A recent letter (SW Olesen et al. NEJM 2019; 380: 1872-3) showed the frequency of filling antibiotic prescriptions in the U.S. from 2011-2014 using the Truven Health MarketScan Research Databases (62 million enrollees).
“The probability of filling an antibiotic prescription at an outpatient pharmacy was 33% … over 1 year, 47% …over 2 years, 55% …over 3 years, and 62%…over 4 years.”
My take: One-third of the population is filling an antibiotic prescription each year. That is way too much –antibiotic stewardship program personnel should have a lot of job security.
A recent NYT story: Why Your Doctor’s White Coat Can Be a Threat to Your Health
A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat…
What many might not realize, though, is that health care workers’ attire — including that seemingly “clean” white coat that many prefer — can harbor dangerous bacteria and pathogens.
A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods…
The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.
My take: Your white coat should probably be washed as often as you wash your underwear (if you decide to wear it).
A recent case report (A Wehrman et al. J Pediatr 2019; 207: 244-7) described steroid free treatment of autoimmune hepatitis (AIH) in 8 patients.
This retrospective review of all patients with AIH at CHOP between 2009-2014 compared patients who had AIH treated with (n=12) and without steroids (aka azathioprine monotherapy). Near normalization of ALT was defined as less than 2 x ULN.
- All children in the steroid group had normalization of liver enzymes by 12 months of therapy compared with only 2 of 8 in the steroid-free group. Though, near normalization of ALT occurred at a median of 5.5 months in the steroid free group (compared with 1.8 months in the steroid group).
- Adverse effects were evident in 75% of the steroid group compared with 11% of the steroid-free group
The authors conclude that “liver enzymes may take longer to normalize without steroids, but this difference was not statistically significant in our small cohort, nor did it lead to any adverse outcomes.”
My take: Standard therapy for AIH is prednisone for induction with subsequent azathioprine. This study shows that in patients unwilling to take steroids or with intolerance that azathioprine monotherapy may be an effective alternative though liver enzymes are likely to take much longer to improve.
Related blog posts:
A recent prospective study (A Carrocio et al. Gastroenterol 2019; 17: 682-90) with 78 patients who were diagnosed with “nonceliac gluten or wheat sensitivity” (NCGWS) by double-blind challenge had duodenal and rectal biopsies collected and analyzed. More commonly NCGWS is referred to as NCGS.
- Duodenal tissues from patients with NCGWS had hihger numbers of eosinophils than non-NCGWS controls as did rectal mucosa. Other elevated markers included epithelial CD3+ T cells, and lamina proppria CD45+ cells.
- Rectal mean eosinophil infiltrations was more than 2.5-fold the upper limit of normal and it was almost 2-fold increased in the duodenum.
- Sensitivity and specificity of rectal eosionphilia, defined by >9 eos in the lamina propria) was 94% and 70% respectively.
My take: This study is intriguing but needs more confirmation. Overall, it appears that the frequency of NCGS is very low.
Related blog posts:
Synagogue of Santa María la Blanca. Toledo Spain
A recent retrospective study (J Robson et al. Clin Gastroenterol Hepatol 2019; 17: 107-14) utilized a pathology database encompassing the vast majority of Utah pediatric cases to determine the incidence and prevalence of eosinophilic esophagitis (EoE) from 2011 to 2016.
The authors determined cases of EoE by looking for symptomatic children with isolated esophageal eosinophilia (more that 14 eos/hpf) in the absence of other comorbid conditions.
- 1060 children met the criteria for a new diagnosis of EoE
- Average annual incidence of EoE was 24 per 100,000 children; this is nearly double the previously reported rate 12.8 per 100,000 from Hamilton County, Ohio in 2003.
- Prevalence of EoE was 118 per 100,000 children
The authors speculate on several factors that produced this increased incidence rate –all related to EoE risk factors:
- Predominant non-Hispanic White population
- High rates of atopy
- Increased capture rate of their database
- Also, the authors did NOT exclude PPI-responsive esophageal eosinophilia (which is a subtype of EoE and not a different disease
The authors note that “there is reason to believe that this [high incidence rate] is a conservative estimate:”
- ~2% of pathology reports had 10-14 eos/hpf. Further review of these cases would likely have identified some which have exceeded the >14 threshold
- Some pediatric EoE cases are diagnosed by adult gastroenterologists who did not use the pathology databases
My take: This study shows high rates of EoE but comes as no surprise. And, there are likely a large number of individuals with mild EoE which has not been diagnosed. In my experience, families and physicians often overlook altered eating habits as related solely to behavior. Useful questions to uncover dysphagia include the following: how long does it take your child to eat? does your child have to drink a lot of liquids when eating? does food get stuck frequently?
Related blog posts:
A recent review provides some helpful advice: “A Practical Guide to the Safety and Monitoring of New IBD Therapies” (B Click, M Regueiro. Inflamm Bowel Dis 209; 25: 831-42).
This review discusses infection risk, malignancy risk, immunologic issues and other complications.
In terms of infection risk assessment, the authors describe a pyramid in which they stratify the risks of medications. The safest to least safe in their assessment: vedolizumab –>ustekinumab–>anti-TNF monotherapy–>thiopurine or tofacintinib–>thiopurine/anti-TNF combination–>steroids.
- Table 1 lists potential infections and vaccination recommendations
- Table 2 suggests management of active infections by IBD Medication Class
- For anti-TNF agents and for IL12/23 agents: the authors recommend continuation of agent if viral (eg EBV, VZV, HSV) or bacterial (eg. Strep/Staph)/C difficile infections (unless severe) but holding for opportunistic infections.
- For integrin agents, the authors recommend continuation of medications in the face of infections except “consider holding dose” during active C difficile infection
- For JAK agents, the authors recommend stopping during viral infections and with opportunistic infections. They recommend continuing with bacterial infections (hold if severe) and continuing with C difficile infection
- Table 3 suggests management in the setting of active malignancy
- Table 4 lists recommendations in the setting of immunologic complications. Theses categories include antidrug antibodies,lupus-like reactions, demyelinating conditions, and psoriasis.
- One of the points alluding to in this chart is that addition of methotrexate may help in patients receiving anti-TNF therapy with psoriasis.
- No psoriatic reactions have been reported with vedolizumab, ustekinumab or tofacitinib; ustekinumab is FDA-approved for use in psoriasis and tofacitinib is FDA-approved for psoriatic arthritis.
- Table 5 suggests recommendations in the setting of altered liver enzymes and altered lipids/creatine kinase
A recent population-based cohort study (MS Kristensen et al. Inflamm Bowel Dis 2019; 25: 886-93) indicates that antidepressants are likely to be beneficial for patients with inflammatory bowel disease and could lower disease activity in addition to improving mood.
This study population, n=42,890, with prospectively collected data comprised all patients in the Danish National Patient Registry from 2000-2017 with ICD diagnoses of ulcerative colitis (UC, 69.5%) or Crohn’s disease (CD, 30.5%). Outcome measures included markers of disease relapse:
- hospitalizations with IBD as primary diagnosis
- surgery with IBD as primary operation code
- step-up medications with corticosteroids or anti-TNF treatment
- After adjusting for confounders, lower incidence rate of disease activity was found among antidepressant users than nonusers.
- For CD, the incidence rate ratio was 0.75 (CI 0.68-0.82).
- For UC, the incidence rate ratio was 0.90 (CI 0.84-0.95).
- For CD patients without prior use of antidepressants before diagnosis of CD, there was markedly lower incidence rate ratio of 0.51 (CI 0.43-0.62).
- 28% of the study population redeemed at least 1 prescription for an antidepressant at some point. This is similar to a Finnish study in which antidepressant use in IBD was 28% compared to 19% in general population
The authors note that anti-depressants may affect the level of pro-inflammatory cytokines which are involved in the pathogenesis of IBD. This study did not assess potential adverse effects of using anti-depressants.
My take: This study is intriguing and suggests that antidepressants may improve the disease course in IBD. Whether this is related to more favorable brain-gut interaction or whether this is related to drug effects on inflammatory agents is unclear.
Related blog post: Psychosocial Problems in Adolescents with IBD
Park Guell -Fantastic Park in Barcelona (need to buy a pass to get to some parts)
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.