarrhea

Laboratory

  • ESR 0 points if <20, 7.5 points if 20-50, 15 points if >50
  • Albumin 0 points if ≥3.5 g/dL, 10 points if 3.1-3.4 g/dL, and 20 points if ≤3.0 g/dL

Examination

  • Weight 0= Weight gain or stable or voluntary weight loss, 5=involuntary weight loss 1-9% or involuntary weight stable, 10= weight loss ≥10%
  • Perirectal Disease 0=None or asymptomatic tags, 7.5= 1-2 indolent fistula, scant drainage, no tenderness, 15=active fistula, drainage, tenderness or abscess

Extraintestinal Manifestatons: Fever for 3 days (≥38.5), definite arthritis, uveitis, erythema nodosum, or pyoderma gangrenosum

  • Points: 0=None, 10 ≥1

Total Score 0-125: ______________________

As compared with PCDAI, the weighted PCDAI drops height velocity, abdominal examination, and hematocrit.  Turner et al note “their exclusion does not mean that they have no role in reflecting disease activity, but that the other included items, as a whole, are inclusive of the contribution of the 3 items.” Also, the weighted PCDAI simplifies the “extraintestinal manifestation” into a simple choice; overall, this affects few scores due to the low frequency of these manifestations.

Related blog posts:

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: