Monthly Archives: September 2013

Abdominal distention – a medical mystery?

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A recent ‘think like a doctor’ case in the NY Times involved a patient sent to a pediatric gastroenterologist for abdominal distention.  It’s worth a read (thanks to Ben Enav for sharing this reference).

http://well.blogs.nytimes.com/2013/09/05/think-like-a-doctor-the-gymnasts-big-belly/

With regard to bloating and distention, the ‘smartphrase’ that I use to discuss this issue with parents is based on the “5 Fs” that I learned during fellowship.  I decided to modify the phrase a little bit based on the above case:

” I reviewed the issue of bloating/distention with family. Typically, distention or bloating can be caused by “5 Fs” which include flatus (gas), feces (constipation), fluid, fat, and fetus/masses. Flatus can be caused by swallowing air (aerophagia), malabsorption (celiac, lactose intolerance, parasites), muscular discoordination (abdominal phrenic dyssynergia), and motility problems.”

Are there other etiologies that you discuss with your patients?

Not Understanding Medicare Spending

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A recent report (NEJM 2013; 369: 1066-1073) highlights the lack of understanding regarding the costs of Medicare and the political problems ahead for those who try to reduce these costs.  The data the authors provide is derived from six public opinion polls in 2013 with 1013 to 2017 U.S. adults along with historical data.

Key points:

  • 62% believe Medicare spending is rising faster than it was 5 years ago –it’s not.
  • The three top reasons why the public thinks Medicare has rising costs: poor government management, fraud and abuse, and excessive charges by hospitals .
  • Only 53% are aware that it is one of the largest federal budget items.
  • Only 31% believe it is a major cause of the deficit.
  • Two thirds of respondents believe that most Medicare recipients get benefits worth about the same (27%) or less (41%) than what they have paid in payroll taxes/premiums.  In fact, “Medicare beneficiaries on average pay approximately $1 for every $3 in benefits.”
  • Political implications: among registered voters, 12% say they would be more likely to vote for a congressional candidate who favored cuts in Medicare spending to reduce  the federal budget deficit compared with 58% who be less likely to vote for that individual.

Take-home message: Expectations to solve all of Medicare’s projected costs/financial sustainability by eliminating mismanagement along with fraud and abuse are misguided.  A better public understanding of Medicare’s finances would aid the long-term resolution of these issues.

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Esophageal distensibility with FLIP and EoE disease severity

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In patients with eosinophilic esophagitis (EoE), the development of fibrosis due to ongoing inflammation is one of the concerns as this can lead to more difficulty with swallowing,  food impactions, a smaller caliber esophagus, and stricturing.  A recent report highlights a way to measure esophageal distensibility and its correlation with disease severity (Clin Gastroenterol Hepatol 2013; 11: 1101-7).

This report describes the evaluation of 70 patients with EoE (ages 18-68 years with median of 38 years`, 50 men) who underwent endoscopy along with high-resolution impedance planimetry.  The average followup was 9.2 months. The functioning luminal imaging probe (FLIP) system was used after the endoscopy by placing a catheter transorally.  The catheter had 16 ring electrodes spaced 5-mm apart in the 8-cm measured segment.  The FLIP distal recording began 3 cm proximal to the esophageal gastric junction.  Esophageal cross-sectional areas were measured during 2-mL stepwise distentions and increasing to a maximum of 40 mL.

Patient EoE Clinical Features at baseline:

  • 26 patients had a history of food impaction
  • 37 patients had dysphagia
  • 5 patients had chest pain
  • 2 patients had heartburn
  • Ringed esophagus: 9 (13%) had severe endoscopic findings, 17 (24%) had moderate endoscopic findings, 40 (57%) had mild endoscopic findings
  • Primary treatment: PPI treatment (78%), Topical steroids (10%), diet 4 (6%)

Key findings:

  • Patients with food impaction had significantly lower distensibility plateau (DP) than those with solid dysphagia alone (see manuscript Figure 1).
  • Mean DP in food impaction 113 mm2 compared with 229 mm2 for those without a history of food impaction
  • The severity of mucosal eosinophilia did not correlate with risk for food impaction, distensibility, or requirement for dilatation.

In many ways, the findings are completely obvious.  If an individuals esophagus is less distensible, it makes sense that food could get stuck. However, the article highlights a novel way of assessing esophageal distensibility in this population.  While the study did not identify higher mucosal eosinophilia as a marker of distensibility, this may be a precursor to future problems.  In the discussion, the authors note that a 12.5 mm barium tablet test correlates with a 125-mm2 threshold. Thus, their data suggest a corresponding diameter of 17 mm as a prerequisite to avoid food impactions.

Bottomline: this study identifies a new way to assess the risk for food impactions in EoE by measuring esophageal distensibility.

Related blog entries:

Practical Advice on Enteral Nutrition

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In a previous post (NASPGHAN: Enteral Nutrition for Crohn’s Remission | gutsandgrowth), this blog provided a link to NASPGHAN information on enteral nutrition. Having reviewed this information further, I wanted to post some more information about one of the references which offers a terrific professional-quality 32 minute video (from IWK Health Centre in Canada).  This You-tube video on tube feeds provides interviews mostly from kids/family members along with some input by physicians and nutritionists; it is a fabulous resource for families weighing the option of tube feeds.  Around minute 23, a teen walks through the process of NG placement including advice on taping.  Around minute 31, a number of written tips are given like cleaning tubing with vinegar (& then rinsing with water).  According to the website there were only 275 views when I had clicked on this.  If that is accurate, it is a real shame.

Here’s the link:

Crohn’s Survival Guide: The Real Deal on Tube Feeds – YouTube

Other information from the NASPGHAN handout (which offers CME) in the link above:

  • Duration of enteral nutrition to induce remission: 8-12 weeks.  Enteral nutrition can induce remission in about 80% and is similar in effectiveness as corticosteroids.
  • Caloric needs: typically 120% of recommended daily allowance
  • Other foods? usually allowed water or clears like sodas, soup broth, and popsicles.  In some studies, up to 10% of energy intake as various other foods have been allowed; however, this creates a lot of difficulty monitoring.
  • Maintenance strategies: partial enteral nutrition (nighttime feeds only) can reduce recurrence.  More typical approaches included maintenance medication for long-term treatment, or enteral therapy in combination with maintenance medical therapy.  Alternatively, maintenance treatment can be instituted with cycles of 1 month exclusive enteral nutrition every few months.
  • What type of formula for NG tube? most commonly polymeric formulas
  • Refeeding syndrome: in children with severe malnutrition institution of tube feedings should be instituted more slowly over several days with electrolyte monitoring.

Tracking down a serial killer

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Truth be told, I really do like the murder mystery genre.  In medicine, that particular type of drama is usually absent.  Nevertheless, it is fascinating when epidemiologists can track down an agent responsible for multiple deaths and widespread illness.  The latest example: Listeria monocytogenes (NEJM 2013; 369:  944-53).

This recent report isolated Listeria monocytogenes as the agent responsible for 147 outbreak-related cases in 28 states; there were 33 deaths.  The investigators used multistage epidemiological, trace-back, and environmental studies.  Molecular finger printing of the cases identified five distinct patterns which defined the outbreak cases. By comparing the outbreak cases to sporadic cases using the “Listeria initiative,” the authors were able to determine that uncut cantaloupe ingestion was much more common among the outbreak-related cases.  Subsequently, the source of the contaminated cantaloupe were traced back to a Colorado  farm that had switched to a different cleaning method in 2011.

Other data:

  • Only 7 cases (5%) were pregnancy-associated; 1 miscarriage occurred
  • The median age was 77 years in this cohort.
  • Most of the deaths were in the elderly, with only 2 deaths occurring in individuals less than 60
  • 143 patients required hospitalization

While this report discussed 147 outbreak-related cases, there were undoubtedly many more outbreak-related cases which were unidentified due to milder illness.

Bottomline: this report provides a framework for identifying outbreaks of contaminated produce.  It reinforces the need for good agricultural practices to minimize food borne-pathogen infections. It is a good read.

Related blog posts:

PPIs in Neonates –Helpful?

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Acid suppression in infants has not been proven to be effective in reducing gastroesophageal reflux (GER) symptoms. In a systemic review, this was thought to be either “because the symptoms are not caused by GER or if due to GER, because the symptoms are caused by volume reflux, rather than acidity.”  This quote is noted in the background information of another study which came to the same conclusion (J Pediatr 2013; 163: 692-8).

The pharmaceutical-supported study enrolled neonates (n=52) at 3 centers with gestational ages between 28-44 weeks.  Half of the participants were randomized to esomeprazole (0.5 mg/kg/day) and half placebo.  GER symptoms that were required for enrollment included any 2 of the following:

  • apnea with or without bradycardia
  • apnea with or without oxygen desaturations
  • irritability/pain
  • vomiting/gagging

Participants underwent extensive testing with video monitoring, esophageal pH & impedance testing, and cardiorespiratory monitoring.  They were followed for 14 days.

Findings:

  • There were no significant differences in any GERD-related signs and symptoms.
  • The esomeprazole group had improvement in acid reflux parameters on testing at 7 days, including number of reflux episodes (35 –>23) and mean percent time with pH<4.0.  The latter change was -10.7% was statistically significant (p= .0017) compared to placebo group which had an increase in time with pH<4.0 (2.2% increase).
  • No new safety signals were identified.

Despite its widespread usage, the authors had difficulty enrolling a larger cohort.  The small sample size was one of the study’s limitations along with the 14-day study period.  This limitation also precludes conclusions regarding the safety of these medications in neonates.

Bottomline: this study adds to the growing body of evidence that proton pump inhibitors (PPIs) are not effective in infants with so-called ‘signs and symptoms of reflux.’  PPIs are effective at reducing acid exposure and could be helpful in proven mucosal disease (eg. esophagitis and gastritis).

Related blog entries:

When you gotta go…looking for a clean bathroom

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According to consumer advice guru, Clark Howard, clean bathrooms are a necessity for businesses and now there are mobile apps (eg. SitorSquat) to help people find them.  For patients with GI disorders, this app may be very helpful as well.

Here’s the link from Clark Howard:

Clark Howard: Valued workers translate into a company’s success …

An excerpt:

“Now USA Today reports that dirty bathrooms can hurt business in some very direct ways. Nearly 50 percent of restaurant patrons who experience a dirty bathroom will tell friends. Almost three in 10 restaurant patrons won’t give a place a second chance if they encounter a dirty bathroom. And if you’re a restaurant owner, remember, this is the era of the smartphone where customers are taking pictures of your dirty bathroom and sharing it on social media.

Of course, when you gotta go, you gotta go. That’s why several different smartphone apps like SitorSquat have been developed (for both Android and iOS), pointing you to the nearest clean bathrooms.”

For IBD patients, sometimes taking your own toilet can be helpful, here’s a link to portable products:

Top 5 Portable Toilets – IBD – About.com

Graphic Ads Motivate Smokers to Quit

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From NY Times (coverage of Lancet article), those graphic anti-smoking ads seem to be helping.
http://nyti.ms/18RT9Kq

An except:

For almost two decades, Lisha Hancock smoked between one and two packs of cigarettes a day…..

Then she saw a graphic television commercial featuring a former smoker, Terri Hall, who developed head and neck cancer. The widely seen advertisement shows Ms. Hall inserting a set of false teeth and placing a small speaker inside a hole in her neck.

“It scared me because I had always had problems with my throat,” said Ms. Hancock, 38, who lives in Kentucky. “When I saw that, it made me realize that there are other types of cancer besides lung cancer, and that really hit home for me.”

The ad prompted her to give up smoking about eight months ago, using a combination of an exercise and healthful eating regimen along with nicotine lozenges, and she has not had a cigarette since. But Ms. Hancock may be just one of thousands of Americans who quit smoking after seeing the commercial featuring Ms. Hall, which was part of a series of antismoking ads put out by the federal government last year. The campaign, called Tips From Former Smokers, was notable both for its raw images and because it marked the first time that the government directly attacked the tobacco industry in paid, nationwide advertisements.

According to a new study published on Monday in The Lancet, the ads may have prompted more than 100,000 Americans to give up smoking for good. (emphasis added by blog)

The study, led by a team at the Centers for Disease Control and Prevention, surveyed 5,300 Americans before and after the campaign, including 3,000 smokers. The paid ads ran for three months beginning in March, just after the New Year resolution season, when the percentage of smokers trying to quit is typically on the decline.

The researchers found that over all, four of five of smokers had seen the commercials, and the percentage who reported trying to quit rose by 12 percent. Of those who tried to quit, about 13 percent remained abstinent after the campaign had ended.

Using census data, the researchers estimated that as many as 1.6 million smokers nationwide attempted to quit as a result of the ad campaign. Most smokers require several attempts before they give up cigarettes for good, so only a fraction of those who were motivated by the campaign would have succeeded. The ads were expected to spur about 50,000 smokers to quit permanently, but the Lancet study estimated that twice that number were successful….

Historically, about half of the nation’s 45 million smokers try to quit every year, and yet cessation rates hover around 5 percent annually. Public health officials have long been telling smokers that cigarettes shave years off your life, contributing to more than 400,000 deaths every year.

The new campaign went in a different direction, focusing not on death but on quality of life. The creators of the campaign used focus groups and feedback from smokers to develop sobering ads showing real smokers with amputations, paralysis and disfigurement from heart and lung surgeries.

“I think the fact that you may die is not highly motivating to people,” Dr. Frieden said. “The fact that the remainder of your life may be very unpleasant is, and that’s what the data shows. Not only do smokers die about ten years younger than most people, but they feel about ten years older than their age.”

The campaign last year cost about $54 million and was paid for by the Affordable Care Act. …. Dr. Frieden said the money, which is only a fraction of the $8 billion the tobacco industry spends on marketing and promotion every year, was well spent.

“This is a campaign that has literally saved tens of thousands of lives,” he said. “We would like to be able to have hard-hitting campaigns like this on the air year round. The tobacco industry spends what we spent on this campaign in three days.”

Related blog posts:

Hospital-based Antimicrobial Stewardship

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While there has been growing recognition of antibiotic resistance, the efforts to implement strategies to preserve the effectiveness of our current antibiotics have not been embraced by enough stakeholders.  A recent review provides insight into the antibiotic stewardship (AS) programs that are being implemented by pediatric hospitals (JAMA Pediatrics; 2013; 167: 859-66).  Thanks to Ben Gold for sharing this reference.

AS goals are to “optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance.”  Five specific goals:

  • timely management of antimicrobial therapy -prompt initiation when indicated, avoid when not indicated (eg. viral illness)
  • appropriate antibiotic selection -minimize redundant antibiotic coverage
  • appropriate antibiotic administration and de-escalation of therapy -reassess after 48-72 hrs whether to discontinue antibiotics, monitor levels when needed
  • use of available expertise and resources at point of care
  • transparent monitoring of antimicrobial data usage

Adoption of AS programs has been accelerating in the past few years.  “A recent survey of 43 children’s hospitals showed that 16 institutions (37%) ..currently have an established AS  program supported by full-time equivalents for a pediatric infectious diseases physician and/or clinical pharmacist.”  Another 15 (35%) are in the preparatory stage of implementing an AS program.

Potential barriers for AS programs:

  • Lack of funding or time –these programs have been reported to yield cost savings
  • Lack of hospital leadership
  • Concerns about physician autonomy

Potential outcome variables to measure:

  • Reduction in adverse events
  • Improved (?) antibiotic resistance trends
  • Reduction (?) in C difficile rates

The authors note that on a national level that AS programs have not been mandated. However, multiple societies, including the Infectious Diseases Society and the Society for Healthcare Epidemiology of America, have recommended their widespread adoption.

Bottomline: Improving hospital antibiotic usage with the use of AS programs will help reduce antibiotic resistance, but it is the tip of the iceberg when it comes to addressing this issue (see related blog posts below).

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