Author Archives: gutsandgrowth

Unknown's avatar

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.

Is functional pain more common in children with Celiac disease?

Posted on by

A recent study adds information to the title question but does not resolve it (J Pediatr 2013; 162: 505-09).

The authors note that they expected to find a higher prevalence of abdominal pain and abdominal pain/functional gastrointestinal disorders among children with diagnosis of celiac disease.  They note that functional disorders have been more common after acute gastroenteritis and cow’s milk hypersensitivity of infancy presumably due to preceding inflammation.  Persistent low-grade intestinal inflammation and immune activation have been proposed as precipitating susceptibility to functional abdominal pain.

In this small retrospective study, a statistically significant difference in functional GI disorders was not observed.  Enrolled families were contacted by telephone at least 6 months after the diagnosis of Celiac disease.  They completed a telephone questionnaire and a separate Rome III questionnaire.

Celiac cases (n=49):  abdominal pain (24.5%), functional abdominal pain (4.8%), IBS (6.1%), dyspepsia (4.8%), abdominal migraine (4.8%), nonspecific abdominal pain (6.1%)

Control cases (n=48): abdominal pain (14.6%), functional abdominal pain (6.3%), IBS (2.1%), nonspecific abdominal pain (6.1%)

Given the question that the authors were trying to answer, this study was unlikely to be helpful.  Problems with the study:

  • The biggest problem is the small number of patients.
  • Cross-sectional design
  • Reliance of recall symptoms
  • Lack of information on dietary adherence
  • Collection of information from only parents contributed

Bottomline: While screening for celiac disease is common in patients with possible functional abdominal pain, treatment with a gluten-free diet may not resolve these symptoms. Functional abdominal pain is at least as common in children with celiac disease as in the general population.

Related blog post:

New FDA warning for azithromycin (Zithromax)

Posted on by

“The FDA is warning that a widely used antibiotic from Pfizer can cause rare but deadly heart rhythms in some patients. The agency is adding new warnings to the label of Zithromax, which is used to treat bronchitis, pneumonia and other infections.

Doctors should consider prescribing other antibiotics to patients at risk of heart problems, including those with irregular heartbeats or low levels of potassium or magnesium in their blood. Zithromax is popular because it often can be taken for fewer days than other antibiotics. The warning may prompt doctors to choose other options, though the new label notes that other antibiotics have similar effects on the heart.”

Read more here: http://www.thenewstribune.com/2013/03/13/2511288/fda-issues-warning-about-zithromax.html#storylink=cpy

Also from previous FDA statement:
[05-17-2012] “The U.S. Food and Drug Administration (FDA) is
aware of the study published in the New England Journal of Medicine,
on May 17, 20121, that compared the risks of cardiovascular death in patients treated with azithromycin (Zithromax), amoxicillin, ciprofloxacin (Cipro), levofloxacin (Levaquin), and no antibacterial drug.  The study reported a small increase in cardiovascular
deaths, and in the risk of death from any cause, in persons treated with a 5-day
course of azithromycin (Zithromax) compared to persons treated with amoxicillin,
ciprofloxacin, or no drug. The risks of cardiovascular death associated with
levofloxacin treatment were similar to those associated with azithromycin
treatment.”  Thus, levofloxacin also was associated with an increased risk.
Related link:

Build the information medical highway and expect more traffic

Posted on by

A recent article indicates that increased patient access to online records was associated with increased in-person and telephone contacts (JAMA 2012; 308: 2012-19).

Background (from study introduction): The Institute of Medicine’s report on “Crossing the Quality Chasm” indicated that electronic patient-physician messaging was a promising technology to improve quality and efficiency.  Furthermore, previous studies have suggested that 25-70% of all visits to physicians do not require face-to-face appointments.

Design: To explore this topic further, the authors performed a retrospective cohort study on the use of health care services between 2005-2010 at Kaiser Permanente in Colorado.  This study examined patients ≥18 years old and looked at health care utilization before and after initiation of MyHealthManager (MHM). Users of MHM were compared with nonusers.  And, both groups (users and nonusers) were examined with regard to their health care utilization before and after MHM rollout. The first 30 days before and after activation of MHM were excluded from analysis to minimize the effect of increased utilization at the initiation of MHM.

Results:

  • By June 2009, patient use of MHM had increased to 53.8%.  In total, 87,206 MHM patients were identified and 71,663 nonusers were identified for study participation. 
  • MHM users were slightly older and more likely to be female.
  • After initiation of MHM, the rate of office visits increased by 0.7 per member per year (p<0.001) and the number of telephone encounters increased by 0.3 per member per year (p<0.001).  
  • The authors breakdown this data based on age, absence of chronic disease, presence of specific diseases (diabetes, coronary artery disease, congestive heart failure).  In all of these scenarios, MHM users had increased visits after initiation of MHM.  Nonusers generally had the same or less visits at the same time.
  • Figure 2 shows that MHM and nonusers had identical health care utilization beforehand.  Afterwards, the MHM users maintained a parallel line of increased usage that was fairly consistent for a year after rollout.

Why did this happen?  The authors note that the result was contrary to their expectations.  They speculate that individuals may have increased their in-person use after developing additional concerns following their review of information online and that individuals may sign up who are already more likely to use services.  Online access, in these individuals, may facilitate access to more frequent visits.

I think this article points to a more pervasive miscalculation of the effect of information technology and health care utilization.  While electronic health records (EHRs) can help organize and communicate vast amounts of information, the proposition that they will ultimately reduce health care costs/utilization or improve efficiency is looking dubious.  In my opinion, the best we can hope for is that EHRs, when used optimally, will improve the quality of the care.  It is equally possible, however, that EHRs could result in more legible but less accurate information due to well-recognized issues like copy-forwarding with inadequate editing.

Related blog posts:

Early antibiotic use and the development of inflammatory bowel disease

Posted on by

Another study adds weight to the idea that early antibiotic use may increase the risk of developing inflammatory bowel disease (IBD) (J Pediatr 2013; 162: 510-4).

Using a nested case-control design, the authors matched 2377 controls to 294 children with IBD in a population-based database from Manitoba, Canada.  Specifically, the authors looked at the frequency of otitis media diagnosis and the likelihood of subsequent IBD.  By age 5 years, 89% of IBD cases had at least one diagnosis of otitis media, compared with 82% of the controls.  Despite the high frequency in both groups, the authors determined that individuals with a diagnosis of otitis media before age 5 years were 2.8-fold more likely to be an IBD case.

Some of the strengths of this study included the fact that it was a population-based analysis dating back to 1984 and likely captured almost all pediatric IBD cases (<19 years).  Nearly all physicians in Manitoba submit billing claims to a single publicly funded source.  Due to the nature of administrative data, this eliminates recall bias.

However, administrative data have several limitations as well.  Other confounding conditions may have been present and not identified; this could include family history and autoimmune diseases.

The authors “suspect” that the linkage between otitis media and IBD relates to the usage of antibiotics and subsequent alterations of the intestinal microflora.  Otitis media may serve as a “sensitive proxy measure” of antibiotic use.  Also, as boys are more frequently treated for otitis media, this may relate to the generally higher incidence of pediatric IBD in males.

For anyone interested in the association between antibiotic exposure and IBD, this study is useful and provides a number of references as well.

Related blog entries:

Does negative testing reassure patients?

Posted on by

Probably not according to a recent study (JAMA Intern Med, published online Feb 25, 2013, d0i:10.1001/jamainternmed.2013.2762).

Citation: A Rolfe, C Burton. JAMA Intern Med. 2013;173(6):407-416. Open access! Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease

In this study, the authors systematically reviewed the literature and, after screening 9742 studies, identified 14 randomized controlled trials (n=3828 patients) which met inclusion criteria, including the following:

  • Randomized control trial
  • Adult participants with symptoms indicating a low probability of serious disease

Studies were excluded if they were not published in a peer-reviewed journal or if they were undertaken in a tertiary care setting.  Eight trials involved diagnostic testing for dyspepsia (mainly endoscopy), three involved radiography for back pain, and the other three included testing for chest pain, headache and palpitations.  Long-term follow-up varied from 4 to 18 months.

Key Findings:

  • Patients’ illness concern (odds ratio 0.87 in three trials) and anxiety (standardized mean difference 0.06 [-0.16 to 0.28] in two trials) were not reduced in the short or long term.
  • No overall long-term effect on symptom persistence was noted (odds ratio 0.99)

Limitations:

  • The authors examined only reassurance for patients, not for physicians.
  • Participants were not blinded
  • Overall, small number of study participants

In the discussion, the authors note that observational studies “suggest that illness concerns reappear within hours of receiving a normal (negative) test  result.”

For pediatric gastroenterologists, the conclusions from this article add another wrinkle when deciding how much workup is indicated for conditions like recurrent abdominal pain.  Previous data indicate that maternal anxiety is the most consistent predictor of outcome for recurrent abdominal pain (Acta Paediatr 2007; 96: 697-701); this study does not address whether patient proxies are reassured by negative testing.  And, other studies have shown that patients rate their care higher after diagnostic testing (Don’t miss the gorilla! | gutsandgrowth).

As a fellow, I was told: “Don’t just do something, stand there” from Bill Balistreri; he also recommended avoiding the mentality of “Scope first, think second.” While this current study suggests that there is a lack of long-term benefit when testing is done primarily for reassurance, convincing families that their child does not need testing is often difficult.

Global Justice and Vaccine Policy

Posted on by

I definitely was piqued by the editorial titled “Global Justice and the Proposed Ban on Thimerosal-Containing Vaccines.” (Pediatrics 2013; 131: 154-156) I wondered how vaccine policy could affect global justice.

In high-income countries, vaccines have shifted increasingly to preservative-free single-dose vials.  Whereas in poorer countries, vaccines have continued to rely on multidose vials which frequently contain thimerosal as a preservative.  The move away from thimerosal which contains ethyl mercury “was a precautionary move in response to theoretical concerns, now known to be unfounded.”

Currently, a multinational environmental treaty is close to finalization and this treaty aims to restrict human and environmental exposure to mercury.  The World Health Organization and the broader public health community have recommended that thimerosal be exempt from the treaty to avoid disruption in the global vaccine supply.  However, some nongovernmental groups have objected to the use of thimerosal in poorer countries when it has been phased out in wealthier countries.

Why Thimerosal Should be Exempt from this Ban:

  • No credible scientific evidence of any risk to human health from thimerosal
  • Vaccines with thimerosal are used in >120 countries to immunize ~84 million children every year.  It is estimated that these vaccines save 1.4 million children every year.
  • Potential vaccines affected include hepatitis B, tetanus, and diptheria-tetanus-pertutsis
  • “Although there are other preservatives…, none are yet viable alternatives to thimerosal”

The individuals and organizations who have opposed thimerosal come from wealthier countries and would not suffer the consequences of a potential ban.  “Where’s the justice in that?”

Related references:

  • Pediatrics 2013; 131: 149-151. Public health experts recommend the ongoing use of thimerosal as a preservative.
  • Pediatrics 2013; 131: 152-153.  Provides context for previous AAP joint statement on thimerosal in 1999.

Related blog entry:

Vaccine successes and ambitions | gutsandgrowth

And the Best Prep is…

Posted on by

A meta-analysis has concluded that a 4-Liter split-dose polyethylene glycol prep is best (Clin Gastroenterol Hepatol 2012; 10: 1225-1231).  This is an expected finding and has been discussed previously on this blog (see below).

What is unexpected is the tremendous heterogeneity in studies of bowel preparations. For this study, the investigators identified 1123 potentially relevant references.  Almost all of these were excluded due to criteria which required 1) randomized control trial, 2) English-based language, and 3) specific study design issues.  Thus 9 studies with 2477 patients met inclusion criteria.  Mean age of patients in these studies were 52-59 years.

The pooled odds for excellent or good bowel prep quality for 4-L split-dose PEG was 3.46 compared with other methods.  The comparison regimens included non-split dose PEG, 2-L split-dose PEG, 3-L split dose PEG, Miralax preps (64 oz split dose with or without stimulants).

While the prep results were generally more favorable, there were no differences in other adverse effects, such as cramping, compliance, or overall experience.

Related blog entry:

  • split-dose PEG | gutsandgrowth This blog entry discusses a specific prep, describes the Ottawa scale, and provides additional references. In addition, includes a link to Dave Barry’s column on colonoscopy.

Will salt intake make you fat?

Posted on by

Maybe.  According to a recent study (Pediatrics 2013; 131: 14-20), salt intake is associated with consumption of sugar-sweetened beverages (SSB); hence, it might make you fat.

This cross-sectional study used data (4283 participants, ages 2-16 years) from the 2007 Australian National Children’s Nutrition and Physical Activity Survey.  Calculation of dietary intake (salt, fluid, sugary beverages) was determined by looking at two 24-hour dietary recalls.

Each gram of salt was associated with a 46 gram intake of fluid.  Of those who took SSB (n=2571), salt intake was associated with increased consumption of SSB; each gram of salt was associated with a 17 gram increased intake of SSB.  Participants with SSB intake of more than 1 serving (≥250 g), in turn, were 26% more likely to be overweight/obese (odds ratio 1.26).

Study limitations included the following:

  • 24-hour dietary recalls which likely underrepresented salt intake
  • Salt intake may be clustered with other ‘unhealthy’ dietary habits.  Thus, it may be a marker for undesirable diet rather than a causal factor.

Conclusion: Besides lowering blood pressure and lowering the risk of kidney stones, reducing salt intake may help with obesity prevention.

Related blog post:

Don’t miss the gorilla!

Posted on by

A recent narrative on improving value in health care (NEJM 2013; 368: 959-62) made use of a few psychological experiments to make some excellent points.

The first experiment asked the study participants to focus on a video and to count the number of passes for a team of three basketball players dressed in white while another three-player team dressed in black also played.  “During the video, a woman in a gorilla suit walked across the screen pounding her chest, remaining there for 5 seconds….Consistently, about 50% failed to notice the gorilla.”  Afterwards, when shown the video a second time, many of those who did not see the gorilla insisted that the video had been altered.

The second experiment involved perception.  “One group was initially shown a blurry image of a dog.  Then both groups were shown the exact same image, less blurry.  Those seeing the image for the first time had a much easier time recognizing it as a dog than those who had received previous ambiguous information.”  So, like those in the first experiment who did not  see the gorilla, participants are reluctant to change their opinion even when better information becomes available.

The author notes that the ‘value narrative’ can split patients and physicians into separate teams.  For physicians, value suggests avoiding overuse and providing evidence-based care.  For patients, value means enhancing their experience and catering outcomes that matter to them.  There is a study which shows that patients rate their care as better if they went to an ER for abdominal pain and underwent a CT scan (regardless of whether it was indicated).  Similarly, for back pain, two studies have shown that patients are far more satisfied with their care if they undergo an MRI.

The implications of these experiments on perception is that value in health care needs to be more transparent.

  • “We must admit that turning health care into a customer-service industry may to some extent undermine the delivery of evidence-based care.”
  • We actually know very little “about patients’ values and about how they should or might influence our decision-making.”
  • If we want to control costs and improve quality, “it will first require a look at the whole picture — and then a willingness to believe what we see.”

Can Hepatitis C really be cured?

Posted on by

While many have equated a sustained virologic response (SVR) as a cure for hepatitis C virus (HCV), there have been concerns about “occult” hepatitis C.  A new study indicates that in the vast majority of patients with an SVR, there is “no evidence of ongoing HCV replication…and no evidence that HCV replicates in PBMCs of chronically infected patients” (Hepatology 2013; 57: 483-91, editorial 438-40).

There has been no disagreement that an SVR is associated with improved liver histology, improved clinical symptoms, often a reversal of fibrosis, and lower risk of hepatocellular carcinoma.  However, the study and the accompanying editorial summarize the disparity in studies about the potential for occult HCV and how the virus has been identified in the peripheral blood mononuclear cells (PBMCs) and livers of patients who have had an SVR.

The study examined 67 chronic HCV carriers and examined the liver and other tissues of 2 spontaneously recovered chimpanzees.

Key findings:

  • The authors confirm that HCV RNA can be detected in PBMCs in chronic HCV carriers, but only as nonreplicating virus; therefore, it is probably not harmful to the host or to others.
  • Healthy controls had HCV passively adsorbed to PBMCs in vitro becoming indistinguishable from the HCV RNA in PBMCs of chronic HCV carriers
  • HCV RNA could not be detected in the PBMCs of 59 presumed recovered subjects using a highly sensitive nested PCR assay (measure down to 10 IU)
  • In total, this study and others support the likelihood of absolute HCV clearance in most patients with either spontaneous or treatment-induced recovery

Editorialist recommendation: “it seems appropriate to perform virology and biochemical screening annually…particularly if…there was histologic evidence of fibrosis or cirrhosis”

Related blog entries: