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.

IBD Incidence Increasing: 30 Years of Data from Manitoba

Posted on January 5, 2015 by gutsandgrowth

A recent study (JPGN 2014; 59: 763-66) shows a steady trend of increased incidence of IBD in Manitoba. This figure is available online:

Increasing IBD Incidence in Children from JPGNonline

Abstract:

Objectives: The aim of this study was to describe the incidence and prevalence of inflammatory bowel disease (IBD) in children <17 years of age in 30 years from 1978 to 2007.

Methods: From January 1, 1978, to December 31, 2007, the sex- and age-adjusted annual incidence and prevalence of pediatric IBD per 100,000 population were calculated based on the pediatric IBD database of the only pediatric tertiary center in the province. The annual health statistics records for the Province of Manitoba were used to calculate population estimates for the participants. To ensure validity of data, the University of Manitoba IBD Epidemiology Database was analyzed for patients <17 years of age from 1989 to 2000.

Results: The sex- and age-adjusted incidence of pediatric Crohn disease has increased from 1.2/100,000 in 1978 to 4.68/100,000 in 2007 (P < 0.001). For ulcerative colitis, the incidence has increased from 0.47/100,000 in 1978 to 1.64/100,000 in 2007 (P < 0.001). During the same time period, the prevalence of Crohn disease has increased from 3.1 to 18.9/100,000 (P < 0.001) and from 0.7 to 12.7/100,000 for ulcerative colitis (P < 0.001). During the last 5 years of the study the average annual incidence of IBD in urban patients was 8.69/100,000 as compared with 4.75/100,000 for rural patients (P < 0.001).

Conclusions: The incidence and prevalence of pediatric IBD are increasing. The majority of patients were residents of urban Manitoba, confirming the important role of environmental factors in the etiopathogenesis of IBD.

Unrelated: As a bonus for those who made it to the bottom of this post : there’s a new Bristol Stool App for iPhones. Here’s the link: http://www.bristol-stool-scale.com (from John Pohl’s twitter feed)

Prenatal Testing, Statistics, and Life-Altering Decisions

Posted on January 4, 2015 by gutsandgrowth

Much of my day is spent interpreting lab work. Sometimes it is very easy but not always. Many families and health care professionals do not understand the concepts of sensitivity, specificity, positive predictive value and negative predictive value. These values are affected greatly by the prevalence of the condition (or disease) that is being tested for in a specific population.

For many conditions, doctors prefer a highly sensitive test. Tests that are highly sensitive will detect almost all of the individuals with the condition (or disease) being tested for and miss very few people (false-negative) with the condition. However, tests that are very sensitive often detect individuals who do not have the condition (false-positives). Therefore, when using tests with high sensitivity, more precise followup tests can determine conclusively if the condition (or disease) is present with much greater specificity.

A report from NBC news highlights how tests that are billed as “99 percent” accurate can be quite difficult to interpret and could lead to abortions of healthy fetuses. Here’s the link: Sensitivity, Positive Predictive Value, and Prenatal Testing

Here’s an excerpt:

Positive results can be wrong 50 percent or more of the time…Noninvasive prenatal tests, or the “cell free DNA test,” are merely screening tests of placental DNA found in the mother’s blood…

The true likelihood that a positive test is positive depends on another calculation — the positive predictive value or PPV, which factors in other variables, such as a woman’s age and the prevalence of the disease in that population…

A woman over 35 where genetic disorders are more common — the likelihood of Trisomy 18 given a positive screening result is about 64 percent. For a younger woman, the PPV would be under 50 percent, according to the investigation.

Another example of understanding tests and statistics involves mammograms. The relatively low reduction in averted cancer deaths related to mammograms has been discussed previously on this blog (see links below). A good infographic and description is also available at NPR. Here’s the link: What happens after your mammogram

Related blog posts:

Blue-footed Booby

Enthusiasm for Vedolizumab

Posted on January 3, 2015 by gutsandgrowth

A recent GI & Hepatology News article quoted several leading IBD researchers stating that they consider Vedolizumab a first-line biologic therapy for ulcerative colitis. Here’s the link:

Vedolizumab for UC

Here’s an excerpt:

Dr. Feagan presented outcome results after 80 and 104 weeks of vedolizumab treatment of 278 patients with ulcerative colitis who had completed a full year of treatment during the GEMINI 1 trial [Phase 3, Randomized, Placebo-Controlled, Blinded, Multicenter Study of the Induction and Maintenance of Clinical Response and Remission by Vedolizumab in Patients with Moderate to Severe Ulcerative Colitis] (N. Engl. J. Med. 2013;369:699-710). He reported that the percentage of patients in clinical remission grew from 66% after 52 weeks on treatment (the time of entry into the long-term phase of the study), to 77% after 80 weeks, which then dropped to 73% after 104 weeks. Patients with a clinical response increased from 78% after 52 weeks to 88% after 80 weeks, and then dropped to 83% after 104 weeks.

During weeks 53-104 on treatment the rates of adverse events, serious adverse events, serious infections, adverse events resulting in treatment discontinuation, enteric infections, and malignancies were all low and similar to the event rates seen among the patients randomized to placebo in the GEMINI 1 study.

The results suggest that with vedolizumab treatment of inflammatory bowel disease “once you achieve an effect it is long-lasting,” Dr. Rutgeerts said in an interview. But he cautioned that the long-lasting efficacy was achieved with treatment every 4 weeks. While this approach was safe, it would also be expensive in routine practice, he noted. “The safety looks good, but the cost would be very high.”

“A key concept of vedolizumab is that it builds efficacy over time,” commented Dr. Silvio Danese during a talk at the meeting. “Vedolizumab is not the fastest runner, but [treating inflammatory bowel disease] is a marathon, and the important thing is getting to the finish”

Bottomline: Head-to-head trials would be helpful to determine which biologic agent should be considered first-line.

Related blog posts:

Personal Look at 20 Years of Doctoring (Part 2)

Posted on January 2, 2015 by gutsandgrowth

“. . . For the secret of the care of the patient is in caring for the patient.”

“These words, burned indelibly into the minds of generations of medical students, closed a lecture given by Francis W. Peabody to Harvard students on October 21, 1925” (N Engl J Med 1993; 328:817-818).

Still Striving to Be the Best

Yesterday, I noted how difficult it is to ‘get away from it all.’ Both technology and empathy are to blame. The flip side of the message is that I still want to be the best.

In medical school I was eager to read so many books that discussed what it meant to be a physician. Now having worked as a physician for 20 years I have my own thoughts. On an abstract level, it is easy to say that you want to be the best physician. To accomplish the task, you work really hard, you read everything you can, you listen intently, and you set aside enough time to think carefully.

Yet, that still is not enough. As a practical matter, it is not so easy to be the best at anything. The biggest problem is that there are other people who are really terrific. How can I be the best when there is always someone smarter, funnier, and more empathetic? In medical school, I was given a few pieces of advice:

‘After 5 years of practice, all of your patients will love you….those that don’t will see someone else.’

‘There are three A’s to being a great physician. Availability, affability, and ability. Since most people have difficulty judging ability, you will probably be judged more on the first two.’

Perhaps, the logical conclusion is that I might be the best physician for some patients and not for others. At this point, I will have to be content with knowing that I am still trying to be as good as I can be.

“When you reach for the stars, you may not quite get one, but you won’t come up with a handful of mud either.” Leo Burnett

If you are a reading this blog, what are you doing to be the best?

Personal Look at 20 Years of Doctoring (Part 1)

Posted on January 1, 2015 by gutsandgrowth

As I start the new year, I decided that instead of reviewing an article, I would begin by sharing some personal thoughts.

It’s Harder Than Ever to Take a Vacation

When I was in high school, I often had some trouble getting to sleep. I had so many ideas rushing through my head about what I wanted to do and what I needed to do the next day, the next week, the next month and so on. One trick I learned was to teach myself to write down these thoughts before I went to bed and to pick them up when I woke up. So when I went to bed, I knew I would not forget all these urgent ideas. After a while I realized that I really did not need to write everything down, but went through the same mental process of putting the ideas aside until the morning. This helped a great deal and I’ve been a good sleeper for a long time. In fact, when I started residency, at first I would sleep through pager alarms.

In medical school, I learned about the idea of dissociation. For me, at that time, this meant focusing on a clinical problem without worrying a lot about the personal aspects of how this problem affected the individual. I think I had a carefree attitude and did not bring problems home with me.

Over time, it became harder to separate the clinical work from the emotional aspects. While empathy can be a wonderful attribute, when one truly understands the suffering that others endure, it is hard not to take that home with you. Despite this, I find that I don’t discuss clinical issues at home. While there are patient privacy issues to consider, the biggest limiting factor is that talking about difficult situations doesn’t seem to help. So, when I get home, I either focus on these issues on a solitary basis or focus on something else entirely (eg. journals, books, exercise, etc).

What I lament these days is how with an interconnected world it is harder and harder to dissociate. Weekends are not long enough. If an issue pops up, it is so easy to reach out to providers like me with direct emails from families, texts from colleagues, or by other methods.

It used to be that when I went out of town, I was definitely on vacation and I would worry if a complicated patient ran into a problem; of course, the reason I worried about it was because it often seemed to happen. Then I would hope that my absence did not adversely impact the patient’s care. Even within a group of 14 highly competent colleagues who are eager to cover, it still seems like it takes a few days to really relax when I’m on vacation. Since I am most familiar with the patients that I have seen, there is always the temptation to check on emails and access the clinical portal (computer records). Even if I don’t check, having a smartphone almost always, except perhaps when out of the country, guarantees unwanted intrusions. That 7:30 am call when I was planning on sleeping in. Crap! I should have gone into the settings to change the blockout times.

Even if I don’t check any electronic devices, my thoughts periodically wander off thinking about the patients who were having some trouble and hoping they are OK. This is perhaps the biggest intrusion of all. Perhaps, I need to go back to the tricks that worked for me in high school, though I wonder if that could really still work. Maybe the biggest problem is that it’s harder to take a carefree vacation because I am much less of a carefree person.

These issues are not unique to physicians/healthcare providers. Anyone else want to comment on whether they have been affected too?

Vaccine Safety Comic Book Version – Will It Help?

Posted on December 31, 2014 by gutsandgrowth

The following link (from Jeff Lewis’ twitter feed) provides a terrific review and summary of the effectiveness of vaccines, the debunked myths, and how “anti-vax” movement hurt not just themselves but others too.

Vaccines Work, Here Are the Facts -Cartoon

Related blog posts:

Could Obesity Be Cured/Created at Birth with Manipulation of Microbiome?

Posted on December 30, 2014 by gutsandgrowth

A concise review (NJEM 2014; 371: 2526-28) quickly describes the latest science on microbiota, antibiotics, and obesity chiefly by summarizing the work of Cox LM et al (Cell 2014; 158: 705-21).

Key points:

In mice, studies have shown that low-dose penicillin in early life induces marked effects on body composition (eg. excessive weight gain) lasting into adulthood
Prenatally administered penicillin to the mother and high-fat diet also induced fat mass of male mice.
Gut microbiota transferred from penicillin-moderated flora mice (at 18 weeks) into the cecums of 3-week-old germ-free mice also resulted in excessive fat mass compared to controls who received gut microbiota transfer from control mice (who did not receive penicillin).
“These results suggest that immunologic and metabolic changes are not caused by direct effects of antibiotics but rather by derived changes in the gut microbiota.”
“It may even be speculated that in families in which obesity is a problem, specific antibiotic treatment at birth could reverse the adverse effect of obesogenic microbiota transferred from mother to infant during delivery.”

Take-home message: Understanding the microbes in our bodies may lead to much more than curing intestinal infections and intestinal maladies.

Dr. Oz Gives Out Wrong/Baseless Advice More Often Than Right

Posted on December 29, 2014 by gutsandgrowth

Dr. Oz, “America’s doctor,” while wildly popular, continues to receive bad press regarding the accuracy of his advice. Recent Washington Post link: “Half of Dr. Oz’s Medical Advice is Baseless or Wrong” (Thanks to Eric Benchimol’s twitter feed for this link)

An excerpt:

The British Medical Journal, which on Wednesday published a study analyzing Oz’s claims along with those made on another medical talk show. What they found wasn’t reassuring. The researchers, led by Christina Korownyk of the University of Alberta, charged medical research either didn’t substantiate — or flat out contradicted — more than half of Oz’s recommendations. “Recommendations made on medical talk shows often lack adequate information on specific benefits or the magnitude of the effects of these benefits,” the article said. “… The public should be skeptical about recommendations made on medical talk shows.”

Related blogs:

How Common is Hepatitis E in the U.S.?

Posted on December 28, 2014 by gutsandgrowth

In a recent study (Hepatology 2014; 60: 815-22), data from the National Health and Nutrition Evaluation Survery (NHANES) 1988-94 was compared with the NHANES 2009-2010 with regard to Hepatitis E virus (HEV) epidemiology. In addition, the most recent surgery coupled with a high performance HEV assay. A total of 8,814 individuals were included in the analysis.

Key findings:

The seroprevalence of HEV was estimated at 6.0% in the U.S. which is only one-third as high as previous estimates.
Birth outside the U.S., Hispanic race, and increasing age were all factors associated with increased HEV seroprevalence. The associations of hispanic origin and birth outside U.S. as risk factors disappear when age is taken into account.

Also noted: Hepatology 2014; 60: 1082-89. “Liver transplantation in the management of porphyria” –useful review.

Can the Mediterranean Diet Change Your DNA?

Posted on December 27, 2014 by gutsandgrowth

According to a recent BMJ study, the Mediterranean diet may protect your chromosomes. From the NY Times link –here’s an excerpt:

They found that the diet is associated with longer telomeres, the protective structures at the end of chromosomes. Shorter telomeres are associated with age-related chronic diseases and reduced life expectancy.

Researchers used data on 4,676 healthy women, part of a larger health study, whose diets were ranked on a scale of one to nine for similarity to the ideal Mediterranean diet. Researchers measured their telomere lengths with blood tests and followed them for more than 20 years with periodic examinations.

The study, published in the journal BMJ, controlled for body mass index, smoking, physical activity, reproductive history and other factors, and found that the higher the score for adherence to the diet, the longer the telomeres. The difference in telomere length for each point on the adherence scale, the researchers estimate, was equivalent to an average 1.5 years of life.

Related blog posts: