2020 AASLD President: Jorge Bezerra

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One of the first articles that I read this year (2021) was “Introducing Jorge A Bezerra, MD, Our 2020 AASLD President” (WF Balistreri. Hepatology 2020; 72: 801-806).

I have a deep admiration and fondness for Jorge. When I first did a gastroenterology rotation during my pediatric residency, he was the first person who handed me an endoscope and showed me how to handle it. During my training as a resident and as a fellow (1991-1997), I had the opportunity to get to know Jorge; for some of that time, he was completing his training as he started his GI fellowship in 1990.

I really enjoyed reading this introduction to learn a lot more about Jorge, because I don’t remember Jorge speaking about himself. Of course, he has been part of some very important advances in pediatric hepatology including the very useful MMP-7 assay, the ‘Jaundice chip’ and the START study.

The article delves into some personal attributes including the description of Jorge being ‘the Pele of pediatric hepatology’ (per Dr. Ronald Sokol). It also describes his family and some characteristics. “He has inspired us with his calm demeanor, decency, humor, positivity, and kindness.”

It is a personal thrill for me to read about one of my heroes in our field.

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CAM Use in Functional Abdominal Pain

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From Journal of Pediatrics Twitter Feed

SL Ciciora et al. J Pediatr 2020; 227: 53-59. Complementary and Alternative Medicine Use in Pediatric Functional Abdominal Pain Disorders at a Large Academic Center

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Most Popular 2020 Posts

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I want to thank all of you who take an interest in my blog, particularly those who give suggestions, references, and encouragement. The following posts were the most popular from the past year.

Related post: Favorite Posts of 2020

Sandy Springs at Sunrise

Favorite Posts of 2020

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These are some of my favorite posts of the past year.

Humor:

GI:

Endoscopy:

Liver:

Nutrition

COVID-19:

Other:

From Picnic Island, Tampa Bay

Effects of Fecal Microbiome Transfer in Adolescents With Obesity

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KSW Leong et al. JAMA Netw Open. 2020;3(12):e2030415. doi:10.1001/jamanetworkopen.2020.30415 (full text): Effects of Fecal Microbiome Transfer in Adolescents With Obesity Thanks to John Pohl’s twitter feed for this reference.

Methods: Single course of oral encapsulated fecal microbiome from 4 healthy lean donors or saline placebo.

Key findings:

  • In this randomized, double-masked, placebo-controlled trial of 87 adolescents with obesity, FMT alone did not lead to weight loss at 6 weeks.
  • There were no observed effects on insulin sensitivity, liver function, lipid profile, inflammatory markers, blood pressure, total body fat percentage, gut health, and health-related quality of life
  • In post-hoc exploratory analyses among participants with metabolic syndrome at baseline, FMT led to greater resolution of this condition (18 to 4) compared with placebo (13 to 10) by 26 weeks (adjusted odds ratio, 0.06; 95% CI, 0.01-0.45; P = .007)

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Sandy Springs, GA

Converting to Monotherapy for Children with Inflammatory Bowel Disease

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W El-Matary et al. JPGN 2020; 71: 740-743. Discontinuation of Immunosuppressive Medications in Children With Inflammatory Bowel Disease on Combination Therapy

This study looked at 105 patients receiving combination therapy; the a median duration of combination therapy was 2.1 years, with infliximab and either methotrexate  (53) or azathioprine (52). 89 patients had Crohn’s disease.

Key findings:

  • 11 (10.5%) patients experienced a clinical relapse over a median duration of follow-up of 12.0 months after stopping the immunomodulator.
  • In the patients who did not relapse, the median IFX trough level at IM discontinuation was 6.2; the IFX trough level was 3.8 μg/mL in those who relapsed.

In their discussion, the authors urge caution in discontinuation of immunomodulators in those with clinically-severe Crohn’s disease and those with low infliximab levels.

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Tons of shells on Picnic Island, Tampa Bay

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Using FLIP

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A recent review article (E Sararino et al. Am J Gastroenterol 2020; 115: 1786-06. Use of the Functional Lumen Imaging Probe in Clinical Esophagology) is a terrific article for understanding Functional Lumen Imaging Probe (FLIP) techonology and uses. Thanks to Ben Gold for this reference.

Link to patient explanation of EndoFLIP at Univ Michigan

The FLIP “measures luminal cross sectional area (CSA) and pressure in the esophagus using impedance planimetry and serves as an adjunct to existing esophageal investigative tests. A distensible balloon encasing a catheter with multiple pairs of impedance electrodes is used, and the balloon is distended with fluid of known conductivity and volume.”

FLIP can be done at time of endoscopy.

  • Distensibility index (DI). This is the ratio of EGJ cross sectional area to intraballoon pressure is generally considered the most useful FLIP metric. Normal DI values in adults range from 3.1 to 9.0 m3/mm Hg. Lower values indicated reduced EGJ opening.
  • FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms.
  • FLIP can be used to assess fibrostenotic remodeling of the esophagus in eosinophilic esophagitis.
  • Lumen diameter measured using FLIP in complex strictures can potentially guide management.

This review has several helpful figures to illustrate the type of visual data available. It also provides a standard protocol for using FLIP. The current limitations for FLIP include the lack of real-time software analysis of the data which hinders reporting, and limited data supporting use.

Related blog post: #NAASPGHAN17 Eosinophilic Esophagitis Session

While this picture makes me look like a scofflaw, in fact one can sit on the sand below the median high tide mark. So there!

5 Signs Your Child Needs a Feeding Tube

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The Nutrition4Kids website (developed by my partner Stan Cohen) has a lot of useful information for families. Here is a link to a recent addition: 5 Signs Your Child Needs a Feeding Tube

An excerpt:

Reasons for needing a feeding tube…

  • Medical necessity, where the child can’t meet their calorie needs due to a medical condition (like, say, a heart defect, neurologic and neuromuscular disorders, or a digestive disorder.)
  • Failure to thrive, often because of food aversions…
  • Trouble learning to suck, swallow, and breathe

Here are some of the most common signs your child may benefit from a feeding tube.

  • Sign #1: Your Physician Brings It Up 
  • Sign #2: You’ve Noticed Development Delays 
  • Sign #3: They’re Malnourished or Chronically Dehydrated
  • Sign #4: You’ve Tried Other Options Without Success
  • Sign #5: You’re Feeling Helpless as the Caregiver

If your child does end up needing enteral nutrition, understand that it doesn’t always mean it’s a forever situation.

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Resource:

www.feedingtubeawareness.com  This site contains a terrific PDF download which explains enteral tubes in an easy to understand style along with good graphics. “What You Need to Know Now, A Parent’s Introduction to Tube Feeding is the guidebook that every parent wished they had when they were first introduced to feeding tubes.”

Picking the Wrong Health Insurance Policy

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NY Times: It’s Not Just You: Picking a Health Insurance Plan Is Really Hard

An excerpt:

Health insurance is a complicated financial product, and study after study has shown that people routinely pick bad plans, even choosing options that leave them worse off financially in every possible scenario…

 Many Americans don’t understand terms like “deductible” or “coinsurance” very well. And few are good at predicting what sort of health care needs they will have in the coming year…

A recent study in the Netherlands, which offers insurance to everyone through an Obamacare-like marketplace, found that only 5 percent of Dutch customers did a better job at choosing an ideal plan than they would have by choosing a plan at random… People with less education and income, who tend to be in worse health, were very likely to choose a plan that cost them more to cover their health care — a situation that might leave them skimping on needed medicine or procedures.

My take: This article is so true. When I choose health insurance, this is always a complicated task despite my familiarity and expertise. I would expect that computer-aided decision-making could be developed and be helpful.

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