Monthly Archives: October 2021

Improvement in Hepatitis C Mortality Rates from 2005 to 2017

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EW Hall et al. Hepatology 2021; 582-590. Open Access. County-Level Variation in Hepatitis C Virus Mortality and Trends in the United States, 2005-2017

The authors used county-level HCV death rates and assessed trends in HCV mortality from 2005 to 2013 and from 2013 to 2017; the study is derived from mortality data from the National Vital Statistics System.

Key Findings:

  • Nationally, the age-adjusted HCV death rate peaked in 2013 at 5.20 HCV deaths per 100,000 persons and decreasing to 4.34 per 100,000 persons in 2017
  • There was heterogeneity in HCV mortality with the highest rates being concentrated in the West, Southwest, Appalachia, and northern Florida. 80% of counties had improvement in HCV mortality

My take: This study showed widespread improvement trends in HCV death rates from 2013 to 2017 and provides benchmarks for further progress. However, other studies have shown increasing rates of HCV tied to opioid crisis which could impact long-term outcomes as well.

Related blog posts:

Irritable Bowel After Campylobacter Enteritis

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A Berumen et al. Clin Gastroenterol Hepatol 2021; 19: 1855-1863. Characteristics and Risk Factors of Post-Infection Irritable Bowel Syndrome (IBS) After Campylobacter Enteritis

The Minnesota Department of Health collects data on symptoms and exposures upon notification of Campylobacter cases. In this 6-9 month followup survey of 1667 (2011-2019) out of a total of 3586 patients, the authors identified 1418 without preexisting IBS.

Key findings:

  • 301 (21%) subsequently developed IBS. Most of these individuals had IBS-mixed (54%), followed by IBS-diarrhea (38%), and IBS-constipation (6%)
  • Additionally, the authors note that 121 patients (8.5%) had new GI problems after infection that did not meet thresholds set by Rome criteria
  • Among patients with IBS-mixed or IBS-diarrhea before infection, 78% retained their subtypes after infection. In contrast, only 50% of patients with IBS-constipation retained that subtype after infection;40% transitioned to IBS-mixed
  • Of patients with pre-existing IBS, 38% had increased frequency of abdominal pain after Campylobacter infection
  • One limitation of the study is ‘responder bias.’ There may be a lower rate of IBS/GI symptoms in the subset of patients who did not respond to survey.

My take: A lot of people develop IBS and other GI symptoms after Campylobacter infection; those with IBS often have intensification of their symptoms.

Related blog posts:

Related study: Am J Gastroenterol  2012 Jun;107(6):891-9. “Norovirus GE leads to the development of PI-IBS in a substantial proportion of patients (13%), similar to that reported after bacterial GE.”

Nutritional Management of Intestinal Failure in Pediatrics

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A recent terrific update from Kipp Ellsworth: Nutritional Management of Intestinal Failure Patients. Slides:

NutritionManagementIntestinalFailure2021Download

Some selected slides:

Related blog posts for Short Bowel Syndrome:

It Hurts Here and Here and Here

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A recent study (below) reminded me of a joke. First the joke (better with the visual effect):

A guy goes to his doctor. The patient says, “Doctor when I touch here on my shoulder (with index finger) it hurts, when I touch here on my leg (with index finger) it hurts, and when I touch here on my stomach (with index finger) it hurts.”

The doctor says: “Your finger is broken.”

BP Chumpitazi et al. J Pediatr 2021; 236; 131-136. Multisite Pain Is Highly Prevalent in Children with Functional Abdominal Pain Disorders and Is Associated with Increased Morbidity

In this cross-sectional study of 7-17 year olds (n=406) with Rome III functional abdominal pain disorder (FAPD), the authors examined the frequency of pain outside GI tract over a 2 week study period. Patients were recruited from both a large academic pediatric GI practice and general pediatric offices in same hospital system.

Key findings:

  • In total, 295 (73%) children endorsed at least 1 co-occurring nonabdominal pain, thus, were categorized as having multisite pain with the following symptoms: 172 (42%) headaches, 143 (35%) chest pain, 134 (33%) muscle soreness, 110 (27%) back pain, 94 (23%) joint pain, and 87 (21%) extremity (arms and legs) pain
  • In addition, 200 children (49%) endorsed 2 or more nonabdominal pain symptoms
  • Participants with (vs without) multisite pain had significantly higher abdominal pain frequency (P < .001) and severity (P = .03), anxiety (P < .001), and depression (P < .001). Similarly, children with multisite pain (vs without) had significantly worse functional disability (P < .001) and health-related quality of life scores (P < .001).

The authors note that due to the design of their study, they cannot establish a causal association between pain symptoms and psychosocial functioning.

My take: A lot of kids with stomach pain have multisite pain as well as anxiety and depression. This study reminds us to ask about them.

Related blog posts:

More Pictures From Atlanta Beltline West End

How Often Does a Fatty Liver Start in Infancy?

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K McNelis et al. JPGN Reports; 2021: 2(3):e113. Open Access: Hepatic Steatosis in Infancy: The Beginning of Pediatric Nonalcoholic Fatty Liver Disease?

In this retrospective study of 65 healthy infants (<3 months of age, median age 2 months) who had CT scans performed due to trauma, the authors investigated the frequency of a fatty liver.

Key findings:

  • Depending on the criteria used, 23% or 26% of infants had evidence of fatty liver on CT scan
  • The prevalence of maternal obesity and/or diabetes was 11% (of the 65 pregnancies) but there was no significant difference in maternal risk factors between infants with and without evidence of steatosis

My take: Whether the fatty liver seen on CT scans in this infant cohort persists and evolves to adolescent and adult fatty liver disease is unknown but intriguing.

COVID-19: Over 120,000 Children Have Lost a Parent or Caregiver

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NY Times: Over 120,000 American Children Have Lost a Parent or Caregiver to Covid-19, Study Says (between April 1, 2020, and June 30, 2021)

“According to the study in Pediatrics, one of every 168 American Indian/Alaska Native children, one of every 310 Black children, one of every 412 Hispanic children, and one of every 612 Asian children have lost a caregiver, compared to one in 753 white children.”

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Updated Bilirubin Nomogram

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TM Bahr et al. J Pediatr 2021; 236: 28-33. A New Hour-Specific Serum Bilirubin Nomogram for Neonates ≥35 Weeks of Gestation

This study which encompassed 397,395 total serum bilirubins provides an updated normogram for serum bilirubins in the first days of life. The data for this nomogram is based on 140 times the number of subjects and is derived from 15 years of universal bilirubin screening (Intermountain Healthcare Hospitals).

Key points:

  • The authors state that this study is one step “toward evidence-based phototherapy decision-making”
  • “We are currently using this nomogram [figure below] routinely in our hospitals in Utah for phototherapy initiation (when a neonate has a TSB exceeding the 95th percentile) and for discharge risk stratification.”
  • “This reduces phototherapy usage…to about 5% of well babies, whereas we had previously been administering phototherapy in 8-10% of well babies.”
  • “Newborns with TSB>75 percentile…receive a recommendation for follow-up within 24 hours.”
  • The authors acknowledge the limitations of their study and caution that more long term outcome data are needed in evaluation of their approach.

My take: Overall, the data is fairly similar to prior data but adoption of these slightly higher values would likely reduce the number of infants requiring phototherapy.

Related blog posts:

In this figure, the new data is indicated by the solid lines and
the prior Bhutani data is indicated by dashed lines.

Liver Shorts: PFIC/FIC1, Best Tenofovir, Ascites Practice Guidance

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DBE van Wessel et al. Hepatology 2021; 74: 892-906. Open Access: Impact of Genotype, Serum Bile Acids, and Surgical Biliary Diversion on Native Liver Survival in FIC1 Deficiency

This huge collaborative study with 130 patients provides a great deal of information about familial intrahepatic cholestasis type 1 (FIC1). Key findings:

  • Survival analysis showed an overall native liver survival (NLS) of 44% at age 18 years. NLS was comparable among FIC1-A, FIC1-B, and FIC1-C (% NLS at age 10 years: 67%, 41%, and 59%, respectively; P = 0.12)
  • The number of predicted protein truncating mutations did not correlate with natural history or prognosis

H Toyoda et al. Hepatology 2021; 74: 656-666. Treatment and Renal Outcomes Up to 96 Weeks After Tenofovir Alafenamide Switch From Tenofovir Disoproxil Fumarate in Routine Practice

In this study, the researchers 834 patients with CHB previously treated with TDF for ≥12 months who were switched to TAF in routine practice at 13 US and Asian center. Key findings:

  • “Overall, we observed continued improvement in virologic response, ALT normalization, and no significant changes in eGFR following switch to TAF from TDF.”
  • HBV DNA suppression increased from 88% to 92% at 48 weeks post-switch, and then 95% at 96 weeks postswitch
  • Improved renal function: “By week 96, 21% (55/267) of patients with CKD stage 2 at switch improved to stage 1 and 35% (30/85) of CKD stage 3-5 patients improved to stage 2 and 1.2% (1/85) to stage 1.”

SW Biggins et al. Hepatology 2021; 74: 1014-1048. Open Access. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

This practice guidance (with 276 references) is an update from similar guidelines published in 2012.

Key Points For Children:

  • Children with cirrhosis and ascites should be referred for evaluation for LT
  • Children undergoing LVP should receive 25% albumin infusion of 0.5-1.0 g/kg, or 6-8 g per liter of ascites removed.
  • Diagnostic paracentesis should be performed in children with ascites and fever, abdominal pain, or clinical deterioration. The risks and benefits of this procedure for use in all children with new ascites but without these symptoms have not been defined.
Atlanta Beltline Murals

Latest on VTE in Pediatric IBD

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MA Aardoom et al. JCC 2021; https://doi.org/10.1093/ecco-jcc/jjab171 The incidence and characteristics of venous thromboembolisms in paediatric-onset inflammatory bowel disease; a prospective international cohort study based on the PIBD-SETQuality Safety Registry

Design: 2016-2020: paediatric gastroenterologists prospectively replied to the international Safety Registry, monthly indicating whether they had observed a VTE case in a patient <19 years with IBD. n=24,802 PIBD patients

Key findings:

  • Twenty cases of VTE were identified (30% Crohn’s disease)
  • The VTE incidence was 3.72 [95%CI 2.27 – 5.74] per 10,000 person-years, 14-fold higher than in the general pediatric population (0.27 [95%CI 0.18-0.38], p<0.001)
  • All but one patient had active IBD, 45% were using steroids and 45% hospitalized.
  • Cerebral sinus venous thrombosis was most frequently reported (50%) VTE

My take: The absolute risk of VTE is low in the pediatric population. In those with active disease, the presence of CVC and use of steroids are known risk factors and require consideration of, at minimum, nonpharmacologic interventions.

Related blog posts:

Pregabalin Helpful for Functional Dyspepsia in Small Study

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I Kotikula et al. AP&T 2021; 54: 1026-1032. https://doi.org/10.1111/apt.16588. Randomised clinical trial: the effects of pregabalin vs placebo on functional dyspepsia

Key findings (8 week, randomized placebo-controlled study)

  • The self-reported adequate relief rates in the pregabalin and placebo groups were 70.6% and 42.1% at week 4 (P = 0.02), and 70.6% and 44.7% at week 8 (P = 0.03), respectively
  • Pregabalin improved the overall quality of life (P = 0.03)
  • The most common adverse event with pregabalin was dizziness, occurring in 51.6% of patients

My take: In this study, pregabalin led to significant alleviation of dyspeptic symptoms, especially in patients with predominant epigastric pain.

Related blog posts:

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