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Intraoperative Liver Biopsy During Adolescent Bariatric Surgery: Is It Really Necessary? Obesity surgery Jones, R. E., Yeh, A. M., Kambham, N., El Haija, M. A., Pratt, J., Bruzoni, M. 2019
Abstract

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is prevalent in children with obesity and is definitively diagnosed with liver biopsy. However, the utility of routine biopsy during adolescent bariatric surgery remains unknown. We describe the usefulness of routine versus selective intraoperative liver biopsy in adolescents undergoing bariatric surgery.METHODS: A retrospective review of adolescents who received bariatric surgery at our institution between 2007 and 2018 was performed. Prior to 2014, all patients routinely received intraoperative liver biopsy. After 2014, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. Demographic, biochemical, and histopathologic data were compared between patients who underwent routine, selective, or no biopsy.RESULTS: There were 77 patients who received bariatric surgery during the study period: 32 underwent routine biopsy, 13 selective biopsy, and 32 no biopsy. Selective liver biopsy was more likely to show pathologic evidence of fibrosis (84.6% versus 31.2%, p=0.000) and steatosis (100.0% versus 59.4%, p=0.003), and higher mean NAFLD activity score compared with routine biopsies (4.4 versus 2.1, p=0.001). Patients with steatosis had significantly higher preoperative fasting insulin (41.4 versus 21.1mIU/L, p=0.000), and patients with fibrosis had significantly higher glycated hemoglobin (6.1% versus 5.5%, p=0.033) and alanine aminotransferase (81.5 versus 52.7mg/dL, p=0.043). There were no biopsy complications or changes in management due to biopsy results.CONCLUSIONS: Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management. Prospective, longitudinal studies are needed to better understand the meaningfulness of liver histopathology in this population.

View details for DOI 10.1007/s11695-019-04136-4

View details for PubMedID 31446562
Integrative Approach to Pediatric Nausea PEDIATRIC ANNALS Arruda, J., Yeh, A. 2019; 48 (6): E236?E242
Abstract

Nausea is a bothersome symptom that is commonly seen in the pediatric population. The pathophysiology of nausea is complex and involves the central nervous system, the enteric nervous system, gastrointestinal tract motility, and psychologic influences. Pharmacologic and nonpharmacologic therapies are available for treating nausea. Mind-body interventions (hypnosis, biofeedback), botanicals and supplements (ginger, enteric-coated peppermint oil), aromatherapy, and acupuncture have emerging evidence for effectively treating pediatric nausea. [Pediatr Ann. 2019;48(6):e236-e242.].

View details for DOI 10.3928/19382359-20190517-01

View details for Web of Science ID 000470985100008

View details for PubMedID 31185115
Pediatric Integrative Medicine in Academia: Stanford Children's Experience CHILDREN-BASEL Ramesh, G., Gerstbacher, D., Arruda, J., Golianu, B., Mark, J., Yeh, A. 2018; 5 (12)
View details for DOI 10.3390/children5120168

View details for Web of Science ID 000454708100013
Yoga as adjunct therapy for adolescents with inflammatory bowel disease: A pilot clinical trial COMPLEMENTARY THERAPIES IN MEDICINE Arruda, J. M., Bogetz, A. L., Vellanki, S., Wren, A., Yeh, A. 2018; 41: 99?104
View details for DOI 10.1016/j.ctim.2018.09.007

View details for Web of Science ID 000453498000014
Wired for Threat: Clinical Features of Nervous System Dysregulation in 80 Children. Pediatric neurology Elbers, J., Jaradeh, S., Yeh, A. M., Golianu, B. 2018
Abstract

BACKGROUND: The negative effect of perceived stress on health has become a cultural epidemic. Despite many health implications, the clinical impact of stress on the nervous system is not well understood. This case series describes the symptom profiles of 80 children with nervous system dysregulation attributed to maladaptive neuroendocrine responses to stress.METHODS: We reviewed of 80 children with nervous system dysregulation identified from a single, tertiary care pediatric neurology clinic. Included patients were between five and 17 years of age, with unexplained medical symptoms lasting three months or longer affecting at least four of six neurological domains: (1) somatization, (2) executive function, (3) autonomic function, (4) digestion, (5) sleep, and (6) emotional regulation. Medical symptoms, diagnoses, and detailed social histories were collected.RESULTS: Of 80 children, 57 were female (71%), 57 were Caucasian (71%), with median age of 14 years. Symptoms had a mean duration of 32 months, and included: 100% somatic symptoms, 100% emotional dysregulation, 92.5% disrupted sleep, 82.5% autonomic dysregulation, 75% executive dysfunction, and 66% digestive problems. Overall, 94% reported chronic or traumatic stressors; adverse childhood experiences were present in 65%.CONCLUSIONS: Perceived stress impacts many functions of the neuroendocrine system through experience-dependent plasticity, resulting in a constellation of symptoms and functional impairments we describe as nervous system dysregulation. The pathophysiology of these symptoms involves dysregulation of subcortical, hormonal, and autonomic circuits, which remain largely untested. Recognition and understanding of maladaptive neurophysiology in stress-related symptoms has important implications for diagnosis, treatment, and advances in health research.

View details for PubMedID 30343833
Integrative Medicine in Child Neurology: what do providers think and what do they need to learn? Karamian, A., Yeh, A., Wusthoff, C. LIPPINCOTT WILLIAMS & WILKINS. 2018
View details for Web of Science ID 000453090800038
Pediatric Integrative Medicine in Residency Program: Relationship between Lifestyle Behaviors and Burnout and Wellbeing Measures in First-Year Residents CHILDREN-BASEL McClafferty, H., Brooks, A. J., Chen, M., Brenner, M., Brown, M., Esparham, A., Gerstbacher, D., Golianu, B., Mark, J., Weydert, J., Yeh, A., Maizes, V. 2018; 5 (4)
Abstract

It is widely recognized that burnout is prevalent in medical culture and begins early in training. Studies show pediatricians and pediatric trainees experience burnout rates comparable to other specialties. Newly developed Accreditation Council for Graduate Medical Education (ACGME) core competencies in professionalism and personal development recognize the unacceptably high resident burnout rates and present an important opportunity for programs to improve residents experience throughout training. These competencies encourage healthy lifestyle practices and cultivation of self-awareness, self-regulation, empathy, mindfulness, and compassion—a paradigm shift from traditional medical training underpinned by a culture of unrealistic endurance and self-sacrifice. To date, few successful and sustainable programs in resident burnout prevention and wellness promotion have been described. The University of Arizona Center for Integrative Medicine Pediatric Integrative Medicine in Residency (PIMR) curriculum, developed in 2011, was designed in part to help pediatric programs meet new resident wellbeing requirements. The purpose of this paper is to detail levels of lifestyle behaviors, burnout, and wellbeing for the PIMR program’s first-year residents (N = 203), and to examine the impact of lifestyle behaviors on burnout and wellbeing. The potential of the PIMR to provide interventions addressing gaps in lifestyle behaviors with recognized association to burnout is discussed.

View details for PubMedID 29690631
Pediatric Integrative Medicine in Academia: Stanford Children's Experience. Children (Basel, Switzerland) Ramesh, G., Gerstbacher, D., Arruda, J., Golianu, B., Mark, J., Yeh, A. M. 2018; 5 (12)
Abstract

Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States. Early research of pediatric integrative medicine modalities shows promise for the treatment of common pediatric conditions such as irritable bowel syndrome, acute and chronic pain, headache, and allergy, among others. In light of the growing prevalence of pediatric illnesses and patient complexity, it is crucial to emphasize the patient's overall well-being. As academic centers around the world start to develop pediatric integrative medicine programs, the aim of this manuscript is to briefly highlight evidence of effective integrative treatments in pediatric subspecialties, to describe the establishment of our integrative medicine program, to summarize its early efforts, and to discuss potential barriers and keys to success.

View details for PubMedID 30545081
Pediatric Integrative Medicine PEDIATRICS McClafferty, H., Vohra, S., Bailey, M., Brown, M., Esparham, A., Gerstbacher, D., Golianu, B., Niemi, A., Sibinga, E., Weydert, J., Yeh, A., Sect Integrative Med 2017; 140 (3)
View details for DOI 10.1542/peds.2017-1961

View details for Web of Science ID 000408820300051
Mind-Body Interventions for Pediatric Inflammatory Bowel Disease. Children (Basel, Switzerland) Yeh, A. M., Wren, A., Golianu, B. 2017; 4 (4)
Abstract

Pediatric inflammatory bowel disease is an autoimmune disease that causes chronic inflammation of the gastrointestinal mucosa. There is emerging evidence that the brain-gut connection affects inflammatory bowel disease (IBD) patients more than previously thought. This is evidenced by comorbid mood disorders, irritable bowel symptoms concurrent with quiescent IBD, and the potential of psychosocial stressors to trigger IBD flares. Mind-body interventions such as psychotherapy, relaxation, mindfulness, biofeedback, yoga, and clinical hypnosis offer an adjunct to standard medical treatment for IBD. We will review the current evidence base for these mind- body interventions in the treatment of pediatric IBD, illustrate a case study, and offer suggestions for future research for this promising field.

View details for DOI 10.3390/children4040022

View details for PubMedID 28368365
Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease. Journal of pediatric gastroenterology and nutrition Martin, M., Garcia, M., Christofferson, M., Bensen, R., Yeh, A. M., Park, K. T. 2016; 63 (5): 508-511
Abstract

Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency (LEP) among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish-speaking (SP) and English-speaking (ES) pediatric IBD patients and parents, and to describe the feasibility and efficacy of a novel peer-group education symposium designed to enhance patient activation as measured with the PAM.Two separate half-day educational symposia in either Spanish or English were presented and moderated by 2 native Spanish-speaking physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self-management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high-quality care). Descriptive statistics were used to describe changes between pre- and post-symposium PAM trends.11 primarily SP and 21 ES families participated in their respective symposium. Paired pre- and post-PAM scores were available from 24 pediatric IBD patients (8 SP; 16 ES) and 41 parents (15 SP; 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female gender in 80% and 62%, respectively. Paired pre- and post-PAM scores for all participants (n?=?65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP-patients 59.1 to 70.3, P?=?0.05; SP-parents 69.8 to 75.2, P?=?0.2; ES-patients 59.9 to 64.0, P?=?0.08; ES-parents 61.9 to 69.1, P?=?0.002), although only the ES-parents group had sufficient sample size (n?=?26) to achieve statistical significance. The overall cohort had an aggregate increase from pre-PAM of 62.9 (SD 14.5) to post-PAM of 69.4 (SD 13.9) (<0.001).We describe a novel peer-group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric IBD patients and their care-giving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.

View details for PubMedID 27031374
Acupuncture and Integrative Medicine for Pediatric Gastroesophageal Reflux and Functional Dyspepsia MEDICAL ACUPUNCTURE Kanak, M., Park, K. T., Yeh, A. 2015; 27 (6): 467?74
View details for DOI 10.1089/acu.2015.1144

View details for Web of Science ID 000217806700012
Bugs and Guts: Practical Applications of Probiotics for Gastrointestinal Disorders in Children NUTRITION IN CLINICAL PRACTICE Barnes, D., Yeh, A. M. 2015; 30 (6): 747-759
Abstract

Probiotics are foods or products that contain live microorganisms that benefit the host when administered. In this clinical review, we evaluate the literature associated with using probiotics in common pediatric gastrointestinal disorders, focusing specifically on antibiotic-associated diarrhea, acute gastroenteritis, Clostridium difficile infection (CDI), colic, inflammatory bowel disease, and functional gastrointestinal diseases. Meta-analysis of several randomized controlled trials have confirmed benefit for the administration of Lactobacillus rhamnosus GG and Saccharomyces boulardii to prevent antibiotic-associated diarrhea and to treat acute infectious diarrhea. Individual studies have also suggested benefit of probiotics to prevent acute gastroenteritis and serve as an adjunct in ulcerative colitis, pouchitis, antibiotic-associated diarrhea, CDI, functional abdominal pain, irritable bowel syndrome, and colic in breastfed babies. Although promising, larger well-designed studies need to confirm these findings. There is currently insufficient evidence to recommend probiotics for the treatment of constipation-predominant irritable bowel syndrome or Crohn's disease.

View details for DOI 10.1177/0884533615610081

View details for PubMedID 26538058
Integrative Treatment of Reflux and Functional Dyspepsia in Children. Children (Basel, Switzerland) Yeh, A. M., Golianu, B. 2014; 1 (2): 119-133
Abstract

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are common problems in the pediatric population, with up to 7% of school-age children and up to 8% of adolescents suffering from epigastric pain, heartburn, and regurgitation. Reflux is defined as the passage of stomach contents into the esophagus, while GERD refers to reflux symptoms that are associated with symptoms or complications-such as pain, asthma, aspiration pneumonia, or chronic cough. FD, as defined by the Rome III classification, is a persistent upper abdominal pain or discomfort, not related to bowel movements, and without any organic cause, that is present for at least two months prior to diagnosis. Endoscopic examination is typically negative in FD, whereas patients with GERD may have evidence of esophagitis or gastritis either grossly or microscopically. Up to 70% of children with dyspepsia exhibit delayed gastric emptying. Treatment of GERD and FD requires an integrative approach that may include pharmacologic therapy, treating concurrent constipation, botanicals, mind body techniques, improving sleep hygiene, increasing physical activity, and traditional Chinese medicine and acupuncture.

View details for DOI 10.3390/children1020119

View details for PubMedID 27417471
Acupuncture for Pediatric Pain. Children (Basel, Switzerland) Golianu, B., Yeh, A. M., Brooks, M. 2014; 1 (2): 134-148
Abstract

Chronic pain is a growing problem in children, with prevalence as high as 30.8%. Acupuncture has been found to be useful in many chronic pain conditions, and may be of clinical value in a multidisciplinary treatment program. The basic principles of acupuncture are reviewed, as well as studies exploring basic mechanisms of acupuncture and clinical efficacy. Conditions commonly treated in the pediatric pain clinic, including headache, abdominal pain, fibromyalgia, juvenile arthritis, complex regional pain syndrome, cancer pain, as well as perioperative pain studies are reviewed and discussed. Areas in need of further research are identified, and procedural aspects of acupuncture practice and safety studies are reviewed. Acupuncture can be an effective adjuvant in the care of pediatric patients with painful conditions, both in a chronic and an acute setting. Further studies, including randomized controlled trials, as well as trials of comparative effectiveness are needed.

View details for DOI 10.3390/children1020134

View details for PubMedID 27417472
Infliximab for the treatment of granulomatous peritonitis. Digestive diseases and sciences Yeh, A. M., Kerner, J., Hillard, P., Bass, D. 2013; 58 (12): 3397-3399
View details for DOI 10.1007/s10620-013-2726-6

View details for PubMedID 23817923
Acute Liver Failure and Aplastic Anemia in an 11-Year-Old Girl DIGESTIVE DISEASES AND SCIENCES Yeh, A. M., Mojtahed, A., Bass, D. 2011; 56 (8): 2237-2240
View details for DOI 10.1007/s10620-011-1678-y

View details for PubMedID 21442323

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Clinical Associate Professor, Pediatrics - Gastroenterology

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