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.

Lost Decade from Smoking

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A recent study (NEJM 2015; 372; 631-40) showed that smoking is more deadly than previously estimated.  Key points:

  • Deaths per year due to smoking: a new analysis suggests the true figure may be closer to 575,000.  That equates to 1 death in every 5 in the United States.
  • Smoking is thought to shorten life expectancy by more than one decade!
  • The 21 causes of death that have been officially blamed on smoking accounted for only 83% of the actual deaths among smokers

Here’s a link to a summary of the article:  Cigarette Smoking is Even More Deadly Than You Thought (from LA Times)

Related blog post:

From NPR: Enormous Ice Formations at Niagara Falls:

From NPR

From NPR

Accelerated Infliximab Dosing in Acute Severe Ulcerative Colitis -plus one link

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A small retrospective study (n=50) suggests that more rapid induction with infliximab may improve response and lower colectomy rate in acute severe ulcerative colitis (UC).

Link: Accelerated Infliximab in Acute UC

Here’s the abstract:

Background & Aims

Administration of infliximab to patients with acute severe ulcerative colitis (ASUC) (rescue therapy) can reduce the rate of early colectomy (within 12 months), but long-term rates of colectomy are the same as those of the pre-biologic era for these patients. The half-life of infliximab is shorter in patients with ASUC than in patients with non-severe UC, so more frequent dosing might be required to produce a therapeutic effect.

Methods

We performed a retrospective analysis of 50 hospitalized patients who received infliximab for steroid-refractory ASUC at a single academic center from September 2005 through 2013. In 2011 an accelerated dosing strategy for infliximab was introduced; we compared outcomes of standard and accelerated dosing regimens. One group of patients (n = 35) were placed on a standard dosing regimen for infliximab and then given the drug at 0, 2, and 6 weeks and then every 8 weeks thereafter. A second group (n = 15) were placed on an accelerated regimen and received 3 induction doses of infliximab within a median period of 24 days. Rates of colectomy were compared between the groups during induction and follow-up periods.

Results

There were no differences between groups in median baseline levels of C-reactive protein, albumin, or hemoglobin. The rate of colectomy during induction therapy was significantly lower with the accelerated regimen (6.7%, 1 of 15) than with the standard regimen (40%, 14 of 35) (Fisher exact test, P = .039). The standard regimen was associated with shorter time to colectomy (log-rank test, P = .042). Among patients who completed induction therapy, subsequent need for colectomy was similar between the groups during the follow-up period. Multivariate analysis showed that factors independently associated with successful induction therapy were level of albumin (g/L) when the treatment began (P = .003) and the accelerated dosing regimen (P = .03).

Conclusions

In patients with ASUC, an accelerated infliximab induction strategy reduces the need for early colectomy. An intensified infliximab dosing strategy in response to clinical or laboratory signs of breakthrough inflammation merits consideration in prospective studies.

One other link: IBD and College: Do the two play nicely (from Jeremy Adler and UofM) -describes college transition issues for our IBD patients.  Probably the most important piece of advice: “Take your medicine.”  Many really good kids decide to see what happens off therapy, often to their detriment.

How Effective are the Treatments for Functional Abdominal Pain?

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According to a recent systematic review (Korterink JJ et al. J Pediatr 2015; 166: 424-31), “there is no evidence to support routine use of any pharmacologic therapy” for pediatric functional abdominal pain (FAP).  How many pediatric gastroenterologists want to discuss this conclusion with their patients?

How did the authors reach their conclusion?

Design: The authors screened 557 articles and ultimately identified only four articles with a total of 6 studies met inclusion criteria which included the following:

  • systemic review or randomized control trial
  • children 4-18 years
  • diagnosis of FAP established with well-defined criteria
  • intervention was compared to placebo or alternative treatment

Results: All of the studies were reviewed –each received an overall quality rating by the authors as “very low.” The particular treatments included amitriptyline, peppermint oil, famotidine, miralax, tegaserod, and cyprohepatadine.  The study with the most patients had only 90 patients and the longest treatment period was 4 weeks.

In the discussion, the authors make several key points:

  • there is a lack of adequately powered, high-quality, placebo-controlled drug trials in children with FAP
  • weak evidence was found in support of peppermint oil, cyproheptadine, and laxatives at reducing pain; amitriptyline and famotidine had weak evidence supporting some improvement in global symptoms or quality of life.
  • problems with the studies: small sample sizes, poorly reported side effects, lack of follow-up, risk of bias
  • “several nonpharmacologic therapies (e.g.. hypnotherapy and cognitive behavioral therapy) have shown their efficacy in treating children with” FAP…with success rates up to 85%.  Moreover, these therapies are not hampered by severe side effects.”

Bottomline: Our office-based psychologist may be more helpful for our patients than all the medications combined.

Related posts:

How to Reduce Suffering

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A recent NY Times article (yesterday) discussed ways to reduce patient suffering and improve physician/hospital evaluations: Doctors Strive to Do Less Harm

  • Minimize waking patients up at night.  Eliminate waking patients up for vital signs and blood draws.
  • Reduce waiting times.
  • Spend more time listening.

Related blog posts:

 

 

Increased Narcotic Usage in Pediatric Patients with IBD

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A summary from the AGA Journals Blog of a recent article highlights the increased use of chronic narcotics, not related to surgery, in pediatric patients with IBD.

Here’s a link:  Chronic Use of Narcotics in Children with IBD and here’s an excerpt:

Jessie P. Buckley et al used data from a large insurance claims database, collected from 2010 through 2011, to compare the prescription narcotic use among children (younger than 18 years old) with and without IBD who were not undergoing surgery. Buckley et al also searched for factors associated with narcotic treatment of pediatric patients with IBD.

Of 4344 children with IBD during the study period, 63% had Crohn’s disease, and 37% had ulcerative colitis.

Buckley et al found that 5.6% among children with IBD vs 2.3% in the general population received chronic narcotic therapy. Associations between IBD and narcotic use revealed a particularly high burden among children with concomitant anxiety or depression.

Cover of Clinical Gastroenterology & Hepatology

Cover of Clinical Gastroenterology & Hepatology –The pills look cool but wrong age depicted

Will Fitness Devices (like your phone) Help?

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A recent NY Times article reviewed a JAMA study looking at the 10 new devices geared at measuring activity. Better Fitness Through Your Phone

N of 1: As a personal aside, since I know that big brother (ie. my phone) is watching and I want to compare favorably to my wife, I definitely am taking more steps and using the stairs a bit more.

Here’s an excerpt:

The pedometer and the accelerometers were generally quite accurate, but one of the wristbands, the Fuelband, underreported the number of steps the volunteers had taken by more than 20 percent.

Others of the monitors were more accurate but, by and large, no more so than the smartphone apps, which cost much less and would likely be more convenient for many people.

The upshot, said Dr. Mitesh S. Patel, an assistant professor of medicine at the University of Pennsylvania who oversaw the study, is that smartphones could offer “an easy, less expensive, but still accurate” means for people to track their activity.

But the broader issue, as Dr. Patel and his colleagues pointed out in a related commentary published recently in JAMA, is that no fitness tracker of any kind has yet proved able to motivate people disinclined to exercise to start moving

Changing Story Regarding Dietary Cholesterol

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From USA Today: Limiting Dietary Cholesterol May Not Be Needed

Here’s an excerpt:

In a draft report issued in December, an influential federal panel — the Dietary Guidelines Advisory Committee — scrapped longstanding guidelines about avoiding high-cholesterol food…The committee will send its final recommendations to the Department of Health and Human Services and the U.S. Department of Agriculture, which issue the dietary advice. Those departments are expected to issue Dietary Guidelines for Americans, 2015 later this year…

“It’s the right decision,” said Steven Nissen, chairman of cardiovascular medicine at the famed Cleveland Clinic. “We got the dietary guidelines wrong. They’ve been wrong for decades.”

He noted that only 20% of a person’s blood cholesterol — the levels measured with standard cholesterol tests — comes from diet. The rest comes from genes, he said.

“We told people not to eat eggs. It was never based on good science,” Nissen said.

Advice to avoid foods high in fat and cholesterol led many Americans to switch to foods high in sugar and carbohydrates, which often had more calories. “We got fatter and fatter,” Nissen says. “We got more and more diabetes.”

Related blog posts:

Good News for Starbucks & Coffee Vendors

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This blog has posted a number of favorable reports on coffee, even though I’m not a coffee enthusiast.  In general, coffee has favorable health effects when it is not paired with alcohol or tobacco.

A recent coffee study (Gastroenterol 2015; 148: 118-25) shows an association between coffee intake and reduced incidence of liver cancer and death from chronic liver disease in the U.S.

Here’s a link to a summary of the article: GastroHepNews Coffee and Liver Disease

  • During an 18-year follow-up period, there were 451 incident cases of hepatocellular carcinoma and 654 deaths from chronic liver disease.
  • Compared with non-coffee drinkers, the researchers noted that those who drank 2–3 cups per day had a 38% reduction in risk for hepatocellular carcinoma.
  • Those who drank ≥4 cups per day had a 41% reduction in hepatocellular carcinoma risk.
  • Compared with non-coffee drinkers, participants who consumed 2–3 cups coffee per day had a 46% reduction in risk of death from chronic liver disease, and those who drank ≥4 cups per day had a 71% reduction.
  • The inverse associations were similar regardless of the participants’ ethnicity, sex, body mass index, smoking status, alcohol intake, or diabetes status.

Related blog posts:

More liver-related news: Man with infected hepatitis C sentenced to 3 years for spitting in officer’s face (from The Republic/AP News)

Does Anyone Know Why This Toilet is in our Parking Garage?

Does Anyone Know Why This Toilet is in our Office Parking Garage?

More Evidence to Support Ethanol Locks

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For many years, ethanol locks have been promoted as a way to reduce central catheter-associated bloodstream infections (CCABSI).  A recent study (Ardura M I, et al. JAMA Pediatr.doi.10.1001/jamapediatrics.2014.3291 -published online Feb 2, 2015, thanks to Ben Gold for this reference) showed a dramatic reduction in CCABSI among 24 children with intestinal failure.

This study examined outcomes from January 2011-Jan 2012 with the outcomes from February 2012-December 2013.  In the latter period, ethanol lock prophylaxis was added to the CCABSI “prevention bundle” both in inpatient and outpatient settings.

Key finding: Rates of CCABSI decreased from 6.99 per 1000 catheter days to 0.42 per 1000 catheter days.

One aspect of this study that is very important is that the QI team included a specialized CVC nurse who evaluated and performed all CVC care and teaching.

Their protocol is detailed in their methods section.  Some of the details:

  • Their ethanol lock utilized a 70% solution on a daily basis.
  • The CVC nurse verified that the catheter was silicone prior to initial lock.
  • CVC nurse used Alteplase prior to initial dwell.
  • Dwell volume was determined by CVC nurse by withdrawing flush until blood return and then adding 0.1 mL for children <15 kg and adding 0.2 mL for children >15 kg (max volume 3 mL).
  • Dwell times were minimum of 2 hours and maximum of 24 hours.
  • At the end of the dwell time, twice the amount of the predetermined ethanol volume was withdrawn and then 5 to 10 mL of normal saline was used as a flush.

Bottomline: Ethanol locks have the potential to reduce CCABSI by 90%; this can reduce hospitalizations, prevent complications, and possibly improve survival.

Related blog posts:

Heart-Shaped Polyp (from ACG twitter feed -recommends screening colonoscopy)

Heart-Shaped Polyp (from ACG twitter feed -recommends screening colonoscopy)

How Commonly Does Cystic Fibrosis Present as Rectal Prolapse?

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Since residency, I have understood that patients with cystic fibrosis patients could present with rectal prolapse.  Yet, I can recollect only one instance in which a family told me that rectal prolapse was a presenting feature in the diagnosis of their child.  It turns out that rectal prolapse is a little less common as a presenting feature, at least these days, and that the majority of cases occur in individuals with cystic fibrosis who have already been diagnosed (JPGN 2015; 60: 110-12).

In this retrospective study (2000-2010), there were 262 patients with rectal prolapse identified: 65% were male and mean age was 4 years 8 months.  Newborn screening for cystic fibrosis(1994 in Wisconsin) had preceded the study period.

The most common reason for rectal prolapse was constipation (52.1%), and then acute diarrhea (12%).  Only 3.6% had cystic fibrosis. Two patients were diagnosed with cystic fibrosis based on testing performed due to rectal prolapse; the remaining five had already been diagnosed.

The authors note that among their cystic fibrosis population that 3.5% also had rectal prolapse.

Take-home message: In patients with rectal prolapse, testing for cystic fibrosis has a low yield in the era of newborn screening but is probably still necessary.

Boat in Chicago Marina

Boat in Chicago Marina –Like the Name?