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The Blog

Analysis of important issues within the field of Pediatric Gastroenterology: latest research, training, academic and private practice concerns, funding, global health, and other current events.

Friday, November 27, 2015

As these words shot from his mother's mouth for the third day in a row, I wondered how the child remembered to breathe. Will he ever learn? Will we be texting him reminders to pick up his clothes and comb his hair every day of his adult life? It is difficult to follow rules. And, I'm giving my son a hard time, but truly the kettle is calling the pot black. There's a wake of broken rules in our house every time I shut off hte nightstand light: a TV left on, a tie on the closet floor, a pair of shoes by the comfy living room chair. The list goes on, and my wife would be happy to detail it for you... But, it's one thing to break the laws of the house. It's another to ignore the collective voice of respected medical societies. In the October 2015 issue of JPGN, Ofei and colleagues report on their center's adherence to clinical practice guidelines for upper endoscopy biopsies for Celiac disease published by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the American College of Gastroenterology (ACG). Link provided below. These guidelines recommend four distal duodenal biopsy specimens and at least one specimen from the duodenal bulb. The recommendations stem from the fact that gastroenterologists have opportunities to identify celiac disease in patients that may not be otherwise discovered due to the patchy nature of histologic changes and good - but not infallible - screening tests. While faculty generally obtained the recommended number of duodenal biopsies in patients with histologic celiac disease, a number did not obtain the recommended biopsy specimens in patients not initially suspected of celiac disease. As the authors state, patients undergoing upper endoscopy for any reason represent an opportunity to identify celiac disease. Celiac disease is estimated to occur in 1% of the general population, but the majority of persons with the disease may remain undiagnosed. With a good portion of the population at risk and the possibility of significant long-term complications of the disease (iron deficiency, bone health among others), we as pediatric gastroenterologists should work to ensure that the silent cases are brought to light. What is your practice? Do your partners or colleagues routinely obtain 4-6 biopsies from the duodenum in all patients for upper endoscopy? Would procedural checklists be helpful at your institution? Regardless, careful thought to our routines during endoscopy is important. Guidelines are typically not made to add to our work, but are suggested to help improve patient care. So is this a case of pediatric gastroenterologists not making their bed? Ryan Fischer, MD Associate Professor of Pediatric Gastroenterology Liver Care Center Children's Mercy Hospital

Thursday, October 22, 2015

I am often asked, what can I do to improve the likelihood that my manuscript will be published? As you know, especially for young professionals in medicine and academia, getting published and cited may be crucial for advancement in their career. Here are a few helpful tips to help you get your paper published. 1. IFA. Carefully read the journal’s “Instructions For Authors” AND follow them. This may seem like a “no brainer”, but you would be surprised how often a potentially good paper is immediately rejected just because the authors failed to adhere to journal parameters. If you are uncertain or do not understand the IFA, write the editorial office for clarification. 2. Study Guidelines. View the guidelines for specific studies and utilize the helpful checklists, such as: STROBE (observational studies), CONSORT (randomised trials), PRISMA (systemic reviews), etc. Or other such useful aids that are available online in your chosen field. 3. English Editing. If English is not your first language, ask a native English-speaking colleague or professional author's editor, preferably knowledgable in the subject matter of your manuscript, to edit it. Remember, it is not the job of the reviewers or editors to try to figure out what you are saying, and more importantly, nor do they have the time! We wish you good luck and success in your future endeavors!

Thursday, July 31, 2014

There has been an increasing focus on the inorganic arsenic content of rice and the possible health implications of arsenic exposure in infants and children.  As a result, the ESPGHAN Committee on Nutrition has recently published recommendations to limit childhood exposure to inorganic arsenic found in rice.  The commentary has been published ahead of print and the link to the full article is included below.

The publication highlights the ambiguity that exists in the regulation of food-based inorganic arsenic exposure.  Various food safety organizations have attempted to set guidelines on food-based inorganic arsenic exposure.  However, inorganic arsenic is considered a first level carcinogen and any exposure may increase one’s risk for various carcinomas and adverse health effects.  Rice has a much higher concentration of inorganic arsenic compared to other grains due to the physiology of rice and the way it is grown in flooded rice paddies.

Special concern exists regarding the exposure of infants and children to inorganic arsenic due to rice exposure.  Rice and rice products are commonly added to infant formula, food, and drinks.  Rice cereal is often the first and most common infant fortified cereal used due to its wide availability and low allergenic potential.  Rice cereal is often used as a thickening agent for infants with oropharyngeal dysphagia and may also be used as a therapeutic strategy to thicken formula in infants with gastroesophageal reflux.  In infants and children who avoid dietary gluten, rice intake and inorganic arsenic exposure can be much higher than those who do not avoid gluten within their diet.

The ESPGHAN Committee on Nutrition concludes that inorganic arsenic intake in infancy and childhood should be as low as possible.  A variety of grains should be used when possible, and rice with the lowest inorganic arsenic content should be used for infant and childhood products.  Rice drinks should not be used in infants and children, and the risks of rice protein based infant formulas should be weighed when considering these products.

For additional information, please refer to the full publication via the link provided below.  The press release from Wolters Kluwer Health is also included below.


Arsenic in Rice - A Cause for Concern. A Comment by the ESPGHAN Committee on Nutrition

Wolters Kluwer Health: Experts Voice Concerns Over Arsenic in Rice

Thursday, July 3, 2014

The July 2014 supplemental issue of JPGN highlights the distinguished career of Dr. David Branski.  Dr. Branski was presented with the ESPGHAN Distinguished Service Award in May of 2013, in part due to his numerous research contributions within the field of celiac disease.  As discussed by his colleagues in this month’s special feature, Professor Branski authored more than 150 peer-reviewed articles, 45 chapters and review articles, 10 books, and 18 book series.  This includes his contributions to the gastrointestinal section of the recent editions of the Nelson Textbook of Pediatrics.

Dr. Branski was active in many professional organizations, both globally and within his native Israel.  He was also one of the most active members of ESPGHAN.  His attendance at annual ESPGHAN meetings was without interruption since 1980.  He was appointed as ESPGHAN Editor-in-Chief of JPGN in 2010 and served in this capacity until the week that he passed away.  His contributions to JPGN extended well beyond his expected duties and were instrumental in furthering the mission of our journal.  Dr. Branski died in August 2013 after a hard-fought battle with cancer.  He left a lasting legacy within our specialty that will lead to the improvement of childhood health for decades to come.

Along these lines, Dr. Branski’s publications within JPGN and his personal research were instrumental in the development of this July 2014 supplemental issue of JPGN.  The links below include the current JPGN supplemental issue on Celiac Disease, as well as the 2012 ESPGHAN guidelines for diagnosis of Celiac disease co-authored by Dr. Branski.

Presentation of the 2013 ESPGHAN Distinguished Service Award to Professor David Branski

July 2014 Supplement 1; Celiac Disease

January 2012: ESPGHAN Guidelines for the Diagnosis of Coeliac Disease


Thursday, May 29, 2014

The U.S. Consumer Product Safety Commission (CPSC) recently announced that an agreement had been reached with the creator of Buckyballs to issue a voluntary recall of their high-powered magnet toys.  These rare-earth magnets have been marketed within toy stores and large chain stores as desk toys.  Buckyballs and similar products are typically sold in packs of multiples, sometimes numbering 100 or more in a single pack.  Due to their small size, they pose a high risk of accidental ingestion in children and toddlers.  High-powered magnets have also been accidentally ingested by teenagers following their use as non-piercing nose rings, lip rings, and tongue rings.  When multiple magnets are ingested, they pose a substantial risk of intestinal injury, including obstruction, ulceration, and perforation.

The agreement with the creator of Buckyballs is the end result of an administrative case filed nearly two years ago by the CPSC in July 2012.  Pediatric gastroenterologists and NASPGHAN leadership have been instrumental in warning policy makers and consumers about the dangers that these high-powered magnets pose to both children and teenagers, and this recall illustrates the impact that advocacy through our national organization can have on the well-being of our patients.

For more information regarding the recall, a link to the CPSC press release is listed below.  The creator of Buckyballs has agreed to provide funding for a recall trust, which will be controlled by the CPSC.  Once this trust has been established, consumers will be allowed to seek a refund through an online registration process.  The CPSC is asking consumers to sign up for email alerts in order to be notified when the recall has officially started.

Important JPGN publications regarding the emerging trend of magnet ingestion and the management of magnet ingestions in children are listed below as well.  Congratulations to everyone who has worked hard to see this important advocacy issue to this initial step toward completion.

CPSC Recall Information

Magnet-Related Injury Rates in Children: A Single Hospital Experience. JPGN 2013; 57: 14-17

Magnet Ingestions in Children Presenting to US Emergency Departments, 2002-2011. JPGN 2013; 57: 18-22

Management of Ingested Magnets in Children. JPGN 2012; 55: 239-242