Pediatric Gastroenterology - Open Access Journals
InterviewPediatric gastroenterologyVasundhara Tolia*: Vasundhara Tolia is currentlyan Adjunct Professor of Pediatrics at Michigan StateUniversity School of Medicine in Lansing (MI, USA).Prior to that, she was a Professor of Pediatrics andDirector of Pediatric Gastroenterology at WayneState University (MI, USA) and Children’s Hospital ofMichigan (MI, USA), respectively. Dr Tolia attended theMedical College of Calcutta (Kolkata, India), completeda residency program and received postgraduatetraining in gastroenterology at Children’s Hospitalin Detroit (MI, USA). Dr Tolia is board certified in Pediatrics and PediatricGastroenterology. She has published over 150 articles in peer-reviewedjournals, reviews and book chapters. In addition to being a researcher,educator, clinician and mentor, she has been on the Best Doctors' list and isan internationally sought speaker. She has lectured extensively throughoutthe world and she has held several editorial board positions. Dr Tolia hasbeen a Fellow of the American College of Gastroenterology, AmericanGastroenterological Association, American Academy of Pediatrics anda member of the Society for Pediatric Research and the North AmericanSociety of Pediatric Gastroenterology, Hepatology and Nutrition. She hasreceived numerous grants and awards, including ‘Woman of Distinction’from the Crohn’s and Colitis Foundation of America.News & ViewsNewsJournal WatchInterviewVasundhara Tolia speaks to Alisa Crisp, Assistant Commissioning Editor.QQWhat led you to a career in pediatrics?I like children, but I think that working withthe different manifestations of diseases at dif ferent levels of development is what I find mostfascinating about pediatric medicine. A simpleurinary tract infection in a baby can cause vom iting, crying and fussiness but an older child cansay 'I’m burning while peeing', so it’s really morechallenging. You are also dealing with a wideage range, right from premature babies up toadults. In the USA, the pediatric age is officially21 years of age, although we start transitioningmost patients over to adult care at 18 years ofage when they start going to college. The diver sity of manifestations of various diseases is verychallenging and interesting to me.What specifically do you find interestingabout gastroenterology?QQPediatric gastroenterology is still a veryyoung field – it’s only about 40 years or soold – compared with many others. And evenduring my career span of 30 years as a pediatricgastro enterologist, there has been tremendousevolution in all aspects of the field. In particular,a major change has been a tremendous increasein the application of technology. Now, we do nothesitate to do the endoscopies and biopsies thatwe would not have thought about doing 30 yearsago in routine practice. I find the combinationof clinical acumen with technological findingsand its applications in the management of thepatient most interesting.Providence Hospital, 16001 West Nine Mile Road, Southfield, MI 48075, USA; vasu.tolia@gmail.com10.2217/CPR.12.67 2012 Future Medicine LtdClin. Pract. (2012) 9(6), 623–627part ofISSN 2044-9038623
News & ViewsInterviewAre there any particular individuals orevents that played an important role inshaping your career?QQI would like to start with an event, rather thanan individual. I trained at Children’s Hospitalof Michigan (MI, USA), where the gastro intestinal division was not involved in research.So whenever I saw interesting cases, I woulddo a literature search and I published somecase series and case reports. When I attendedthe first combined pediatric gastroenterologymeeting of North America and Europe in NewYork City (NY, USA) in 1985, I looked aroundand saw my contemporaries presenting papers.Then I knew that I had to do something morethan I was already doing. So I started look ing for other collaborators in the hospital whowere also interested in research. The chief ofclinical pharmacology at that time, Dr RalphKauffman, currently at the University of Kansas(KS, USA), was very helpful in teaching mehow to design studies, because I did not havemuch knowledge of statistics at that time, asmy training had only been clinical. Therefore,from that point onwards, I would say that I wasreally inspired to do something more than I hadbeen doing and since then I haven’t stopped.Essentially, I nurtured myself to become aclinical investigator.What achievement are you most proud ofin your career?QQBesides having been a mentor to all my fellows,I think that being the first pediatric endoscopistat Children’s Hospital of Michigan and the cre ation of the state-of-the-art pediatric endoscopyunit there, I would consider one of my most sig nificant achievements. Even after establishmentof the unit, it is very important to keep abreastof technology; incorporating newer proceduresand applying them in pediatrics has been oneof my goals.My role was to incorporate and apply tech niques that are first performed in adults intochildren. We have to be sure that a techniqueis safe in adults first, before even thinkingabout doing it in children. For example, someof these new techniques include capsule endos copy, entero scopy, extended pH probe moni toring, impedance and small and large bowelmano metry, among others. I usually startedperforming most of these techniques in clinicalresearch protocols by designing clinical studies624Clin. Pract. (2012) 9(6)on pediatric patients. After establishing safetyand efficacy, they can become mainstreamprocedures.Is there a particular disease in pediatricgastroenterology that you find mostinteresting?QQI find all of pediatric gastroenterology interest ing, mainly because once I had started the fel lowship program, I had to find many topics tostudy to involve the fellows (the post graduatetrainees who come to specialize in pediatricgastro enterology). I have to get them involvedin doing research, so I have probably touched onall aspects of the field. The diseases that I havepersonally studied the most have been gastro esophageal reflux disease (GERD), inflam matory bowel diseases (IBD) and Helicobacterpylori infection.Your current work is on GERD. Can yougive me a bit of background on this diseaseand what it involves?QQThis is a disease that might span the lifetime ofan individual. Whether the disease is becomingmore prevalent or whether we are more aware ofit is really a matter of debate, but we are diag nosing it more and finding a need to intervenein more cases. Right from infants and babiesinto older children and teenagers, this diseaseis prevalent, and it is challenging to take careof it because the evolution and natural historyof the disease is not the same at all ages. Whenit occurs after 2–3 years of age, it can be anongoing issue. It might come and go, with wax ing and waning symptoms. Once you take anindividual off the treatment, the symptoms gen erally recur in a few months, unless the parentsand children are very conscientious in managingthe disease through conservative management,mainly lifestyle modifications. It becomes achronic disease and it is very frustrating for thepatients and children to come back and say it’sback again. I feel that teaching them to handleit is an art. In addition to this, there is a majorconcern in the pediatric age group about takingmedications and their potential long-term sideeffects. Another key part of managing the dis ease is knowing about the safety of the medica tions and making the parents feel comfortablewith using a treatment as necessary. The parentsand children have to understand that this is nota one-time occurrence and that the disease isfuture science group
Interviewgoing to keep coming back and they may needto drastically modify their lifestyle, which is noteasy. You can imagine that a teenager going toa party is going to want some soda and pizza orto indulge in cakes and pastries, and if many ofthose foods bring on an increase in symptoms,they need to know how best to manage it so theycan maintain a good quality of life and still keeptheir symptoms under control.Are there any other complications inspecifically treating children with this disease?QQOne of the major complications in treatingchildren with the disease is the chronicity; thefact that ongoing symptoms lead to the disease.Sometimes the disease can be silent or childrenmay underplay their symptoms. However, thepatients can have significant endoscopic find ings, such as erosions with minimal symptoms.This is particularly an issue in develop mentallyhandicapped children, because they are notalways expressive and cannot say what is hap pening to them. Progression of the disease, ofcourse, occurs in otherwise normal childrentoo. Luckily, complications, such as Barrett’sesophagus, occur very infrequently in children.This is an example of the difference betweenchildren and adults – we do not have to worryabout Barrett’s esophagus as much as in adults.However, symptoms related to other organs,such as the respiratory tract and exacerbation ofasthma, can be part of the problem in children.Are there any exciting treatments thatare currently in clinical trials in the field ofpediatric gastroenterology?QQReflux disease research is currently focusingon GABA receptor agonists to improve refluxsymptoms by decreasing inappropriate loweresophageal sphincter relaxation. I am not awareof other treatments in the pipeline. There issome very exciting research going on in theIBD area, for example, the role of microbes andanti microbial agents, the genetics of the diseaseand gene expression, efficacy and safety of treat ments in the long term, especially the biologicalagents and, the study of racial differences andthe phenotypic presentation of IBD. For manyother conditions, especially symptomatic prob lems, such as constipation, abdominal pain andreflux, we are resorting to developing screeningquestionnaires, whereby through their use, thephysician has a better idea about what sort offuture science groupNews & Viewscategory to classify the symptoms into and whatwould fit best as far as evaluation and manage ment is concerned. The development of thosequestionnaires and including them in clinicaltrials is also interesting; IBD is obviously a dis ease that has significant morbidity and we stillneed to find ways to control it better.Are there particular diseases withinpediatric gastroenterology that you feel weare still far from understanding?QQWe need to try to control the pandemic ofpediatric obesity much better. Being a gastro enterologist, nutrition is a major part of our fieldof practice, so preventive measures to deal withobesity, making individuals aware of lifestylemanagement (exercise and healthy eating) isvery important. This has to be carried out on afamily basis, because you cannot just treat thechild and expect the parents not to be involved.One of the challenges in pediatrics is that halfthe time you are treating the parent rather thanthe child. The parents are naturally concernedabout the health of the child, and so you haveto really reassure the parent and ensure thatthey stay on top of management of the disease,other wise it becomes very challenging to handle.Besides pediatric obesity, another disease thatwe don’t yet understand enough is nonalcoholicsteatohepatitis, which is also becoming moreand more prevalent. It usually manifests initiallywith elevated transaminases on laboratory test ing. That is another condition that we really donot have a good understanding of as yet.I think another disease that is coming to theforefront and we are seeing more of is eosin ophilic esophagitis, which can mimic GERD butis associated with aeroallergies and food allergies.Sometimes we cannot identify a specific aller gen. The disease causes swallowing difficulty,reflux-type symptoms, fussiness and, in babies,another spectrum of the disease can be rectalbleeding. Eosinophilic esophagitis is also a bigchallenge to manage and we do not really havea good understanding of the pathophysiology ofthis particular disease yet.How do you think we can improve ourunderstanding or treatment of these diseases?QQAllergy evaluation is definitely necessary for themanagement of eosinophilic esophagitis after thediagnosis has been established by endoscopy andbiopsy. If you can identify a particular allergenwww.futuremedicine.com625
News & ViewsInterviewor substance then you need to remove that fromthe child’s environment or diet. However, if youcannot find an allergen then we have to lookat other treatments. We have performed a trialwith a biological agent but it did not show sig nificant benefit to be accepted as a therapeuticagent. Instead, we have been using topical ste roids in a cyclical fashion. We use the steroidsfor a few months until resolution of symptomsand withdraw treatment by tapering. We thenrepeat the treatment again when the symptomsrecur; we always want to minimize the use ofsteroids as much as possible because of the poten tial side effects in the long term. We still needto learn a lot about this disease by collectingtissues, studying the genetics, and using longterm observational registries. In pediatrics,multi center studies must be carried out becausethe number of patients in any of these entitiesin one particular center is not very high, so it isnot possible to conduct quick trials. Wheneveryou do multicenter studies, there has got to beuniformity of criteria for diagnosis, interpreta tion of results and management. Otherwise onecenter may be doing something entirely differ ently from another center, and it becomes verydifficult, such as comparing apples and oranges.We therefore really need to have good studiesand proper leadership to understand more aboutmost of the pediatric diseases.You mentioned H. pylori, is this a conditionthat we are coming to know more about or isthere still a lot that we need to understand?QQOverall, I believe that the incidence of H. pylori,is decreasing. We were at the peak of research20 years ago in this disease. Since then, thenatural history of the disease has been altered,particularly with the use of better therapy. In thepediatric age group, antibiotics are frequentlyused for other infections in the body and someof them, although not all, can influence theresistance patterns of the bacteria.When I was studying H. pylori, one of themain things I was focusing on was antibioticresistance. We were doing cultures and studyingantibiotic sensitivity and how to treat the diseaseif the first-line treatment did not work. Screeningthe rest of the family is also important if theinfection is persistent because it is spread by closecontact. We found that the infection can spreadto or from other members of the family; unlessthey are all treated at the same time, there is no626Clin. Pract. (2012) 9(6)hope to eradicate it. In the pediatric age range,H. pylori is often only found when we carry outan endoscopy on the children, which we only dowhen the children are symptomatic. In endos copy, we may see normal findings, hypertrophicnodular gastritis or ulcers. If H. pylori is detected,it is treated. I would not write this off as an inci dental finding on discovering this infection if anindividual was having abdominal pain, which isthe reason for performing the endoscopy. Thereis a theory about H. pylori not causing abdominalpain, but I would say that those data are confus ing it with functional abdominal pain, whichis located in the periumbilical area. H. pylorican cause epigastric abdominal pain. Overall,I believe that the impetus to study H. pylori atthe moment has decreased compared with previ ously. This is not because we know all about it,but its incidence appears to be declining. It mightbe one of those infectious diseases that we aregoing to conquer in the long run.How do you think the field of pediatricgastroenterology or pediatrics in general willevolve in the next 10 years?QQI think that we will focus much more on thegenetics of the disease, including pharmaco genomics. For instance, I have carried out somequestionnaire studies in children proven to haveGERD from endoscopy and biopsies. We didquestionnaires with parents and grandparentsand found that in 42% of these children, a firstdegree relative, such as a sibling or a parent, hadGERD and 12% of patients had three genera tions in the family, even grandparents, with thedisease. There were also some with Barrett’sesophagus. Family history may therefore playa role in this condition. While we know that itis not an autosomal dominant or recessive dis ease, where you can specify the chance of a childdeveloping the disease, when you see a familyhistory of multiple members of the family withthe disease, there is a higher chance of not onlythe child having the disease, but also for it to bepersistent. In addition, genetic anticipation mayoccur. So we need to be focusing on evaluatingfamily history carefully. With early screeningand the use of conservative measures, we can tryto manage these conditions better.Once the diseases are diagnosed, I think bet ter therapeutic measures and improved safetyand efficacy, as well as safe management, is goingto be the focus over the next decade.future science group
InterviewI think that the biggest challenge to thefield of pediatrics itself is improving preventivecare, which is really going to become key in thelong term. This includes developing vaccinesand using pharmacogenomics, where we canunderstand how the body is going to react toa particular medicine before using it. I thinkthat prevention is obviously better than allowingthe disease to occur and have to treat it by theuse of genomic medicine, and intervention evenwhile the baby is in utero, as soon as a treatablecondition is diagnosed. I think that early iden tification of conditions for better managementfuture science groupNews & Viewsand preventing progression is where we need tofocus most.Financial & competing interests disclosureV Tolia has no relevant affiliations or financial involvementwith any organization or entity with a financial interest inor financial conflict with the subject matter or materialsdiscussed in the manuscript. This includes employment,consultancies, honoraria, stock ownership or options, experttestimony, grants or patents received or pending, orroyalties.No writing assistance was utilized in the production ofthis manuscript.www.futuremedicine.com627
the world and she has held several editorial board positions. Dr Tolia has been a Fellow of the American College of Gastroenterology, American Gastroenterological Association, American Academy of Pediatrics and a member of the Society for Pediatric Research and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition.
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1 Section 1. Program Information General Information and Mission Statement The Department of Pediatrics at the University of Tennessee Health Science Center (UTHSC) offers a three-year ACGME accredited Pediatric Gastroenterology Fellowship program in Memphis, Tennessee. Pediatric Gastroenterology Fellowship is a 36-month program that is accredited, in
Correspondence and reprints: Dr Kevan Jacobson, British Columbia's Research Institute and British Columbia's Children's Hospital, Division of Gastroenterology, 4480 Oak Street, Room K4-181, Vancouver, British Columbia, V6H 3V4. . Canadian pediatric gastroenterology workforce (2005/2006) A list of pediatric gastroenterologists, with .
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Pediatric Gastroenterology 2022 Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 57. I.B.1.a).(1) The pediatric gastroenterology program should be geographically proximate to the core pediatric residency program. (Detail) I.B.2. There must be a program letter of agreement (PLA) between the
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