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.

Anti-TNF Agents in Pediatrics Have NOT Been Shown to Cause Lymphoma

Posted on July 15, 2014 by gutsandgrowth

This blog title is supported by a recent publication (Clinical Gastroenterology and Hepatology: http://dx.doi.org/10.1016/j.cgh.2014.01.021)

Here’s the abstract -(I emphasize a key point with bold) or check out the link above:

Background & Aims

Many physicians hesitate to recommend anti–tumor necrosis factor (TNF) therapy for pediatric patients with inflammatory bowel disease (IBD) because of concerns about risk of infection and cancer. We performed a systematic review to quantify the incidence of serious infection, lymphoma, and death among pediatric patients with IBD who received anti-TNF therapy. These values were compared with those expected from other treatments, from adults with IBD, and from the general pediatric population.

Methods

We searched MEDLINE, EMBASE, the Cochrane Collaboration, and Web of Knowledge for studies of infliximab therapy for children with ulcerative colitis or Crohn’s disease, or adalimumab therapy for children with Crohn’s disease. Standardized incidence ratios (SIRs) were calculated, comparing rates of infection and cancer among pediatric patients exposed to anti-TNF agents vs expected rates from pediatric patients not exposed to anti-TNF therapies or adult patients exposed to anti-TNF agents. Our analysis included 5528 patients with 9516 patient-years of follow-up evaluation (PYF).

Results

The rate of serious infections among pediatric patients treated with anti-TNF agents (352/10,000 PYF) was similar to that of pediatric patients who received immunomodulator monotherapy (333/10,000 PYF; SIR, 1.06; 95% confidence interval [CI], 0.83–1.36), but significantly lower than the expected rate for pediatric patients treated with steroids (730/10,000 PYF; SIR, 0.48; 95% CI, 0.40–0.58) or adults treated with anti-TNF agents (654/10,000 PYF; SIR, 0.54; 95% CI, 0.43–0.67). Five treatment-related deaths occurred (4 from sepsis and 1 from arrhythmia). Two patients developed lymphoma (2.1/10,000 PYF). This value was similar to the expected rate of lymphoid neoplasia in the entire pediatric population (5.8/100,000 PYF; SIR, 3.5; 95% CI, 0.35–19.6), and lower than the population of pediatric patients receiving thiopurine monotherapy (4.5/10,000 PYF; SIR, 0.47; 95% CI, 0.03–6.44), and among adults treated with anti-TNF agents (6.1/10,000 PYF; SIR, 0.34; 95% CI, 0.04–1.51).

Conclusions

Based on a systematic review, the risk of lymphoma was no greater among children with IBD who received anti-TNF therapy than those treated with other IBD therapies or adults treated with anti-TNF agents. The rate of serious infection was significantly lower among pediatric patients with IBD treated with anti-TNF agents than those treated with steroids, or adults with IBD who received anti-TNF therapy.

My take: This study shows that the concern for malignancy with anti-TNF agents (monotherapy) is often disproportionate to the true risk. At the same time, much longer followup will be needed to assess the benefit and harm of these agents over decades.

Related blog posts:

Celiac Disease Risk -TEDDY Study

Posted on July 14, 2014 by gutsandgrowth

“The Environmental Determinants of Diabetes in the Young (TEDDY) is a multinational study that follows children at high genetic risk for type 1 diabetes, with the development of celiac disease as a secondary outcome.” A recent publication provides excellent data with regard to the longitudinal risk of developing celiac disease (CD) (NEJM 2014; 371: 42-9).

Methods: 424,788 newborns were screened for at-risk HLA genotypes (from 2004 to 2010) in four countries (U.S, Finland, Germany, and Sweden). 21,589 had one of nine HLA genotypes of interest to the investigators –>8677 infants were enrolled in the study; 6403 of this group had one of the four HLA genotypes reported in this study:

DR3-DQ2 homozygotes
DR3-DQ2/DR4-DQ8
DR4-DQ8 homozygotes
DR4-DQ8/DR8-DQ4

Median follow-up: 60 months

Definitions for study:

Celiac autoimmunity: presence of tTG antibodies on two consecutive tests at least 3 months apart
Celiac disease: CD diagnosis based on biopsy (Marsh 2 or higher) or persistently high tTG (≥100 units) on at least two tests at least 3 months apart

Key findings:

Overall 786 children developed celiac autoimmunity (12%) and 291 had confirmed CD.
Children with DR3-DQ2 homozygosity had more than 5 times the risk of CD than the lowest-risk groups; in addition, the risk was 2.5 times more than the risk for a heterozygote (single DR3-DQ2) haplotype.
By 5 years of age, celiac autoimmunity developed in 26% and 12% respectively among children with DR3-DQ2 homozygosity and in 11% and 3% of those children with DR3-DQ2 heterozygosity.
Residence in Sweden increased risk for CD with hazard ratio of 1.9. The fact that residents with same genetic haplotypes had increased risk suggests that an environmental factor is playing a role. It was noted that these children were given gluten-containing cereals at the earliest age.
CD was more common in females with HR of 2.16 (P<0.001) and in those with family history of CD HR 2.95 (P<0.001)

Take-home message: This prospective TEDDY study is providing useful information about how likely an individual with a genetic predisposition will develop CD and how quickly this develops.

Related blog posts:

How Soccer Can Be Bad for Your Health

Posted on July 14, 2014 by gutsandgrowth

When people complain that “everything is bad for your health,” they just might be right. After yesterday’s soccer match, the NEJM posted a link to a 2008 article (N Engl J Med 2008; 358:475-483). Here’s part of the abstract:

Methods: Cardiovascular events occurring in patients in the greater Munich area were prospectively assessed by emergency physicians during the World Cup. We compared those events with events that occurred during the control period: May 1 to June 8 and July 10 to July 31, 2006, and May 1 to July 31 in 2003 and 2005.

Results: Acute cardiovascular events were assessed in 4279 patients. On days of matches involving the German team, the incidence of cardiac emergencies was 2.66 times that during the control period…On those days, the highest average incidence of events was observed during the first 2 hours after the beginning of each match.

Conclusions: Viewing a stressful soccer match more than doubles the risk of an acute cardiovascular event.

Take-home point: Some people are not lying when they say they live and die with their favorite team.

Pancreas Transplantation -Moving Personal Story

Posted on July 13, 2014 by gutsandgrowth

A recent lengthy article describes the story of one man’s wait and ordeal after pancreas transplantation (due to diabetes). This article, written as a first-person account by a Cincinnati reporter, provides a detailed view from the patient’s viewpoint of both medical aspects and the social/emotional aspects of undergoing a transplantation.

Here’s the link, from USA Today: John Faherty, “How an Organ Transplantation Changed My Life.”

Vaccine Safety -Put into Perspective

Posted on July 12, 2014 by gutsandgrowth

For anyone concerned about vaccine safety, putting the risks into perspective may be helpful:

“The most dangerous aspect of giving your child vaccines is driving to the office to get them,” according to Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia, in Vaccine Safety Article from USA Today.

With regard to exemptions, a recent study has shown that private schools have higher vaccine exemption rates (4.25%) than public schools (1.91%) (J Pediatr 2014; 165: 129-33). Using CDC data for 35 states (& district of Columbia), the authors noted that there were 48,931 exemptions in 2009-2010 with only 7146 for medical reasons. For individual states, Hawaii had the highest private school exemption rate at 14.88% and Washington had the highest public school exemption rate at 6.08%.

The authors note that parents with “higher income and educational levels expressed more concerns about vaccine safety.” However, they state that “parents who object to immunizations have been considered ‘free riders’ as they take advantage of the benefit created by children who assume any potential risk of adverse reactions.”

In a brief summary, Sarah Long, an infectious disease expert and associate editor of The Journal of Pediatrics, questions how these parents can be “so mistrustful of doctors…and yet so confident in their own musings? At the same time that they are attempting to advantage their children by attendant a private school, they are putting their children in harm’s way.”

Related blog posts:

AASLD/NASPGHAN 2014 Guidelines for Evaluation of Pediatric Liver Transplantation

Posted on July 11, 2014 by gutsandgrowth

I want to congratulate the authors of a recent AASLD/NASPGHAN report (Hepatology 2014; 60: 362-98 & JPGN 2014; 59: 112-31) and in particular Rene Romero who has been a terrific colleague in Atlanta. I’m grateful for his timely advice to me and my colleagues along with the excellent care that he has provided to children referred for liver transplantation (LT).

The link to full article, Evaluation of Pediatric Liver Transplantation, and other AASLD practice guidelines can be accessed from this website: AASLD guidelines.

Some of the useful recommendations include the following:

For biliary atresia, “patients who are post hepatoportoenterostomy (HPE) should be promptly referred for LT evaluation if the total bilirubin is greater than 6 mg/dL beyond 3 months from HPE” and should be considered if total bilirubin is ≥2 mg/dL. According to the authors in the Hepatology article, ‘84% of those with a total bilirubin <2 mg/dL will survive with native liver beyond 2 years of age whereas only 16% will if total bilirubin is >6 mg/dL.’ [Interestingly, this information is stated differently in the JPGN article where the authors state “up to 70% of patients with BA may have prolonged transplant-free survival if the total serum bilirubin falls below 2 mg/dL” w/in 3 months following HPE.]
For biliary atresia: HPE is recommended as 1st line treatment except in infants with “evidence of decompensated liver disease.”
Ascites management: can be managed with an aldosterone antagonist. Reserve more aggressive measures (paracentesis, TIPS, surgical shunt) for those with compromised respiratory effort or severely impaired quality of life.
Recurrent disease: families should be informed that autoimmune hepatitis, PSC, and bile salt excretory pump disease can recur post-LT.
Recommends screening with use of pulse oxygen with the patient in upright position in all patients with possible portosystemic shunting.
Discusses immunizations for child and for family members (all family members need to fully immunized).
The review provides recommendations specific for virtually each liver condition, including Alagille, Wilson’s, Tyrosinemia, PFIC, hemangioendothelioma, Cystic fibrosis, urea cycle defects, autoimmune hepatitis, PSC, Hepatoblastoma, Alpha-1 Antitrypsin deficiency, Bile Acid Synthesis Disorders, Glycogen Storage Disease, Fatty Acid Oxidation defects, Parenteral Nutrition-Associated Liver Disease (PNALD), and many others.
Contraindicated for LT: Alper’s syndrome/valproate-associated liver failure, mitochondrial disease with severe extrahepatic disease, Hepatocellular carcinoma with extrahepatic disease and rapid progression, uncontrolled systemic infection, Niemann-Pick Disease Type C, and severe medically-refractory portopulmonary hypertension

Take-home message: This practice guideline is an excellent resource in the evaluation of pediatric liver transplantation and pre-transplant management. The ease of accessing the entire report online is a big plus too.

Related posts:

More Data on Early-Onset Pediatric Inflammatory Bowel Disease

Posted on July 10, 2014 by gutsandgrowth

In 2009, a large prospective database involving Italian Pediatric Gastroenterologists was established. A recent study describes the classification (Paris) and phenotype of early-onset pediatric inflammatory bowel disease (EO-IBD) (Inflamm Bowel Dis 2014; 20: 597-605).

In 506 consecutive patients, 224 had Crohn’s disease (CD), 245 ulcerative colitis (UC) and 37 IBD-unclassified.

Key findings:

11% were aged 0-5 years, 39% 6-11 years, 50% were 12-18 years.
UC was more frequently diagnosed in 0-11 years of age whereas as CD was more common in 12-18 years.
EO-Crohn’s showed more frequent isolated colonic disease
EO-UC noted 62% with pancolitis compared with 38% in 6-11 years and 31% in 12-18 year group

Take-home message: The authors conclude that “EO-IBD exhibits an extensive phenotype and benefit from aggressive treatment strategies, although surgical risk is similar to later-onset disease. A family history for IBD is not common in EO disease.”

Safety with Peripheral IVs

Posted on July 9, 2014 by gutsandgrowth

Since completing my training at Cincinnati, I regularly receive a “staff bulletin.” One item that I thought was particularly worthwhile in the June 2014 was a discussion on minimizing harm related to peripheral intravenous (PIV) access and infusions.

The Cincinnati Vascular Access Team has developed a protocol to assess PIV sites (hourly nurse checks) and has developed a list of medicines, with the idea that higher risk medications should be given via a central line. The lists that follow are based on this staff bulletin and should be useful references.

High Risk Medicines include the following:

acyclovir
amiodarone
caffeine citrate
calcium (all salt forms)
dextrose (>12.5%)
doxycycline
esmolol
mannitol (20% and 25%)
promethazine
potassium (>60 mEq/L)
Sodium bicarbonate
Sodium chloride ≥3%
TPN ≥950 mOsm/L
Vasopressors such as dopamine
Chemotherapy drugs

Intermediate Risk Medicines include the following:

Acetazolamide
Allopurinol
Amikacin
Amphotericin B
Arginine
Ciprofloxacin
Dextrose 10 to 12.5%
Diazepam
Erythromycin
Ganciclovir
Lorazepam
Midazolam
Morphine
Ondansetron
Nafcillin
Non-ionic Radiology contrast
Phenobarbital
Phenytoin
Potassium ≤60 mEq/L
TPN ≤950 mOsm/L
Vancomycin

Lower Risk for the following:

aminophylline
amphotericin B liposomal
ampicillin, ampicillin/sulbactam
cefazolin
cefotaxime
ceftazidime
ceftriaxone
cefuroxime
clindamycin
D5LR
dextrose <10%
fentanyl
forsphenytoin
furosemide
gentamicin
heparin
imipenem
IVIG
lactated ringer’s
lipids
magnesium sulfate
meropenem
normal saline
pentamidine
piperacillin, piperacillin/tazobactam
ticarcillin, ticarcillin/clavulanate
tobramycin

One further warning: “No intravenous infusate is ‘safe.’ Gross extravasation, even of normal saline, may result in serious harm, including compartment syndrome, ischemia, and loss of tissue or permanent loss of limb function.”

ACA -A Report Card

Posted on July 8, 2014 by gutsandgrowth

A recent succinct commentary describes the ~20 million people who gained coverage as a result of the Affordable Care Act/Obamacare; the exact number who were uninsured prior is not known. While the article provides a clearer picture of this expansion, it also makes the point that there are many issues that need to be addressed including cost containment. Other subjects:

Cancelled policies
Risk pools and premiums (lower than projected thus far)
Narrow Provider Networks
Crucial Younger Age Group Enrollment
Small Business and Mandate
Individual Marketplaces
State Marketplaces
Medicaid Expansion (limited in many states)

Here is the link –the entire report is worth a read: ACA -20 million Americans

Here is an excerpt:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3 Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

No Habla Appendicitis

Posted on July 7, 2014 by gutsandgrowth

Before today’s blog, I wanted to state that our physicians now can treat Clostridium difficile with fecal microbiota transplant (would have been more relevant to yesterday’s blog: “Gut Microbiome”) :

GI Care for Kids is one of the few places in the region to offer this capability for children (thanks to Jeff Lewis for working to navigate the logistics/regulatory burdens).

Today’s blog: Though physicians make efforts to combat language barriers with translators, the personal connection between physicians and patients is undoubtedly weakened in those with limited English proficiency LEP). Recently, one of my emergency room colleagues explained that he had ordered a CT scan on a young man in part due to his hispanic ethnicity and concern that this would lead him to overlook a diagnosis of appendicitis. According to a recent study, my emergency room colleague was right –hispanic ethnicity and language barriers increased the risk for appendiceal perforation (J Pediatr 2014; 164: 1286-91).

The researchers performed a secondary analysis of a prospective, cross-sectional, multi center study of children aged 3-18 years who presented with abdominal pain/possible appendicitis (2009-2010) at 10 tertiary care pediatric emergency departments in the U.S.

Results:

Of the 2590 patients enrolled, 1001 (38%) had appendicitis.
Hispanics with LEP had an odds ratio of 1.44 of having appendiceal perforation. In addition, these patients were less likely to undergo advanced imaging (OR 0.64)

Bottomline: Patients/families who speak English are more likely to communicate the severity of their medical problem. Those with limited English proficiency are at increased risk for complications and this extends beyond perforation with appendicitis.