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.

When you gotta go…looking for a clean bathroom

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According to consumer advice guru, Clark Howard, clean bathrooms are a necessity for businesses and now there are mobile apps (eg. SitorSquat) to help people find them.  For patients with GI disorders, this app may be very helpful as well.

Here’s the link from Clark Howard:

Clark Howard: Valued workers translate into a company’s success …

An excerpt:

“Now USA Today reports that dirty bathrooms can hurt business in some very direct ways. Nearly 50 percent of restaurant patrons who experience a dirty bathroom will tell friends. Almost three in 10 restaurant patrons won’t give a place a second chance if they encounter a dirty bathroom. And if you’re a restaurant owner, remember, this is the era of the smartphone where customers are taking pictures of your dirty bathroom and sharing it on social media.

Of course, when you gotta go, you gotta go. That’s why several different smartphone apps like SitorSquat have been developed (for both Android and iOS), pointing you to the nearest clean bathrooms.”

For IBD patients, sometimes taking your own toilet can be helpful, here’s a link to portable products:

Top 5 Portable Toilets – IBD – About.com

Graphic Ads Motivate Smokers to Quit

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From NY Times (coverage of Lancet article), those graphic anti-smoking ads seem to be helping.
http://nyti.ms/18RT9Kq

An except:

For almost two decades, Lisha Hancock smoked between one and two packs of cigarettes a day…..

Then she saw a graphic television commercial featuring a former smoker, Terri Hall, who developed head and neck cancer. The widely seen advertisement shows Ms. Hall inserting a set of false teeth and placing a small speaker inside a hole in her neck.

“It scared me because I had always had problems with my throat,” said Ms. Hancock, 38, who lives in Kentucky. “When I saw that, it made me realize that there are other types of cancer besides lung cancer, and that really hit home for me.”

The ad prompted her to give up smoking about eight months ago, using a combination of an exercise and healthful eating regimen along with nicotine lozenges, and she has not had a cigarette since. But Ms. Hancock may be just one of thousands of Americans who quit smoking after seeing the commercial featuring Ms. Hall, which was part of a series of antismoking ads put out by the federal government last year. The campaign, called Tips From Former Smokers, was notable both for its raw images and because it marked the first time that the government directly attacked the tobacco industry in paid, nationwide advertisements.

According to a new study published on Monday in The Lancet, the ads may have prompted more than 100,000 Americans to give up smoking for good. (emphasis added by blog)

The study, led by a team at the Centers for Disease Control and Prevention, surveyed 5,300 Americans before and after the campaign, including 3,000 smokers. The paid ads ran for three months beginning in March, just after the New Year resolution season, when the percentage of smokers trying to quit is typically on the decline.

The researchers found that over all, four of five of smokers had seen the commercials, and the percentage who reported trying to quit rose by 12 percent. Of those who tried to quit, about 13 percent remained abstinent after the campaign had ended.

Using census data, the researchers estimated that as many as 1.6 million smokers nationwide attempted to quit as a result of the ad campaign. Most smokers require several attempts before they give up cigarettes for good, so only a fraction of those who were motivated by the campaign would have succeeded. The ads were expected to spur about 50,000 smokers to quit permanently, but the Lancet study estimated that twice that number were successful….

Historically, about half of the nation’s 45 million smokers try to quit every year, and yet cessation rates hover around 5 percent annually. Public health officials have long been telling smokers that cigarettes shave years off your life, contributing to more than 400,000 deaths every year.

The new campaign went in a different direction, focusing not on death but on quality of life. The creators of the campaign used focus groups and feedback from smokers to develop sobering ads showing real smokers with amputations, paralysis and disfigurement from heart and lung surgeries.

“I think the fact that you may die is not highly motivating to people,” Dr. Frieden said. “The fact that the remainder of your life may be very unpleasant is, and that’s what the data shows. Not only do smokers die about ten years younger than most people, but they feel about ten years older than their age.”

The campaign last year cost about $54 million and was paid for by the Affordable Care Act. …. Dr. Frieden said the money, which is only a fraction of the $8 billion the tobacco industry spends on marketing and promotion every year, was well spent.

“This is a campaign that has literally saved tens of thousands of lives,” he said. “We would like to be able to have hard-hitting campaigns like this on the air year round. The tobacco industry spends what we spent on this campaign in three days.”

Related blog posts:

Hospital-based Antimicrobial Stewardship

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While there has been growing recognition of antibiotic resistance, the efforts to implement strategies to preserve the effectiveness of our current antibiotics have not been embraced by enough stakeholders.  A recent review provides insight into the antibiotic stewardship (AS) programs that are being implemented by pediatric hospitals (JAMA Pediatrics; 2013; 167: 859-66).  Thanks to Ben Gold for sharing this reference.

AS goals are to “optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance.”  Five specific goals:

  • timely management of antimicrobial therapy -prompt initiation when indicated, avoid when not indicated (eg. viral illness)
  • appropriate antibiotic selection -minimize redundant antibiotic coverage
  • appropriate antibiotic administration and de-escalation of therapy -reassess after 48-72 hrs whether to discontinue antibiotics, monitor levels when needed
  • use of available expertise and resources at point of care
  • transparent monitoring of antimicrobial data usage

Adoption of AS programs has been accelerating in the past few years.  “A recent survey of 43 children’s hospitals showed that 16 institutions (37%) ..currently have an established AS  program supported by full-time equivalents for a pediatric infectious diseases physician and/or clinical pharmacist.”  Another 15 (35%) are in the preparatory stage of implementing an AS program.

Potential barriers for AS programs:

  • Lack of funding or time –these programs have been reported to yield cost savings
  • Lack of hospital leadership
  • Concerns about physician autonomy

Potential outcome variables to measure:

  • Reduction in adverse events
  • Improved (?) antibiotic resistance trends
  • Reduction (?) in C difficile rates

The authors note that on a national level that AS programs have not been mandated. However, multiple societies, including the Infectious Diseases Society and the Society for Healthcare Epidemiology of America, have recommended their widespread adoption.

Bottomline: Improving hospital antibiotic usage with the use of AS programs will help reduce antibiotic resistance, but it is the tip of the iceberg when it comes to addressing this issue (see related blog posts below).

Related blog entries:

Do antivirals lower the risk of Hepatocellular Carcinoma in HBV?

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Meaningful endpoints of therapy are often difficult to demonstrate in clinical studies due to the length of followup that may be needed.  For patients infected with hepatitis B virus (HBV), most clinical studies use surrogate biologic, virologic and histologic markers rather than endpoints like hepatocellular carcinoma (HCC) and death.  In addition, long-term randomized trials with untreated controls are difficult to justify given the success of current treatments in improving these surrogate markers.

A recent Japanese study (Hepatology 2013; 58: 98-107 and editorial pg 18) reports data on a large entecavir-treated cohort (n=472) which was matched with a historical control (retrospective control group, n=1143).  The authors used propensity score matching to eliminate any baseline differences.

Findings:

  • Cumulative incidence of HCC rate at 5 years was 3.7% (for entecavir group) and 13.7% (for controls)
  • Using regression analysis and adjusting for known HCC risk factors, patients treated with entecavir had a hazard ratio of 0.37 for developing HCC.
  • Patients with more risk factors for HCC (eg. older, more active disease, cirrhosis) obtained greater benefit from entecavir treatment (shown in Figure 4 in manuscript)
  • The authors also showed that entecavir-treated patients also had less risk of developing HCC than lamivudine-treated patients
  • Entecavir-treated patients had low rates of resistance (0.8%) at 3.2 years of treatment

Take-home message: suppression of viral replication in HBV cirrhosis patients reduces but does not eliminate the risk of HCC.  In noncirrhotic patients, the magnitude of risk reduction is less.  Thus, patients with active disease should be treated.

Causes of Death with Hepatitis B in U.S.

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A recent study followed 6,689 patients with hepatitis B virus (HBV) between 1996-2005 and analyzed causes of death (Hepatology 2013; 58: 21-30, editorial pg 6). This study used a large prospectively-collected database.

The patients were all part of Kaiser Permanente Northern California health plan.  Patients were not eligible if they were coinfected with HIV or HCV.  Causes of death were divided into HBV-related (eg. decompensated cirrhosis [DCC], hepatocellular carcinoma [HCC]) and other causes, including cancer and cardiovascular.

Among this cohort, 68.3% were Asian-Pacific Islander (API) descent, and 11.8% were white (non-hispanic); the remainder were other or unknown descent.  The cohort had a mean age of 41 years.

Findings:

  • Males had higher overall 10-year death rates than females for total deaths (8.9% versus 4.1%) and for HBV-related deaths (4.8% versus 1.2%).
  • 46.7% of all deaths were HBV-related.
  • Death rate rose with increasing age; approximately 40% of deaths after age 40 were HBV-related.
  • Among HBV-related deaths, the death rate from HCC was twice the rate of DCC
  • “We did not find that subjects of API descent origin were at higher risk of death from HBV-related complications.”  This was unexpected because presumably “they are often infected in childhood and therefore have disease of longer duration.”
  • Limitations included absence of data on alcohol, cigarettes and coffee.  In addition, the study period occurred when treatment options for HBV were more limited.

The accompanying editorial notes wide variability in mortality outcome data depending on the study setting.   “Studies in patients with incidentally detected HBV infection, mostly conducted in blood donors in Western countries, tend to portray a benign course…with…their incidence of complications of chronic liver disease, HCC, or liver-related mortality is not significantly higher than that in hepatitis B surface antigen-negative healthy controls.”  In China, the lifetime risk for an infected patient to die from an HBV-related cause “has been estimated to be up to 50% in men and 15% in women.”

Related blog posts:

Growth after Liver Transplantation

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A retrospective chart review of patients from Australia and Japan who underwent liver transplantation between 1985-2004 provides some insight into the growth potential after liver transplantation (J Pediatr 2013; 163: 537-42).  The study included height data from 98 patients and weight data from 104 patients.

Study characteristics:

  • 58% were Australian and 42% were Japanese
  • 76 of 98 patients were transplanted for biliary atresia
  • 47% were younger than 2 years at the time of transplantation
  • Measurements were recorded pre-transplant, 1, 5, 10 and 15 years later

Findings:

  • Height recovery continued for at least 10 years to reach the 26th percentile (Z-score -0.67) 15 years after transplant.  Australian patients had better height recovery, reaching the 47th percentile (Z-score -0.06).
  • Weight recovery was most pronounced in 1st year after transplantation but also continued for 15 years.
  • The median height, weight, and BMI Z-scores are listed in Table II for all time periods
  • Those most malnourished and growth impaired at transplant exhibited the most catchup but remained significantly shorter and smaller 15 years later.

While the Australian patients had better growth in this study, this may be attributable to the fact that nearly all the Japanese in this study were transplanted before 1996 whereas Australian patients were transplanted over the entire period of the study.  Improvements in post-operative management with improved immunosuppressive treatment regimens (eg. reduced steroids) may have played a role.

Take-home message:  Most pediatric liver transplantation patients can expect to be normal-sized adults.  Those who are very malnourished at the time of transplantation, though, are likely to have some reduction in growth potential.

Related blog posts:

Immunization Recommendations from CDC 2013

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The following was copied from the ImproveCareNow Circle Newsletter (conta.cc/145rO5T):

The Centers for Disease Control and Prevention (CDC) offers easy-to-print schedules for regular childhood immunizations and “maintenance”. These are good resources for parents and patients to keep track of their vaccine schedule. You can access them here:

It is important to note: Patients taking immunosuppressant drugs (such as prednisone, 6MP, Methotrexate, biologic agents like Remicade or Enbrel) CANNOT receive a “live vaccine” because they can become ill as a result of the vaccine. This is especially important during fall when the flu vaccine is recommended. The intranasal flu vaccine (flu mist) is a live vaccine and should NOT be given to patients taking immunosuppressant drugs.

Yearly flu [injection] shots are encouraged for kids with IBD because the flu can be very serious in someone taking immunosuppressant drugs or who has a chronic illness.  Also, because the flu is a viral infection it can stimulate the immune system and could cause a flare.

Related blog link:

Protecting the most vulnerable | gutsandgrowth

Why Some Genetic Mutations May Be Helpful: HFE

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When one looks at diseases, it is important to consider that the mutations that cause the disease may confer other selective advantages.

A classic example has been sickle-cell disease.  The heterozygous state is usually asymptomatic and makes an individual less prone to malaria.  “In the USA, where there is no endemic malaria, the prevalence of sickle-cell anaemia among blacks is lower (about 0.25%) than in West Africa (about 4.0%) and is falling. Without endemic malaria, the sickle cell mutation is purely disadvantageous and will tend to be selected out of the affected population via natural selection.” —Sickle–cell disease – Wikipedia, the free encyclopedia

Another common disorder is hemochromatosis.  A recent letter in the New England Journal of Medicine (NEJM 2013; 369: 785-6) explains why having the HFE gene could be advantageous.  According to the authors the genetic mutation arose in Celtic populations who were notably taller than other populations.  As such, the authors hypothesized that the patients with HFE hemochromatosis would have better growth by having an abundant supply of iron during periods of rapid development.

They assessed a cohort of 176 Swiss patients with HFE hemochromatosis.  93% were homozygous for the C282Y mutation, 7% had a compound H63D-C282Y mutation.  All of the patients had verified iron overload determined as a ferritin > 300 mcg/L or a transferrin saturation >45%.

Compared with an age-matched, sex-matched Swiss reference population, men with hemochromatosis (n=120) were 4.3 cm taller on average. In women (n=56), the difference was 3.3 cm.  To avoid bias due to population origin, the cohort was also compared with data from Ireland where the data remained validated.

Take-home message: Extra iron in the first two decades of life promote better growth (and probably other advantages).  However, iron overload later in life can lead to cirrhosis, diabetes, heart disease, and reproductive problems.

Related blog post:

AASLD Hemochromatosis Guidelines: