Monthly Archives: November 2016

In the News: UCSF Soda Ban

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NY Times: Putting Sugary Soda Out of Reach

An excerpt:

Last year, U.C.S.F. removed sugar-sweetened beverages from every store, food truck and vending machine on its campus. Even popular fast-food chains on the campus, like Subway and Panda Express, have stopped selling Sprite, Coca-Cola and their sugary brethren at the university’s request….

“We’re a public health institution, and there’s something not right about us making money off of products that we know are making people sick,” said Laura Schmidt, a professor at the medical school who spearheaded the beverage initiative…

Nationwide, at least 30 medical centers have restricted the sale of soda and full-calorie sports drinks, including the Cleveland Clinic in Ohio and the University of Michigan Health System…

the beverage industry argues that the strategy is flawed. It points out that obesity rates have been climbing even as America’s soda intake has declined in recent years. And it says that focusing blame on soda alone, rather than calories from all foods, is misguided.

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Good News from the Bad News Department: Outcomes of Intestinal Transplantation in Patients with Crohn’s Disease

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Briefly noted:  A recent retrospective study (BN Limketkai et al. Clin Gastroenterol Hepatol 2016; 14: 1574-81) examined outcomes of 142 patients with Crohn’s disease (CD) out of a total of 1115 cases of intestinal transplantation.  The authors examined the Scientific Registry of Transplant Recipients. Since intestinal transplantation would be a very undesirable outcome in patients with CD, I titled this post as coming from the “Bad News Department.”  The good news is that in the last 15 years, patients with CD disease do not appear to have worsened outcomes compared to patients without CD.  Overall, during the period 1990-2014, the risk of graft failure was higher, mainly due to the initial 10 years.  Graft failure was 18.6% at 1 year, 38.7% at 5 years, and 49.2% at 10 years in patients with CD compared with 14.1%, 32.1% and 41.0% in non-CD patients.  The cumulative risk of death at 10 years for CD patients was 59.7%.

My take: It is good that intestinal transplantation outcomes for CD patients are now similar to all patients.  In addition, intestinal transplantation outcomes are improving. Nevertheless, there is still a high death rate over 10 years.

World Toilet Day and Poo-ems

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Thanks to my favorite blog reader for pointing me towards this NPR piece:

World Toilet Day: Read Winning Poo Haikus About Diarrheal Disease

An excerpt:

That’s the idea behind Poo Haiku, a competition created by Defeat DD, a campaigndedicated to the eradication of diarrheal disease.

Although everybody’s had the runs, it’s not something most folks talk about, says Hope Randall, digital communications officer for PATH’s Center for Vaccine Innovation and Access, which created DefeatDD to bring together resources on vaccines, nutrition, oral rehydration therapy, sanitation and more…

this winning entry from Kat Kelley of the Global Health Technologies Coalition, which references a recent study published in The Lancet:

Just six pathogens
But eighty percent of kids’
Diarrheal deaths….

Check out all of the poo-ems, including some videos, by searching for the hashtag #poohaiku on Twitter.

My take: Today is World Toilet Day -a great day to write your own poo-em. 2.4 billion people do not have access to a toilet.

World Toilet Day this year is November 19th (today).

Sandy Springs

Sandy Springs

 

iPatient and Physician Work Circa 2016

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An interesting commentary (DI Rosenthal, A Verghese. NEJM 2016; 375: 1813-5) provides a closer glimpse into the meaning and nature of physicians’ work at this time.

Key points:

  • Medical students and residents spend 40-50% of their day in front of a computer & much of the rest of their day on the phone (coordinating care).
  • Time spent with patients “has remained stable over the past six decades.”
  • Flipping through the electronic record before seeing patients is commonplace but can lead to a ‘framing bias.’
  • “Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care”…”despite all the rhetoric about ‘patient-centered care,’ the patient is not at the center of things.”
  • The authors equate the digital representation of the patient as an ‘iPatient.’
  • Physicians are “resentful of the time required to transcribe and translate information.”
  • Higher satisfaction is associated with perceptions of higher quality of care.
  • The authors advocate working on “rebuilding our practices and physical spaces to promote human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses.”

My take: The authors provide a closer glimpse of the problem showing how our digital health has hindered meaningful interactions that go to the heart of medicine –to provide comfort and care.

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Neighborhood tree a few weeks ago

Neighborhood tree a few weeks ago

Autism Drugs: Fat and Happy?

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“The reason fat people are happy is that their nerves are well protected.”
– Luciano Pavarotti

It is not uncommon to see kids with behavioral problems that are also obese.  Many times, medications which help improve behavioral problems may contribute to obesity by increasing appetite.

A recent study (K Shedlock et al. J Pediatr 2016; 178: 183-7) provides some insight into this issue. In this retrospective study, using the Military Health System database (2000-2013) with 48,762 individuals with autism spectrum disorder and with 243,810 matched controls, children with autism spectrum disorder (ASD) had significantly higher rates of obesity with OR 1.85 along with obesity-related conditions.  These conditions include type 2 diabetes, hypertension, hyperlipidemia, and NAFLD/NASH.

Key points:

  • In children with ASD, mood stabilizers, antipsychotics, antiepileptic drugs, and selective serotonin reuptake inhibitors (SSRIs) were associated with obesity.  Mood stabilizers had the greatest risk in this study, with adjusted OR of 1.41; the other medications had fairly small risk with adjusted ORs between 1.13 to 1.16.
  • When kids with ASD develop complications like NAFLD/NASH or hyperlipidemia, they may be less likely to adhere with recommended lifestyle changes.  This can be due to sensory aversions and social deficits.

My take: Children with autism spectrum disorder are likely at increased risk for obesity at baseline; some of the medications to treat behavior problems may contribute to obesity, though they may be partly an epiphenomenon or a marker of a more severe autism spectrum disorder.

Portland Head Light

Portland Head Light

Vedolizumab Study in IBD

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From CGH Associated Editor Charles Kari:

Effectiveness and Safety of Vedolizumab Induction Therapy for Patients With Inflammatory Bowel Disease

Vedolizumab is a biologic agent which targets the integrin receptor and is approved for the treatment of patients with moderate-severe ulcerative colitis (UC) and Crohn’s disease (CD). Vedolizumab inhibits the interaction between α4β7 integrin and mucosal addressin cell adhesion molecule-1 (MAdCAM–1).

In this [November] issue of Clinical Gastroenterology and Hepatology, Amiot and colleagues report the effectiveness and safety of vedolizumab induction therapy in patients with moderate-to-severe active UC and CD who previously failed anti-TNF therapy. Active IBD was defined according to the Harvey-Bradshaw index (HBI) >4 for CD patients and the Mayo Clinic score ≥6 for UC patients. Patients received intravenous vedolizumab at a dose of 300 mg at weeks 0, 2 and 6 and then every 8 weeks through week 52. Concomitant use of corticosteroids, immunomodulators, or methotrexate was permitted. The primary outcome measure was steroid-free clinical remission at week 14, which was defined as a HBI ≤4 for CD patients and a partial Mayo Clinic score ❤ with a combined stool frequency and rectal bleeding subscore of ≤1 for UC patients. A total of 294 patients were enrolled (CD, 173; UC, 121), of whom 276 completed the induction period. At week 14, 63 (36%) and 47 (39%) patients were in clinical remission in the CD and UC groups, respectively, of whom 53 (31%) and 43 (36%), respectively, were in steroid-free clinical remission. The clinical response rates at 14 weeks were 64% for CD patients and 57% for UC patients. Adverse events occurred in 93 patients (31.6%) out of 294 patients with serious adverse events in 24 (8.2%) and adverse events leading to vedolizumab discontinuation in 15 (5.1%) including one case of pulmonary tuberculosis.

In conclusion, in a cohort of IBD patients who failed anti-TNF therapy and received vedolizumab, about one third experienced steroid-free clinical remission at 14 weeks, with good safety profile (Figure 3).

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Compared with Zika, CMV is a Greater Threat and Less Discussed

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A recent article in NY Times provides another example of how a common infectious problem has been overshadowed by a more recent epidemic.  CMV is A Greater Threat to Infants Than Zika

Two years ago, it was well-recognized that the flu virus is vastly more dangerous for U.S. than Ebola (Related post:Scarier than Ebola -the Flu | gutsandgrowth). This year, CMV should get more attention.

Here’s an excerpt:

Every year, 20,000 to 40,000 infants are born with CMV. At least 20 percent — up to 8,000 — have or develop permanent disabilities, such as hearing loss, microcephaly, intellectual deficits and vision abnormalities. There is no vaccine or standard treatment…

CMV is the most common congenital viral infection and the leading nongenetic cause of deafness in children. Roughly 400 children die from it annually. By contrast, roughly 900 pregnant women in the continental United States have contracted the Zika virus…

CMV is the most common congenital viral infection and the leading nongenetic cause of deafness in children. Roughly 400 children die from it annually. By contrast, roughly 900 pregnant women in the continental United States have contracted the Zika virus.

The American College of Obstetricians and Gynecologists used to encourage counseling for pregnant women on how to avoid CMV. But last year, the college reversed course, saying, “Patient instruction remains unproven as a method to reduce the risk of congenital CMV infection.”

My take: Perinatal CMV infection merits more discussion.

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Trail to Iceberg Lake, Glacier Nat'l Park

Trail to Iceberg Lake, Glacier Nat’l Park

Safer Than You Think: Biologic Therapies for IBD and Risk of Infection and Malignancy

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While there have been a number of studies which have highlighted the potential risks of biologic agents, many studies have NOT identified any risk of infection or malignancy.

Another recent systematic review/meta-analysis (S Bonovas et al. Clin Gastroenterol Hepatol 2016; 14: 1385-97) provides reassuring data regarding the following biologics: infliximab, adalimumab, certolizumab, golimumab, natalizumab, and vedolizumab.

The authors identified 49 randomized placebo-controlled studies with 14,590 participants.

Key findings:

  • There was a moderate infection risk with odds ratio of 1.19 (19% increase in odds of developing an infection) and significant increase in opportunistic infections (eg. tuberculosis) OR 1.90
  • Risk of serious infections was NOT increased in patients treated with biologics with OR 0.89.  In studies with low risk of bias, the risk of serious infections had OR of 0.56.
  • No increase in malignancy risk was identified with OR 0.90 but the authors note that data was insufficient in terms of exposure and follow-up to be conclusive.

The authors note that the studies including in this review challenge some of the findings of observational studies. “However, observational studies lack the experimental random allocation of participants…the discrepancies between observational studies and randomized trial evidence might be explained by the inability of observational designs to fully address the complex and important differences between the IBD patients receiving and those not receiving biologics.”

Study limitations include “sponsorship bias -because the trials were supported by pharmaceutical companies and limited followup of 24 months. In addition, most of the trials in the meta-analysis were judged to be at high or unclear risk of bias because of their methodological characteristics.

My take: This study indicates that biologic therapies do not appear to increase the risk of serious infections and may not increase the overall risk of malignancy.

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Portland Fish Market

Portland Fish Market

 

 

Image: Duodenal Ulcer due to an Unusual Cause

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This ulcer was identified in a 26 year old and determined to be due to Strongyloides stercoralis infection. From Clin Gastroenterol Hepatol Nov 2016; DOI: http://dx.doi.org/10.1016/j.cgh.2016.04.019 “This case also highlights the importance of including strongyloidiasis in the differential diagnosis when a patient presents with ulcer bleeding and eosinophilia.”

Image Only: Middle Schoolers as Likely to Die From Suicide as From Traffic Accidents

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From NY Times:  Full Text

It is now just as likely for middle school students to die from suicide as from traffic accidents.

That grim fact was published on Thursday by the Centers for Disease Control and Prevention. They found that in 2014, the most recent year for which data is available, the suicide rate for children ages 10 to 14 had caught up to their death rate for traffic accidents.