Gastroenterology, Hepatology and Nutrition

Research Highlights

Division Overview

Our Vision

We will be the leaders in the care of children with digestive diseases

Our Mission

• Care: We will deliver exceptional, safe, and affordable care
• Research: We will catalyze high-impact research in digestive diseases
• Education: We will train the future leaders of the field

Our Values

• We are respectful
• We are honest
• We speak the truth
• We value diversity
• We work as a team

Innovation in Clinical Care

The location of the division is on the eighth and ninth floors of the Clinical Sciences Building, where clinical, research and training projects permit integration to provide the most innovative, evidence- and expert-based care for children with all forms of digestive disease. Delivery of direct patient care occurs in the outpatient Gastroenterology Clinic and in inpatient units for gastroenterology (A4S) and hepatology and liver transplantation (A4N). Our team also provides timely consultation to all clinical services at Cincinnati Children’s Hospital, where we work as a multi-disciplinary team to improve the care of the children we serve. The scope of care starts with the most common digestive problems. It extends to the most rare and complex disorders that require ever-improving technologies to aid in diagnosis and to design new therapies. Some of our specialized services include liver and intestinal transplantation, intestinal rehabilitation, total pancreatectomy with islet auto transplantation, trans nasal endoscopy for evaluation of esophageal disorders, and multi-disciplinary management of complex aerodigestive, inflammatory, and motility disorders (described below). The current U.S. News and World Report rankings recognize us as the top program in the United States for Pediatric Gastroenterology and Gastrointestinal Surgery.

Our medical and nurse specialists also provide care in satellite clinics with the goals to bring gastroenterology expertise to our communities and improve patient experience. We hold daily clinics at the Cincinnati Children’s Liberty Campus focusing on gastroenterology, and an increasing number of subspecialty clinics (example: NASH, liver and Neurogastroenterology / Motility) and gastrointestinal endoscopies. Other satellite gastroenterology clinics are available at Cincinnati Children’s facilities in Mason, Green Township, Anderson, Portsmouth, Crestview, KY, Maysville, KY, and Batesville, IN. Our experts also partner with other programs via TeleHealth or other forms of professional-to-professional digital consultations in Kalamazoo (MI), Lexington (KY), Akron (OH), and in Park View (IN).

Innovation in Research

The division is a scientific hub for digestive disease research for Cincinnati Children's and the University of Cincinnati College of Medicine. The foundation of our research programs is on the premise that defects in development, genetics and immunology play key roles in determining the phenotypes of digestive diseases in children. We aim to discover the biological underpinnings of digestive diseases that begin in childhood. To this end, physician-scientists and researchers receive funding from the National Institutes of Health and industry to use novel model systems in the laboratory and to perform clinical trials. Our commitment is to increase the tempo of translation of new discoveries to the clinics so that the investments from our hospital and our society can translate into actionable items in the clinic and improve the outcome of children with digestive diseases. The listings below are a review of our broad research portfolio by the individual Centers of Excellence.

Innovation in Education

For over 25 years, a NIH T32 grant is what provides funding for our training program. Most of our graduates hold academic positions, with several serving as division chiefs in the US. A primary goal of our gastroenterology T32 training program, and Digestive Health Center, is to support the career development of clinicians and researchers, including those from backgrounds with underrepresentation in medicine and science. This includes 21% of our T32 post-doctoral trainees over the past two decades, many of whom are now leaders in academic medicine. Our commitment is to integrate the clinical and research programs into an arena of opportunities for advanced training in the field of gastroenterology and related subspecialties. Our training programs include:

• Fellowship Program in Gastroenterology, Hepatology and Nutrition
• Advanced fellowship training in Hepatology and Liver Transplantation, Neurogastroenterology / Motility, Nutrition, and IBD
• Short-term clinical observation / clerkships for US and international trainees
• Research training for international scientists

Below, we present summaries and accomplishments by individual Centers of Excellence.

Digestive Health Center: A Catalyst for Research on Digestive Disease

Members:

Jorge Bezerra, MD, Director
Lee (Ted) Denson, MD, Associate Director
Heidi Kalkwarf, PhD, Associate Director
Cynthia Wetzel, PhD, Center Manager

The Digestive Health Center (DHC) is one of only 17 Silvio O. Conte Digestive Diseases Research Core Centers with funding from the National Institutes of Health in the US, and the only one with a dedication to pediatric digestive diseases. Aaron Zorn, PhD, from the Division of Developmental Biology, serves as an associate director. The center seeks to improve child health through better diagnosis, treatments and outcomes that will emerge from highly innovative work in our three key research themes: 1) Mechanisms of liver disease, 2) Digestive disease and immunity, and 3) Stem cell and organoid modeling of digestive disease. Three scientific cores link these themes to provide investigators with timely access to state-of-the-art technologies at three scientific cores: Integrative Morphology, Gene Analysis, and Stem Cell / Organoid and Genome Editing Cores. An additional clinical component facilitates patient-based research. With 69 investigators, the DHC supports faculty from 17 divisions within the Department of Pediatrics and eight other departments within the University of Cincinnati, College of Medicine. This group of investigators has a research portfolio with funding of $37.4 million in digestive disease research and publications of 377 papers during the past 12 months, with 179 focusing on digestive disease research. To strengthen pediatric digestive disease research and the career development of junior investigators, the DHC funds highly promising pilot and feasibility projects and sponsors a dynamic enrichment program of scientific seminars, workshops and annual symposium. The DHC Pilot and Feasibility Program invested $2.73 million among 62 early-stage investigators since 2007. These investigators attracted an additional $85.2 million in extramural grant funding.

In addition to the accomplishments described above, the following DHC investigators received national and international recognition for their clinical, research and educational accomplishments this past year:

• Theresa Alenghat, VMD, PhD—The TEDx Cincinnati Women event chose Alenghat to present her research
• Jorge Bezerra, MD—Selected as the Chairman of the Board of Scientific Councils for NIDDK Intramural Research
• Lee Denson, MD—The annual Hinda Kopelman Memorial Lecture, Canadian Digestive Diseases Week annual meeting chose Denson to present his research
• James Wells, PhD—Named the Academic Editor for the Journal of Development

Advanced Nutrition

Members:

Conrad Cole, MD, MPH, MSc
Lee (Ted) A. Denson, MD
Heidi Kalkwarf, RD, PhD
Samuel Kocoshis, MD
Sarah Orkin, MD
Marialena Mouzaki, MD, MSc, Director
Stavra Xanthakos, MD, MS

Our mission is to optimize the nutritional status of children exposed to chronic medical conditions and environmental hardships through surveillance of at-risk patients and identifying and implementing best treatment practices. We seek to improve the prevention and treatment of childhood diarrhea, obesity and undernutrition by implementing best practices and creating new knowledge through bench-to-bedside research collaborations between Cincinnati Children’s Hospital Medical Center and global partners.

Mouzaki, in collaboration with Xanthakos and Jeffrey Schwimmer, MD, at the University of California San Diego, are recipients of NIH funding to launch a study investigating non-invasive biomarkers for pediatric NAFLD. Mouzaki continues investigating the interplay between maternal NAFLD and offspring hepatic steatosis through collaborations with Trout in the Department of Radiology and Jessica Woo, MHSA, PhD, in the Division of Biostatistics and Epidemiology, along with Laura Woollett, PhD, and Emily DeFranco, PhD, both from the University of Cincinnati. Lastly, Mouzaki, in collaboration with Orkin, continues to study the role of food insecurity in pediatric NAFLD.

Xanthakos continues to focus on the liver-related and metabolic outcomes of adolescents who participated in an NIH-funded study and completed either intensive lifestyle interventions or weight loss surgery, including the role of dietary changes.

Kalkwarf investigates the relationship between nutrition and bone health in diverse pediatric populations. She is investigating the long-term effects of adolescent bariatric surgery on bone density in young adulthood. In another model of nutritional impairment, she investigates the age-related trajectory of bone density in children who had intestinal failure before age 3. Lastly, she investigates the influences of dietary intake, growth, and body composition on bone mineral accrual in healthy children ages 1-5.

Denson continues collaboration with investigators at the University of Virginia and three international sites on patient-based studies to define the pathogenesis of environmental enteropathy in affected children. A high-impact journal published the results of this single-center study. Recently, meta-analysis across sites is complete. He is also leading the first multi-center NIH RCT of the prebiotic 2’-fucosyllactose nutritional supplement in children and young adults with Crohn’s disease and ulcerative colitis, with results for young adults with Crohn’s disease expected soon.

Cole continues to have collaboration / consulting roles in projects in Ghana and Sierra Leone focused on micronutrient deficiencies (zinc and iron) in undernutrition, diarrheal diseases and development of endoscopy skills and services. Cole and Kocoshis are center investigators in clinical trials and patient-based research involving patients with intestinal failure.

Celiac Disease Center

Members:

Temara Hajjat, MD
Daniel Mallon, MD

The Celiac Disease Center at Cincinnati Children’s offers expert care from pediatric gastroenterologists, registered dietitians and nurses in one well-coordinated clinic. Our team has the deep experience and expertise to provide an accurate diagnosis, education about celiac disease and the support your family needs to adapt to a gluten-free lifestyle. We also care for young people with wheat allergies and non-celiac gluten sensitivities.

This specialized clinic is part of the Division of Gastroenterology, Hepatology and Nutrition at Cincinnati Children’s, which has a long history of caring for children, adolescents and young adults with digestive disorders, including celiac disease. Our celiac team builds on this strong foundation and dedication to meet the highest standard of care and family support.

Each year, about 200 children, adolescents and young adults from a wide geographic area rely on celiac disease experts at Cincinnati Children’s for their care. Our team provides patients and families with the following:

• State-of-the-art diagnostic testing
• Expert follow-up care to monitor symptoms and related health concerns that may arise in people with celiac disease
• Education and active support to help children with celiac disease maintain a gluten-free lifestyle
• Opportunities to participate in clinical research studies, which can lead to better care for people with celiac disease
• Second-opinion appointments for patients who receive a diagnosis elsewhere and would like an additional perspective

We also offer a joint clinic with the Diabetes Center at Cincinnati Children’s for children with type 1 diabetes and celiac disease.

Pediatric gastroenterologists at Cincinnati Children’s actively engage in research to better understand celiac disease and develop new treatments. This research includes several clinical studies, many of which with sponsorship from national organizations focusing on celiac disease research. Our patient families appreciate the opportunity to take part and help advance care for children and adults with this chronic condition.

Current research topics include:

• Improving methods to identify a person’s risk of gluten exposure
• Determining how telehealth appointments may impact celiac disease care
• Finding new methods to monitor medical issues that sometimes arise in people with celiac disease
• Evaluating new strategies to identify and treat patients with celiac disease and type 1 diabetes
• Investigating how celiac disease can impact heart health for children who also have type 1 diabetes

Cincinnati Center for Eosinophilic Disorders

Members:

Phil Putnam, MD, GI Director
Vince Mukkada, MD, GI Associate Director
Scott Bolton, MD

The Cincinnati Center for Eosinophilic Disorders (CCED) is an established multidisciplinary referral center for the evaluation and treatment of eosinophilic gastrointestinal disorders (EGID) in children and adults. Physicians representing the Divisions of Gastroenterology, Hepatology and Nutrition, Allergy and Immunology, and Pathology provide comprehensive clinical services with the support of experienced nurses, dieticians, a psychologist and a social worker. Over 70% of our patients agree to participate in clinical and basic science research studies. Our clinical research includes important studies of both dietary and pharmacologic management of eosinophilic disorders. We continue to focus on identifying less invasive means of diagnosis and disease monitoring. Putnam, Bolton and Mukkada collaborate with other leading investigators both within the CCED as well as nationally and internationally in studies of genetic and immunologic factors underlying the development of eosinophilic inflammation in the gut, and in evaluating the effectiveness of biological agents (including IL-4 receptor binding antibodies, anti-IL5 receptor binding antibodies, anti-IL13 antibodies, and anti-Siglec8 antibodies) and topical glucocorticoids in the management of eosinophilic disease.

Recent research includes prominent roles for a number of CCED investigators, including Sandy Durrani, MD, J. Pablo Abonia, MD, Justin Schwartz, MD, PhD, Marc Rothenberg, MD, PhD, from the Division of Allergy and Immunology, Margaret Collins, MD, from the Division of Pathology, and Mukkada, in a number of recent publications on clinical trials of novel therapeutics in EGID. These trials, and several others we currently participate in, (including phase 2 trials of an anti-IL5 receptor antibody in EoE and EG, an anti-Siglec 8 antibody in EoE, the anti IL-4 receptor antibody in EG, and phase 3 trials of the anti-IL4 receptor antibody in EoE, the anti-Siglec 8 antibody in EG/ED, an anti-IL13 antibody in EoE, and the anti-IL5 receptor antibody in EG) led to the exciting news of the approval in late May of 2022 of the first FDA therapeutic for eosinophilic esophagitis, duplilumab (the IL-4 receptor binding monoclonal antibody), for patients with EoE ages 12 and up. Given our role in numerous current trials, as well as a number of upcoming planned ones (both investigator initiated and industry sponsored), we fully expect to remain at the forefront of translation of basic science to the bedside and the development of novel therapeutics for eosinophilic GI disease. In a collaborative effort across the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR), a number of very recent significant publications on advances in the field include consensus documents on uniform nomenclature for use in EGID research, a manuscript identifying distinct colonic molecular signatures in eosinophilic colitis (EoC), and a new clinical severity index for eosinophilic esophagitis. Bolton continues to establish himself as an expert in the role of mast cells in eosinophilic GI disease, with participation in three recent manuscripts including one utilizing single-cell sequencing of the mast cells in eosinophilic esophagitis identifying distinct populations of mast cells in this disease and affirming their importance in disease activity.

We continue to involve our trainees in cutting-edge research in eosinophilic disease. Recent graduates published manuscripts examining the potential role of estrogen receptors in the pathogenesis of EoE, the potential role of eosinophil progenitor cells as noninvasive biomarkers of disease activity in EoE and identifying the effect of EoE and its treatment on bone health in our local patient population. They also looked at a novel characterization of very early onset EoE comparing it to a control group of adolescent patients, the development and characteristics of EGID in patients who have undergone liver or small bowel transplants, a report of our experience with benralizumab in patients with EoE, and an additional manuscript in development describing the clinical history and disease characteristics of a large cohort of patients with eosinophilic gastritis.

With support from the National Institutes of Health to Rothenberg, the CCED leads a consortium of organizations with a common goal to conduct clinical research into eosinophilic disorders and to train investigators in clinical research. We are in our first five-year renewal of the consortium’s work. This Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) is a collaboration of clinician investigators, translational scientists, physicians, patients, families and patient advocacy groups. It is part of the Rare Disease Clinical Research Network (RDCRN). Work from this collaborative group focuses on studying of the natural history of eosinophilic disease as well as a number of studies looking at treatments, including an ongoing trial of the anti-IL4 receptor antibody dupilumab in the treatment of eosinophilic. It is exciting to extend our work with a new focus on diversity, equality and inclusion, encompassing not only a renewed focus on making our research efforts relevant and inclusive for all, including underserved populations but also in a renewed focus on training a diverse group of clinicians and investigators with interests in this work. Abonia and Mukkada hold prominent roles in the Diversity Committee within CEGIR.

Clinically, Bolton leads the development of our program utilizing non-sedated transnasal endoscopy in the office setting, with Mukkada joining him as a second provider in the second year of our program. Expanding this program will allow our current patients more opportunities to utilize this novel technique, and is already drawing new referrals to our clinical and research programs.

Gastroenterology Center of Excellence

Members:

The Gastroenterology Center of Excellence's purpose is to assist patients seeking a second opinion for diagnosis and management of their gastrointestinal disorders. The center receives over 400 local, regional, and national referrals annually, many of which require multidisciplinary evaluation or coordinated procedures and testing. To determine the goals for a visit, families talk directly with our intake coordinator to establish the questions or issues they would like to address. Our EPIC-based system allows for rapid collection and review of records as well as efficient communication for coordination of scheduling. Families can expect a review of records and a plan for their visit within a week of the referral. In addition, the center coordinates training for our regional partners at Parkview Health Pediatric GI and offers expedited referrals from their practice for second opinions, interventional procedures and multidisciplinary evaluation of complex patients. The center also reviews and assists in care for Destination Excellence patients needing GI primary management or consultation while at Cincinnati Children's. These efforts help us to meet the expectations of families seeking additional options for their care.

Inflammatory Bowel Disease: The Schubert-Martin Inflammatory Bowel Disease Center

Members:

Lee “Ted” Denson, MD, Director
Phillip Minar, MD, MS, Medical Director
Jasbir Dhaliwal, MBBS, MRCPCH, MSc
Yael Haberman-Ziv, MD, PhD
Jennifer Hellmann, MD
Kelli VanDussen, PhD
Kaitlin Whaley, MD

The Division of Gastroenterology, Hepatology and Nutrition and the Schubert-Martin IBD Center cares for over 1100 patients with inflammatory bowel disease (IBD). The center diagnosed 139 patients with IBD during the 2022 fiscal year and provided 80 second opinions on IBD patients from 12 states and abroad. These numbers present a steady increase in total patient volume over the last five years and reflect the growing incidence of IBD in children worldwide. The center is an integral and leading participant in collaborative consortia, including the ImproveCareNow (ICN) Quality Improvement Network and the Crohn’s and Colitis Foundation’s PRO-KIIDS Clinical Research Network. This role reflects superior outcomes for our patients, with 82% of IBD patients within the center being in remission, 65% in sustained remission, and 92% expressing a high level of confidence in disease management. Quality improvement focuses on developing care algorithms and therapeutic drug monitoring (TDM) for patients receiving biologic therapy. Implementing TDM guidelines is quite effective, with 89% of patients on infliximab achieving the target level (>5 µg/mL), a key driver of sustained remission. Whaley is now leading efforts to optimize our use of other biologics, including adalimumab. A priority going forward, in conjunction with the Cincinnati Children’s Community Health Needs Assessment, will be to address healthcare disparities in our IBD patient population with respect to routine health maintenance and optimal use of biologic therapies.

The IBD Center continues to utilize telehealth to maintain care and these outcomes for our IBD population, including those living in our tri-state area (Ohio, Kentucky, and Indiana). These processes and outcome measures are shared transparently on the center’s website and with other ICN centers. During the past year, with our full-time social worker, we are focusing on transition readiness assessments and strengthening our collaboration with the University of Cincinnati IBD Center. Our Annual IBD Family Education Day, co-hosted by the local chapter of the Crohn’s and Colitis Foundation, continues to be one of the largest educational events of its kind in the country.

Investigators within the center continue to lead basic and translational research to inform new therapies. In collaboration with investigators in the Cincinnati Center for Stem Cell and Organoid Medicine (CuSTOM), Denson’s team report the development of an intestinal organoid model for refractory small bowel Crohn’s disease and demonstrated effects of potential therapeutic small molecules (published in Inflammatory Bowel Diseases). In platform presentations at the recent Digestive Diseases Annual Meeting, VanDussen delineated host and dietary factors which maintain the intestinal epithelial brush border, and are associated with response to biologic therapy. Haberman-Ziv and Denson's participation in an international collaboration defined shared microbial community shifts across prevalent chronic diseases and a specific inflammatory bowel disease signal (published in Genome Biology). Collectively these data inform the design of our NIH multi-center RCT of the human milk oligosaccharide 2’-fucosyllactose in children and young adults with IBD, aiming to promote a healthier microbial community.

Our clinical research is advancing patient classification and optimizing current therapies. Dhaliwal is a recipient of a grant from the Crohn’s and Colitis Foundation to leverage state-of-the-art deep learning approaches to discover new predictive histologic features in patients with ulcerative colitis to advance stratification and underlying disease pathogenesis. A publication of a study in Alimentary Pharmacology & Therapeutics led by Minar describes the effect anti-drug antibodies have on infliximab clearance in children, identifying important risk factors of developing anti-drug antibodies. Minar is the recipient of an R01 award to conduct a multi-center clinical trial to assess whether a novel precision dosing intervention will achieve superior intestinal healing for patients with Crohn’s disease. Hellman and colleagues reported in Inflammatory Bowel Diseases on improved outcomes when starting an immunomodulator for high-titer anti-drug antibodies in IBD patients within our center. Collaborators within the institution from the James M. Anderson Center for Health System Excellence, the Center for Adherence and Self-Management, CuSTOM, and from the Divisions of Allergy and Immunology, Adolescent and Transitional Medicine, Behavioral Medicine and Clinical Psychology, Developmental Biology, Immunobiology, Pathology, Pediatric General and Thoracic Surgery, and the Department of Radiology, continue to make significant contributions to finding a cure as well as improving outcomes and self-management skills for children suffering from IBD.

Interdisciplinary Feeding Team

Members:

Scott Pentiuk, MD
Vince Mukkada, MD
Candace Hochstrasser, APRN
Lisa Witte, APRN
Kaaren Shebesta, APRN

The Interdisciplinary Feeding Team (IFT) provides comprehensive evaluation for children with swallowing / feeding disorders. This multidisciplinary team includes experts from the Divisions of Gastroenterology, Hepatology and Nutrition, Otolaryngology, Speech-Language Pathology, Occupational Therapy, and Social Services. Over 1200 patients and 300+ new patient visits occurred in the IFT in fiscal year 2022. In addition to comprehensive consultation and care, the IFT offers unique multidisciplinary outpatient treatment sessions and child-adult relationship enhancement training for families. IFT added telemedicine options both for outpatient appointments and therapies. Ongoing research projects by IFT investigators include developing and using the pureed by G-tube diet and methods to evaluate children with swallowing dysfunction.

Interventional Endoscopy Center (IntEC)

Members:

Tom K. Lin, MD, Director
David S. Vitale, MD, Associate Director

The vision of the Interventional Endoscopy Center (IntEC) is to offer specialized advanced diagnostic and therapeutic endoscopic interventions to children in our region and serve as a national leader in the adoption and advancement of pediatric interventional endoscopy techniques and technologies.

Diagnostic and therapeutic endoscopy are an integral part of caring for children with complex gastrointestinal disorders, with substantial technological advances in the last 10-15 years. While many of these technologies and procedures are available and in practice at adult institutions, there is a lack of availability at pediatric institutions and under recognition of potential utility by providers. IntEC serves as a coordinated approach to increase awareness and access to these advanced endoscopic services locally and regionally. Development of the center is a collaboration with surgery and interventional radiology to offer synergy and complementarity expertise, improve utilization of existing resources, and partner in the development and / or validation of new technologies. In its inaugural year, within FY22, patient referrals for IntEC consultations or procedures occurred from 25 states, including California. Patients and referring physicians seek our center for the ability to perform comprehensive, less invasive, interventional endoscopic approaches not available elsewhere due to inadequate pediatric training and accessories.

The program has a multidisciplinary team approach, with contributions from surgical and radiology transplant, hepatobiliary and pancreatic specialists, a full-time clinical program manager, a clinical research coordinator and two pediatric trained interventional endoscopists. Access to novel procedures is increasing, with development of a partnership with hepatology for access to endoscopic ultrasound (EUS) guided liver biopsies and development of a double balloon enteroscopy (DBE) program.

In FY 22, IntEC performed 284 procedures. These included 178 endoscopic retrograde cholangiopancreatographies (ERCP)s, 95 EUS and 11 DBEs. The center offered multiple other referrals, informal and formal consultations for local, regional and national patients. Further physical infrastructure with a GI-dedicated fluoroscopy suite is in the design phase with construction to start in FY23.

Local and regional outreach is an important aspect of the center in FY22. Lin and Vitale presented to pediatric and adult gastroenterologists, surgeons and other providers at multiple regional institutions in Ohio, Indiana and Tennessee, with further visits planned in FY23. Local news and radio in a media outreach story featured Vitale regarding button battery safety.

Another important aspect of the center rests in its cutting-edge contribution to the field of pediatric interventional endoscopy research. Scientific highlights during FY22 include publications on the role of magnetic resonance cholangiopancreatography (MRCP) vs ERCP for detection of anatomic variants of the pancreatic duct in children (PMID: 35065151); Endoscopic mucosal resection in children (PMID: 34347680); Interventional endoscopy for abdominal transplant patients (PMID: 35725058) and Endoscopic advancements in pediatric pancreatitis (PMID 35783303). Lin and Vitale's presentations on original research abstracts and cases at multiple national meetings include research investigating risk factors for post ERCP pancreatitis in pediatric patients, novel pediatric EUS guided liver biopsies, biliary glue injection for a bile leak, and placement of non-EUS guided cyst-gastrostomy stent in conjunction with interventional radiology in a hybrid operating room. Extramural research funding from the National Pancreas Foundation in FY22 supported Vitale as a primary investigator for the project ‘Incorporating Endoscopic Ultrasound and Elastography toward improving outcomes of Pediatric Pancreatitis Management.’

The center and its physicians are nationally and internationally recognized. Invited presentations included Endoscopic Applications to Pediatric Pancreatitis for the national Collaborative Alliance of Pancreatic Education and Research (CAPER) Pancreas Academy; Pediatric Biliary Interventional Endoscopy: Year in Review for the national pediatric ERCP significant interest group and Endoscopic Management of Pancreatic Disorders for the Saudi International Pediatric Advanced Endoscopy Symposium. IntEC members are actively involved in the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and its ERCP Special Interest Group. Lin is the group's vice chair for two years, starting January ‘22. Vitale is an active member in the NASPGHAN endoscopy committee and the ERCP Special Interest Group.

Intestinal Rehabilitation and Intestinal Transplantation Programs

Members:

Conrad Cole, MD, MPH, MSc, Medical Director, Intestinal Rehabilitation Center
Samuel Kocoshis, MD, Medical Director, Intestinal Transplantation Program
Stephanie Oliveira, MD
Michael Rogers DO, MPH

These two programs continue to expand their clinical profiles and facilitate the translational and clinical research conducted by both programs. Our circumspect and thoughtful approach to intestinal rehabilitation removes the need for intestinal transplantation for many patients with a referral for transplantation, as less than one in five patients with a referral receive a transplant. Our mission is to provide the best possible care for children with intestinal failure through innovation. Outcomes for both intestinal rehabilitation and intestinal transplantation are excellent. Our central line-associated bloodstream infection (CLABSI) rate of 1.5/1000 catheter days is among the best in North America. We are working on identifying alternate measures and lock therapy to prevent CLABSI as the cost of ethanol lock therapy is impacting the use of ethanol locks in our patient population. As of July 2022, our one-year intestinal transplant survival is 100% for four patients. We continue involvement in post hoc analysis of teduglutide extension study data. In addition, we participate in the Boston Children’s teduglutide registry with funding from Takeda pharmaceuticals. Studies of the prevalence of choline deficiency in patients with intestinal failure-associated liver disease are about to begin. We continue to address micronutrient deficiencies in our population, including those of iodine and iron in an effort to develop novel therapeutic options for children with intestinal failure. Oliveira is leading efforts using remote patient monitoring (RPM) to improve the management of our long distant patients in between their clinic visits. Preliminary data from RPM indicates that this allows for clinical management to make changes between clinic visits. We continue to monitor these modalities and are actively working on identifying the shortest duration of exclusive parental nutrition that associates with the development of specific micronutrient deficiencies. Wales is a new member of the program joining as the surgical director and will lead the surgical program in using unique surgical procedures related to better outcomes in these patients. Helmrath’s laboratory studies the biology of intestinal stem cells as a key to unravel the mechanism involved during the disease process. He is collaborating with Kocoshis in the “Cure Project” delivering organoids containing recipient epithelium to allograft bowel with already developed exfoliation. The anticipation is that the organoids will accept and reconstitute an intact allograft epithelium that requires little or no immunosuppression.

Liver Care Center

Members:

Jorge A. Bezerra, MD, Director
William F. Balistreri, MD
Akihiro Asai, MD, PhD
Kathleen Campbell, MD
Chandrashekhar Gandhi, PhD
Stacey Huppert, PhD
Alexander Miethke, MD, Associate Director
Anna Peters, MD, PhD
Michael Rogers, DO, MPH
Pranav Shivakumar, PhD
Takanori Takebe, PhD
Amy Taylor, MD
Chunyue Yin, PhD

The Pediatric Liver Care Center provides comprehensive care for children with liver diseases. It serves a national and international referral population via a comprehensive evaluation of all medical and surgical aspects of liver diseases. The evaluation includes a full spectrum of metabolic analysis, autoimmune and inflammatory processes, and gene sequencing techniques to diagnose mutations that cause clinical phenotypes. The multi-disciplinary nature of the comprehensive care makes the center a “one-stop-shop” for timely consultation with hepatologists, surgeons, pathologists, radiologists and nutritionists with expertise in pediatric liver disease to optimize patient care. It also catalyzes patient-based research to narrow the knowledge gap and solve clinical challenges with the ultimate goal of improving outcomes.

Physicians, surgeons and scientists in the center are performing exciting research with the goals of understanding the mechanisms of liver development, advancing tissue engineering, discovering the causes and pathogenesis of pediatric liver disease, and designing new therapies to block progression of liver injury. Their work, with funding from independent grants from the National Institutes of Health, Foundations, and industry, aims to close the knowledge gap in the field, focusing on translating new discoveries into improved clinical care.

There were over 20 original scientific report publications this last year by our faculty. Below is a brief summary of key findings:

• Development of a human iPSC-derived hepatocyte system to model the cholestatic liver disease of TJP2 deficiency (Asai, published in Journal of Hepatology Reports)
• Discovery of deleterious variants in ABCC12 as cause for chronic cholestasis and loss of intrahepatic bile ducts (Yin and Miethke, published in Gastroenterology)
• Description of risk factors for mortality from primary non-function in the early period following liver transplantation in children (Rogers and Campbell, published in Pediatric Transplantation)
• Engineering of human hepato-biliary-pancreatic organoids from iPSC (Takebe, published in Nature Protocols), and review of opportunities and challenges of organoid transplant approaches for the liver (Takebe, published in Transplant International)
• Discovery of maternal regulation of biliary disease in neonates via gut microbial metabolites (Bezerra, published in Nature Communications) and identification of risk factors for variceal bleeding and pre-transplant mortality in children with biliary atresia (Bezerra and Miethke, published in Hepatology)
• Determination of prevalence and risk factors for sarcopenia in children with autoimmune liver disease (Taylor and Miethke, published in Liver International)
• Role of endotoxin-stimulated hepatic stellate cells in augmenting acetaminophen-induced hepatocyte injury (Gandhi in American Journal of Pathology)
• Report of a case of SARS-CoV-2 associated autoimmune hepatitis and liver failure (Peters, published in Journal of Pediatric Gastroenterology, Hepatology, and Nutrition)

We have several lines of ongoing and new clinical and translational investigation addressing disease mechanisms and new treatments. Peters and Asai lead a multi-center clinical trial on the safety and efficacy of thymoglobulin as a treatment for pediatric acute liver failure. In the Center for Autoimmune Liver Disease, Miethke leads a multi-disciplinary team studying radiological, biomarker, and genetic underpinnings of autoimmune liver disease. Taylor spearheads the multi-center Autoimmune Liver Network for Kids (A-LiNK) to establish evidence-based care for children with AIH or PSC through quality improvement science. Rogers and Miethke are leading studies investigating the efficacy of ASBT inhibitors in improving the cholestatic liver diseases PFIC and biliary atresia. Asai uses CRISPR-editing to introduce patient-specific mutation in pluripotent stem cells, generate inducible hepatocytes and study mechanisms of cholestasis. Balistreri, Asai, and Yin founded the Center for Undiagnosed and Rare Liver Disease (CURL) in 2021 to transform the care for children with chronic liver conditions. This center builds on the divisional strengths in detecting genetic variants in patients with suspected inherited liver disease, assigning biological relevance to these variants and testing targeted therapies.

In the laboratory, Huppert is studying mechanisms of cellular plasticity in the liver, with exciting work investigating re-programming mechanisms to regenerate the biliary epithelium. Gandhi is pursuing studies defining the cellular crosstalk among sinusoidal endothelial cells, hepatic stellate cells and inflammatory cells that regulates fibrogenesis. Using zebrafish models, Yin is uncovering molecular mechanisms of cell injury and biliary secretion that drive pathogenic mechanisms of cholestatic syndromes. Takebe continues to push the limits of how induced pluripotent stem cell-derived organoids use can model hepatobiliary diseases and serve organ replacement therapy and liver transplantation in the future.

Neurogastroenterology and Motility Disorders Center

Members:

Ajay Kaul, MD, Director
Khalil El-Chammas, MD, Associate Director, Medical Director of MDMC Program, Director of Advanced Motility Fellowship Program
Neha Santucci, MD, Director of Disorders of Gut-Brain Interaction (DGBI) Program
Kahleb Graham, MD
Leslie Fitzharris APRN
Sherief Mansi, MD

Despite the pandemic, the Neurogastroenterology and Motility Disorders (NGM) Center continues to experience unprecedented growth, with 1780 outpatient encounters (7.49% more than prior FY) while performing 455 manometry procedures, over 107 impedance studies, 70 endoflip studies, and 19 transrectal ultrasound studies. We added a fifth faculty member, Mansi to the NGM Center, focusing on GI motility disorders. With his advanced motility training and expertise, Mansi will significantly impact our productivity. Over the past year, the center received between 50-60 new referrals / second opinions per month, primarily from patients outside of our primary service area. Patients came from 31 states for evaluation at the NGM Center. El-Chammas, as medical director of the collaborative Multidisciplinary Motility Clinic (MDMC) with the Colorectal Center, is instrumental in the successful management of the unprecedented growth of the program. The MDMC program saw children with complex motility disorders from the region and across the nation. Santucci, with her expertise in disorders of gut-brain interaction (DGBI), led an effort to develop a novel program for managing children with pain-related GI disorders. Since its inception in 2019, and with the addition of Graham, the program is experiencing significant growth with a total of 375 clinic visits for IB stim device placement. Santucci's and Graham's development of a DGBI registry delivers improved care as well as community support tools to assist general pediatricians in the diagnosis and management of DGBI. They are also members of the Cincinnati Children's advisory team to design a combined medical and psychiatric unit for children with complex FGID. Our team made significant contributions to the evolving neuromodulation program by placing percutaneous electric nerve field stimulation devices in a record 87 patients with DGBI and working with our CRC colleagues in managing patients with sacral nerve stimulators (SNS) for intractable constipation. We continue to improve our diagnostic armamentarium and treatment modalities incorporating the latest advancements in technology and knowledge.

In addition to the exemplary clinical services, the NGM Center is very productive in its academic pursuits. Exploring new research opportunities, the center's involved in multi-center trials on the use of percutaneous electrical nerve field stimulation (PENFS) in DGBI, the characterization of high-resolution colon manometry studies, and the use of mirtazapine in functional abdominal pain, amongst others. Santucci is a recipient of the Procter Scholar and Heubi Investigator grants to study sleep mechanisms in children with DGBI and the effect of neuromodulation, respectively. The team is working on other cutting-edge studies to assess PENFS outcomes in combination with behavioral intervention as well as other disorders, including eosinophilic esophagitis, chronic pancreatitis and inflammatory bowel disease.

Our advanced fellowship program in pediatric NGM is one of few in the nation with three trained fellows. After graduation, these fellows are now faculty members at Children’s Hospital of Pittsburgh (University of Pittsburgh Medical Center), Children’s Mercy Hospital (University of Missouri-Kansas City), and Cincinnati Children’s Hospital Medical Center. We are currently training our fourth advanced motility fellow and our first international graduate from Israel. Due to the COVID-19 pandemic, our team members could not host the annual National Workshop on Pediatric Manometry Training for physicians and nurses in 2020 and 2021. However, to continue sharing knowledge and advances with the pediatric GI community, we collaborated with the sponsors to start a series of educational (10) webinars on related topics during this time. During this pandemic year, members of the NGM Center were part of presentations at regional, national and international virtual meetings and conferences, spoke on podcasts, were recipients of young investigator awards, published in peer-reviewed journals and made contributions to book chapters.

Pancreas Care Center

Members:

Maisam Abu-El-Haija, MD, MS, Medical Director
Tom K. Lin, MD, Associate Director, Endoscopy Director
David Vitale, MD

Our vision is to be the leader in delivering world-class healthcare to children with pancreatic disease, through comprehensive multidisciplinary management that puts patient outcomes at the forefront of our overarching goals. Our implementation of chronic care algorithms enhances care coordination and applies state-of-the-art research methodology to lead innovation in patient care.

The program, which is also inclusive of providers in surgery, endocrinology, pain management and psychology, currently cares for more than 800 patients from over 30 states. Patients seek the Pancreas Care Center (PCC) for various pancreatic disorders, including pancreatitis, exocrine pancreatic insufficiency, congenital anomalies of the pancreas and pancreatic tumors. Our center offers comprehensive treatment options, including endoscopic retrograde cholangiopancreatographies (ERCPs), endoscopic ultrasounds (EUS), and total pancreatectomy with islet autotransplantation (TPIAT).

Since its inception in FY13, the program consists of a multidisciplinary care team to evaluate and treat complex pancreatic disorders. This also includes establishing a REDCap database for a prospective pancreatitis patient registry. The database is a robust registry and biorepository for pancreatic surgical patients for future research initiatives. In 2020, in collaboration with the endocrine team, we built a diabetes registry for post-TPIAT patients to better track our patients’ insulin requirements in real time. The existing database design allows the generation of data that drives healthcare outcomes positively.

The PCC performed its first TPIAT operation in FY15, with nine TPIAT surgeries performed in FY22. In April of 2022, we exceeded 100 TPIATs performed. The 100 surgeries mark a milestone and restores the quality of life for patients with debilitating pancreatitis. Our outcomes exceed national outcomes, with weaning of over 90% of our patients off opiates by three months postoperatively. At one-year post-surgery, over half of the patients require minimal insulin, 20% require full insulin coverage and a third are off insulin. There were over 500 gastroenterology pancreas clinic visits in FY22, including 128 new pancreas patient visits. Thirty-one of the new patient visits include those with an evaluation for TPIAT for the first time. Our advanced endoscopists, Lin and Vitale, performed 184 ERCPs and 95 EUS in FY22.

Our scientific highlights for this past year include a publication in PLoS ONE on cutting-edge research on the role of matrix metalloproteinases and their tissue inhibitors in severe acute pancreatitis in children, and a publication in the Journal of Pediatrics on cytokine profile analysis in severe acute pancreatitis. Our report in Pancreas is on an international study on COVID-19 and pancreatitis risks across a multi-center platform. Importantly, as this is a critical outcome measure, we describe predictors of glycemic outcomes following TPIAT in Diabetes Care.

Abu-El-Haija is the PI of an NIDDK K23 grant which aims to predict severity and improve outcomes for children with acute pancreatitis. Her R03 award in association with the K23, aims to conduct beta cell function studies post-acute pancreatitis to define the types of diabetes which develop in this setting. Vitale is the recipient of an award from the National Pancreas Foundation to test the role of endoscopic ultrasound and elastography in improving outcomes for children with pancreatitis. Our center is also participating in additional NIH-funded multi-center studies listed below that will advance the care of children with acute and chronic pancreatitis and following TPIAT.

PCC extramural funding during FY22:

1. NIH U01 Abu-El-Haija (Site PI) - CPDPC INSPPIRE International Study Group to Study Pediatric Acute Recurrent and Chronic Pancreatitis: In Search for a Cure. Cincinnati Children's is the highest recruiting center out of 21 national and international centers for the past four years.
2. NIH R01 Abu-El-Haija (Site PI) - Advancing Treatment for Pancreatitis: A Prospective Observational Study of TPIAT. Our center is the highest enrolling center for pediatric TPIAT nationally in this consortium.
3. NIH P30 award, Abu-El-Haija (co-investigator)- Personalized Cystic Fibrosis Therapy and Research Center, Core title: Personalized Model Systems.

We also widely market our pancreas gene panel, which we developed and launched in collaboration with the Molecular Genetics Laboratory. It is now clinically available to test for genes known to cause pancreatitis using next generation sequencing technology. Since the launch in November 2016, 28 external centers utilize our laboratory for this testing option. Remarkably, in FY 22, 52% of our tests were from external sites. We consistently perform ~10 tests/month using the pancreas gene panel. Our lab has a 12% increase (from 108 to 123) in our utilization of our pancreas gene panel testing compared to FY21.

Nationally, PCC members actively participate in the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Abu-El-Haija is the current chair of the Pancreas Committee and a course director for the National Pancreas Foundation (NPF) annual meeting. Abu-El-Haija is on the American Gastroenterology Association Pancreas Selection Committee, is president of the Collaborative Alliance for Pancreatic Education and Research (CAPER), and is on the planning committees of NASPGHAN, PancreasFEST and CAPER national meetings. Vitale is an active member of the NASPGHAN endoscopy committee. Lin and Vitale are active members of the NASPGHAN ERCP Special Interest Group. The PCC at Cincinnati Children's is one of only a select few pediatric centers that are an NPF-approved Center of Excellence for pancreatic care in the nation. We are a referral destination sought out by patients and physicians from around the country based on a reputation for excellence in patient care and commitment to innovative research.

Pediatric Liver Transplantation

Members:

Alexander Miethke, MD, Medical Director
Akihiro Asai, MD
William Balistreri, MD
Jorge A. Bezerra, MD
Kathleen Campbell, MD
Anna Peters, MD, PhD
Michael Rogers, DO, MPH
Amy Taylor, MD

The mission of the Pediatric Liver Transplant Center is to advance the care of liver transplant recipients by providing unparalleled clinical care, addressing gaps in knowledge through patient-based and basic laboratory research, improving health care delivery system through continuous quality improvement, and serving as advocates for organ donation and allocation in our community and country. As one of the country's largest pediatric liver transplant programs, we have performed 816 liver transplants since the program began in 1986.

We performed 31 liver transplants in pediatric recipients or young adults in 2021, making Cincinnati one of the busiest pediatric liver transplant programs in the nation. These livers were transplanted isolated or in combination with the small intestine, heart, or kidney. Our patient and graft survival rates are at or above the national average, as evidenced by the SRTR data released in July 2022, showing a 96.4% probability of surviving the first year after primary liver transplantation in recipients <18 years of age which is above the average in the US of 92.4%. We perform living donor liver transplantation from patient relatives or altruistic donors. In addition to providing care for the most common pediatric liver disorders leading to transplantations, we leverage institutional strengths to provide care and the best outcome available to several patients with rare diseases and extremely complex needs. This care includes children with advanced liver tumors. Since 1994, the Cincinnati Children's Liver Transplant Team performed 84 liver transplants for pediatric patients with hepatic tumors, more than any other program in the United States.

Chronic liver disease and transplantation impact other organs especially the kidney and heart. In collaboration with the Division of Nephrology, we provide innovative renal replacement therapies, including molecular adsorbent recirculating system (MARS) before transplant or during the surgery, protect renal function following transplant through multi-disciplinary care coordination, and for those in need, we perform simultaneous liver-kidney transplants. We have performed six combined heart-liver transplants for patients with congenital heart disease and chronic liver failure from failing Fontan physiology. Collaborating with the renowned Cancer & Blood Diseases Institute, we have performed successful liver transplantations in patients with primary immunodeficiency, Langerhans cell histiocytosis, or dyskeratosis congenita.

In addition to providing outstanding patient care, the Liver Transplant program is a leader in multi-center clinical and translational research studies and national quality improvement efforts. These include studies in pediatric liver transplantation (SPLIT), quality improvement, community and clinical registry, and multiple local projects. In collaboration with the Center for Transplant Immunology (CTIMM), Peters uses single-cell sequencing technology to molecularly define transplant rejection responses to better understand the biological processes underpinning late-onset acute cellular rejection and ultimately personalize immunosuppression therapies. Following successful liver-heart transplantation for a patient with dyskeratosis congenita, we now support a multi-center effort to study liver disease phenotype and solid organ transplant outcomes in this rare bone marrow failure syndrome. Analyzing the UNOS database, Rogers identified risk factors for mortality following liver transplantation from primary non-function, which early re-transplantation can prevent.

At the program level, our multi-disciplinary teams undertake various QI initiatives and innovative approaches to improve patient outcomes. These include live vaccines for post-transplant patients, remote home monitoring for freshly transplanted patients, and barrier assessment and intervention to improve medication compliance and reduce late allograft rejection. Our formation of a working group of hepatologists, surgeons, interventional cardiologists, and hematologists optimizes surgical techniques to decrease the rate of hepatic venous outflow obstruction, to establish non-invasive imaging protocols for more accurate diagnosis of this complication, and to refine protocols for endovascular intervention and oral anticoagulation.

Pancreas Care Center

Members:

Maisam Abu-El-Haija, MD, MS, Medical Director
Tom K. Lin, MD, Associate Director, Endoscopy Director
David Vitale, MD

Our vision is to be the leader in delivering world-class healthcare to children with pancreatic disease, through comprehensive multidisciplinary management that puts patient outcomes at the forefront of our overarching goals. Our implementation of chronic care algorithms enhances care coordination and applies state-of-the-art research methodology to lead innovation in patient care.

The program, which is also inclusive of providers in surgery, endocrinology, pain management and psychology, currently cares for more than 800 patients from over 30 states. Patients seek the Pancreas Care Center (PCC) for various pancreatic disorders, including pancreatitis, exocrine pancreatic insufficiency, congenital anomalies of the pancreas and pancreatic tumors. Our center offers comprehensive treatment options, including endoscopic retrograde cholangiopancreatographies (ERCPs), endoscopic ultrasounds (EUS), and total pancreatectomy with islet autotransplantation (TPIAT).

Since its inception in FY13, the program consists of a multidisciplinary care team to evaluate and treat complex pancreatic disorders. This also includes establishing a REDCap database for a prospective pancreatitis patient registry. The database is a robust registry and biorepository for pancreatic surgical patients for future research initiatives. In 2020, in collaboration with the endocrine team, we built a diabetes registry for post-TPIAT patients to better track our patients’ insulin requirements in real time. The existing database design allows the generation of data that drives healthcare outcomes positively.

The PCC performed its first TPIAT operation in FY15, with nine TPIAT surgeries performed in FY22. In April of 2022, we exceeded 100 TPIATs performed. The 100 surgeries mark a milestone and restores the quality of life for patients with debilitating pancreatitis. Our outcomes exceed national outcomes, with weaning of over 90% of our patients off opiates by three months postoperatively. At one-year post-surgery, over half of the patients require minimal insulin, 20% require full insulin coverage and a third are off insulin. There were over 500 gastroenterology pancreas clinic visits in FY22, including 128 new pancreas patient visits. Thirty-one of the new patient visits include those with an evaluation for TPIAT for the first time. Our advanced endoscopists, Lin and Vitale, performed 184 ERCPs and 95 EUS in FY22.

Our scientific highlights for this past year include a publication in PLoS ONE on cutting-edge research on the role of matrix metalloproteinases and their tissue inhibitors in severe acute pancreatitis in children, and a publication in the Journal of Pediatrics on cytokine profile analysis in severe acute pancreatitis. Our report in Pancreas is on an international study on COVID-19 and pancreatitis risks across a multi-center platform. Importantly, as this is a critical outcome measure, we describe predictors of glycemic outcomes following TPIAT in Diabetes Care.

Abu-El-Haija is the PI of an NIDDK K23 grant which aims to predict severity and improve outcomes for children with acute pancreatitis. Her R03 award in association with the K23, aims to conduct beta cell function studies post-acute pancreatitis to define the types of diabetes which develop in this setting. Vitale is the recipient of an award from the National Pancreas Foundation to test the role of endoscopic ultrasound and elastography in improving outcomes for children with pancreatitis. Our center is also participating in additional NIH-funded multi-center studies listed below that will advance the care of children with acute and chronic pancreatitis and following TPIAT.

PCC extramural funding during FY22:

1. NIH U01 Abu-El-Haija (Site PI) - CPDPC INSPPIRE International Study Group to Study Pediatric Acute Recurrent and Chronic Pancreatitis: In Search for a Cure. Cincinnati Children's is the highest recruiting center out of 21 national and international centers for the past four years.
2. NIH R01 Abu-El-Haija (Site PI) - Advancing Treatment for Pancreatitis: A Prospective Observational Study of TPIAT. Our center is the highest enrolling center for pediatric TPIAT nationally in this consortium.
3. NIH P30 award, Abu-El-Haija (co-investigator)- Personalized Cystic Fibrosis Therapy and Research Center, Core title: Personalized Model Systems.

We also widely market our pancreas gene panel, which we developed and launched in collaboration with the Molecular Genetics Laboratory. It is now clinically available to test for genes known to cause pancreatitis using next generation sequencing technology. Since the launch in November 2016, 28 external centers utilize our laboratory for this testing option. Remarkably, in FY 22, 52% of our tests were from external sites. We consistently perform ~10 tests/month using the pancreas gene panel. Our lab has a 12% increase (from 108 to 123) in our utilization of our pancreas gene panel testing compared to FY21.

Nationally, PCC members actively participate in the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). Abu-El-Haija is the current chair of the Pancreas Committee and a course director for the National Pancreas Foundation (NPF) annual meeting. Abu-El-Haija is on the American Gastroenterology Association Pancreas Selection Committee, is president of the Collaborative Alliance for Pancreatic Education and Research (CAPER), and is on the planning committees of NASPGHAN, PancreasFEST and CAPER national meetings. Vitale is an active member of the NASPGHAN endoscopy committee. Lin and Vitale are active members of the NASPGHAN ERCP Special Interest Group. The PCC at Cincinnati Children's is one of only a select few pediatric centers that are an NPF-approved Center of Excellence for pancreatic care in the nation. We are a referral destination sought out by patients and physicians from around the country based on a reputation for excellence in patient care and commitment to innovative research.