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.

Mobile Technology Medicine Improves Bystander CPR

Posted on June 28, 2015 by gutsandgrowth

A recent study (Ringh M, et al. NEJM 2015; 372: 2316-25) shows that the ubiquitous nature of mobile phones/smartphones can lead to improved rates of bystander CPR.

The authors conducted a blinded, randomized controlled trial in Stockholm (2012-2013) using a mobile-phone positioning system. The intervention group had trained bystanders dispatched who were within 500 meters of individuals with out-of-hospital cardiac arrest. The control group received standard care. The primary outcome was bystander-initiated CPR before the arrival of ambulance, fire, and police services.

Key finding: With a network of 9828 trained volunteers, the intervention group had CRP initiated in 62% (188 of 305) compared with 48% for the control group (172 of 360)

The associated editorial (pg 2349-50) notes that in the U.S., every hour there are 38 people who have out-of-hospital cardiac arrest and fewer than 1 of 10 survive. They note they timely CPR improves survival rate. In a previous study, provision of CPR prior to EMS arrival increased survival from 4.0% to 10.5%. Besides technological limitations in the U.S., another potential barrier for trained bystanders would be allowing access to their location at all times and the “fear of being sued if they do not respond to a call.”

Bottomline: While there are barriers to be overcome, this is another example of reimagining the uses of new technology and developing a truly interconnected health network.

Dungeness, Cumberland Island

The Upside of Too Much Screen Time

Posted on June 27, 2015 by gutsandgrowth

Briefly noted: A recent study (Campbell LB, et al. J Pediatr 2015; 166: 1505-13) has shown a reducing incidence of melanoma in children and adolescents in the U.S. during the 2000-2010 study period. This study used data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry. In adolescents, between 2003-2010, the rate of this very rare cancer decreased ~11% per year from 2003-2010.

While the authors do not know the reason for this improved trend, besides speculation about improved used of sunscreen, they also speculate that decreased time spent outdoors may be a factor. My hunch is that this is a much more likely a contributor to this trend due to the pervasive nature of television, computers and other electronic devices.

Cumberland Island

Money Matters in Pediatric Inflammatory Bowel Disease

Posted on June 26, 2015 by gutsandgrowth

A very pragmatic article (Sin AT et al. Inflamm Bowel Dis 2015; 21: 1368-77) describes the out-of-pocket cost burden in pediatric inflammatory bowel disease (IBD). For anyone who lives on planet earth, how much a procedure or treatment costs weighs very heavily on many decisions. This is particularly relevant in pediatric IBD.

In a cross-sectional cohort analysis, the researches collected data with surveys from 150 parents of children with IBD (67 Crohn’s disease, 83 Ulcerative colitis). The median patient age was 14 years.

Findings:

Annually, out-of-pocket expenses were >$5000 in 5.3%, >$1000 in 28.6%, and >%500 in 63.6%.
Increased expenditures were derived from the following: emergency department visits with 36% having had an ED visit in past year, procedures/testing with 20% who spent >$2000, and from treatments (medications/diet). 10.7% reported missing medications due to cost.
“Families with household incomes between $50,000-100,000 had a statistically-significant probability (80.6%) of higher annual OOP costs than families with lower income…or higher income.”
Not surprisingly, patients with IBD “who have relapsing or uncontrolled IBD states are particularly at risk to require acute care services, which represent high OOP costs for families.”
The authors also describe missed workdays and lost wages as another financial burden.

Take-home message: This study helps quantitate the out-of-pocket expenses and financial burden that families face when they have a child with IBD. In some patients, improved control of IBD will lower these expenses by decreasing costs from emergency department visits, office visits, and hospitalizations.

Cumberland Island

PCDAI -Not Good Enough

Posted on June 25, 2015 by gutsandgrowth

Two articles reinforce the view that the pediatric Crohn’s Disease activity index (PCDAI) is not good enough to rely on for research and for clinical practice.

Sun H et al. JPGN 2015; 60: 729-36
Vubin G, Peter L. Inflamm Bowel Dis 2015; 21: 1386-91

The first article is a review of the PCDAI and its derivatives (abbreviated, short, modified, and weighted) as well as the Harvey-Bradshaw Index (HBI). Key points:

There was an “absence of evidence demonstrating correlation with clinically relevant inflammation.”
“Available evidence indicates that CDAI, HBI, and 5 versions of PCDAI lack adequate measurement properties for use as a primary endpoint for phase 3 trials.”
“Endoscopic or radiology-based mucosal and histological examination may need to be considered as 1 outcome measurement.”

The second article describes a prospective cohort of 24 newly diagnosed children (<16 years). The authors found the following:

At diagnosis, PCDAI had poor correlation with endoscopic disease activity (SES-CD)
After induction: 11/24 had inactive disease based on SES-CD; however, PCDAI had poor correlation. Many children with active disease (SES-CD ≥3) had normalization of PCDAI as well as CRP.
Fecal calprotectin had better correlation.

Take-home point: These articles add to the growing literature regarding the lack of reliability of clinical activity indices.

Related blog posts:

Cumberland Island

Soiling Stinks!

Posted on June 24, 2015 by gutsandgrowth

The initial title of this post was too boring: “Documenting the Detrimental Effects of Fecal Incontinence on Quality of Life”

In perhaps one of the least surprising conclusions, the authors of a recent study (Kovacic K, et al. J Pediatr 2015; 166: 1482-7) have shown that “fecal incontinence significantly decreases quality of life compared with functional constipation alone in children.” This multicenter prospective study surveyed families of 410 children (2-18 years).

Despite the obvious findings, I still think that the burden of fecal incontinence is underestimated by families and practitioners. Here is an excerpt from this article’s discussion:

“Fecal incontinence impairs general functioning for children and their families…[it] is an insidious burden with substantial economic impact and adverse effects on quality of life…this effect increases as children approach adolescence…The devastating effect of fecal incontinence on quality of life and social functioning make it imperative that health professionals address defecation disorders proactively. When aggressive and appropriate medical therapies are unable to provide a satisfactory outcome, then a multidisciplinary approach or a surgical option (e.g. cecostomy tube for antegrade enema) may be justified.”

Bottomline: Soiling stinks! We need to keep working on this problem even if aggressive interventions are needed.

Related blog posts:

Not Letting Go of a Log -Can Lead to Problems

Modest Evidence That Antidepressants Improve Functional Esophageal Disorders

Posted on June 23, 2015 by gutsandgrowth

A systematic review (Weijenborg PW, et al. Clin Gastroenterol Hepatol 2015; 13: 251-9) identified 15 randomized, placebo-controlled trials as well as 1 conference abstract and 2 case reports that provided evidence that antidepressants can be helpful for esophageal pain.

Antidepressants that were included included tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Table 1 list the studies; most of these drugs were dosed at low doses (eg. TCAs typically 25-50 mg).

Key findings:

Esophageal pain thresholds increased by 7% to 37% after antidepressant therapy
Functional chest pain improved by 18% to 67%
Heartburn improved over a range of 23% to 61%

Take-home message (from authors): “The results of the trials included in this systematic review provide modest evidence that both TCAs and SSRIs modulate esophageal sensation and reduce functional chest pain.”

Related blog posts:

Cumberland Island

“Some Hospitals Marking Up Treatments By as Much as 1000%”

Posted on June 22, 2015 by gutsandgrowth

Why is it that I don’t find the title of a recent NBC report surprising?

NBC Summary of Recent Study: “Some Hospitals Marking Up Treatments By as Much as 1000%”

Here is an excerpt:

Twenty of the hospitals in the top 50 when it comes to marking up charges are in Florida, the researchers write in the journal Health Affairs. And three-quarters of them are operated by two Tennessee-based for-profit hospital systems: Community Health Systems and Hospital Corporation of America…

Hospitals negotiate different rates with different payers.

Then there are in-network and out-of-network rates. And patients often don’t know until after they’ve received a treatment whether their insurance will pay for it, or for the doctors who delivered it…

States can and should regulate what hospitals charge. Maryland sets hospital rates but is the only state that does. West Virginia regulates rates, while only California and New Jersey have state legislation that requires for-profit hospitals to offer discounts to eligible uninsured patients.

My personal experience

Recently, a hospital on the northside charged my family in excess of $3000 for handling/processing an outpatient biopsy specimen (not pathologist interpretation) which was at least 10-fold what an independent pathology lab charged for the same service. When I received the bill, I was quite upset. The physician who sent out the specimen did not inform me that he intended to send the specimen to this hospital and seemed to have no idea about the costs.

I am certain that if I were given the choice of several pathology labs for processing that I would not have been convinced that there was added value in the specimen going to the hospital.

As a physician, when families ask me how much a procedure is going to cost, it is usually not an easy question and often requires a fair amount of research, particularly if the something involves a procedure at the hospital.

Take-home message: How is it that in this information era that medical costs are not transparent?

Unfortunately, you really do not know how good your medical coverage is until you find out through personal experience.

Related blog posts:

Sandy Springs

Watch Vitamin Levels in Shwachman-Diamond Syndrome

Posted on June 21, 2015 by gutsandgrowth

According to a recent small retrospective study in Pancreas (May 2015 – Volume 44 – Issue 4 – p 590–595) with 21 children, there were high rates of vitamin deficiencies (particularly vitamin A) and selenium deficiency.

Nutritional Status in Children with Schwachman-Diamond Syndrome

From abstract:

Results: Twenty patients (95%) had pancreatic insufficiency receiving PERT, 10 (47%) had a combined vitamin and trace element deficiency, 6 (29%) had an isolated vitamin deficiency, and 4 (19%) had an isolated trace element deficiency. Vitamins A and E deficiency occurred in 16 (76%) and 4 (19%) of 21, respectively. Low serum selenium was found in 10 (47%), zinc deficiency in 7 (33%), and copper deficiency in 5 (24%). Eleven patients (52%) were on multivitamin supplementation, and 2 (10%) on zinc and selenium supplements. No statistical differences were found between repeated measurements for all micronutrients.

Conclusions: More than 50% of the children had vitamin A and selenium deficiencies despite adequate supplementation of PERT and supplements. Micronutrients should be routinely measured in SDS patients to prevent significant complications.

Less Litigation: Better Communication, Not More Testing

Posted on June 20, 2015 by gutsandgrowth

A recent NY Times articles sums up articles over more than two decades which show that better communication, rather than more testing, reduce malpractice lawsuits.

To Be Sued Less, Doctors Should Consider Talking to Patients More

An excerpt:

As far back as 1989, a study of obstetricians in Florida found that about 6 percent of obstetricians accounted for more than 70 percent of all malpractice-related expenses over a five-year period… Doctors who are sued are different in some way from those who aren’t…Some doctors were more likely to be sued, regardless of whether the cases against them were eventually found to have merit…

Doctors sued most often were complained about by patients twice as much as those who were not, and poor communication was the most common complaint…

At the University of Michigan about 15 years ago, a program was begun to improve communication around medical errors. When errors occurred, the program encouraged physicians to tell patients about them, how they happened, and what would be done to make them less likely to occur in the future. Doctors were also encouraged to apologize, and offer compensation for harm if it occurred.

A study of the program published in 2010 found that in the years after it began claims dropped 36 percent, and lawsuits dropped 65 percent. The monthly cost of total liability and patient compensation dropped 59 percent, and legal costs dropped by 61 percent.

A later study, published last year, looked at how the program affected gastroenterology claims and costs. It found that despite a 72 percent increase in clinical activity, the rate of claims per patient encounters dropped 58 percent…The total cost to the health care system of malpractice in gastroenterology decreased by 64 percent.

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From Hammock

10 Years of Anxiety and Upper Endoscopy Correlation

Posted on June 19, 2015 by gutsandgrowth

A recent 10-year Swedish study (Aro P, et al. Gastroenterol 2015; 148: 928-37) provided further evidence of a link between anxiety, but not depression, and functional dyspepsia (FD).

This study took a group of 1000 individuals who had been randomly selected to undergo upper endoscopy, the Abdominal Symptom Questionnaire, and the Hospital Anxiety and Depression Scale Questionnaire (1998-2001). Among the 887, who completed the initial portion of the study, 703 subjects were available for followup study in 2010.

FD was defined in this study based on the Rome III definition: weekly bothersome postprandial fullness or early satiety; epigastric pain or burning without organic findings on endoscopy. FD was further divided into postprandial distress syndrome which consisted of postprandial fullness or early satiety or epigastric pain syndrome.

Key findings:

At baseline, 15.6% of subjects had FD. At followup, 13.3% had FD including 48 new cases.
Anxiety at baseline was associated with new-onset FD at the followup evaluation with an odds ratio of 7.6.
Anxiety was also associated with postprandial distress syndrome at baseline with an odds ratio of 4.83.

Take-home point: Anxiety often precedes functional dyspepsia. This association was not evident with depression.

Related blog posts:

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.

Zoo Atlanta