The first several slides are from David Rubin. The last two slides were shared by my colleague, Seth Marcus. I think the speaker was Gary Lichtenstein.
Author Archives: gutsandgrowth
Predicting Survival Without Disability Among Preterm Infants
A recent article (J Bourke et al. .J Pediatr 2019; 215: 90-7) made me wonder if my outlook on disability-free survival of preterm infants has been skewed by the population that I encounter. That is, the outcomes from this large Australia study were better than I would have guessed.
This retrospective cohort study identified 720.091 live births from 1983-2010; in this group, 12,083 were diagnosed with a disability and 5,662 died. The authors sought to determine rates of intellectual disability or autism as identified by the IDEA (Intellectual Disability Exploring Answers) database. Because this is a retrospective study, it did not capture milder and more common neurodevelopmental disorders like attention deficit hyperactivity disorder.
Key findings:
The probability of disability-free survival to 25 years was the following:
- 4.1% for those born at 22 weeks gestation
- 19.7% for those born at 23 weeks gestation
- 42.4% for those born at 24 weeks gestation
- 53.0% for those born at 25 weeks gestation
- 78.3% for those born at 28 weeks gestation
- 97.2% for those born full term (39-41 weeks)
Risk factors for lower rates of disability-free survival:
- Aboriginal population (instead of Caucasian), low Apgar score, male sex, low socioeconomic status, and remote region of residence
My take: This data shows the marked improvement in outcomes with longer gestation age.
Tweets: Obesity Projections (Increasing), & Measles (Lots of Cases)
Some Newsworthy Tweets:
“America’s Huge Health Care Problem”
From Vox: A CT scan costs $1,100 in the US — and $140 in Holland
An excerpt:
The Health Care Cost Institute put out a new report Tuesday showing how the prices paid for medical services by private insurance in the United States stack up against prices in other countries. As expected, American prices are collectively higher than the rest.
But four charts, based on the report, show just how thoroughly the United States is outspending other countries for almost every medical service or prescription drug.
Image Available on Twitter and Can be Found in Article
Related blog posts:
- Healthcare: “Where the Frauds Are Legal”
- Marketing of Insulin Explains a Lot About Our Health Care System
- Healthcare Costs Rising
- Do you know about the “Choosing Wisely… | gutsandgrowth
- Deriving Measures of High Value Pediatric Care | gutsandgrowth
- Value-based care | gutsandgrowth
- Implementing High-Value Care | gutsandgrowth
- What physicians can learn from fast-food restaurants… | gutsandgrowth
- 5000% Increase for Well-Established Drug | gutsandgrowth
- Some Hospitals Marking Up Treatments By As Much As 1000%
- Cornering the Generic Markup | gutsandgrowth
- Considering Cost in Treatment Choices | gutsandgrowth
Low FODMAPs Diet for Inflammatory Bowel Disease?
A recent small study (SR Cox et al. Gastroenterology 2019: doi: 10.1053/j.gastro.2019.09.024. [Epub ahead of print]) examined the use of a low-FODMAP diet to reduce symptoms in inflammatory bowel disease.
A summary of the study in GI & Hepatology News: Low-FODMAP diet eases gut symptoms in IBD
An excerpt:
While previous research has shown that a low-FODMAP diet can relieve gut symptoms such as swelling and flatulence in people with irritable bowel syndrome, the diet has been little studied in IBD patients, for whom gut symptoms often persist even in the absence of gastrointestinal inflammation.
In a study published in Gastroenterology, Selina Cox, MD, of King’s College, London, and colleagues randomized 52 people with ulcerative colitis or Crohn’s disease with persistent gut symptoms but without active inflammation to 4 weeks on a low-FODMAP diet (n = 27) or a control diet comprising sham dietary advice (n = 25).
At 4 weeks, Dr. Cox and her colleagues reported more patients on the low-FODMAP diet reported “adequate” relief of gut symptoms (52% vs. 16%, P = .007), and saw slight improvements in health-related quality of life scores, compared with the control group. Patient-reported flatulence and bloating were significantly lower in the treatment group, while few other symptom-specific differences were seen between groups…
There were no significant between-group differences in bacterial diversity or in biomarkers of inflammation.
My take: A low-FODMAP diet may help reduce symptoms but there is no indication that this diet is an effective treatment to reduce complications or reduce inflammation for patients with Crohn’s disease or ulcerative colitis. In addition, assistance from a dietician is recommended when implementing a low-FODMAP diet.
Related Blog Posts:
- Dietary Therapy for Inflammatory Bowel Disease -Useful Update
- Nutrition Week (Day 7) Connecting Epidemiology and Diet in Inflammatory Bowel Disease
- Spice It Up? Curcumin for Ulcerative Colitis | gutsandgrowth
- Head-to-Head: Nutritional Therapy versus Biological Therapy in Pediatric Crohn’s Disease | gutsandgrowth
- Good Food and Bad Food for Crohn’s Disease -No Agreement | gutsandgrowth
- Pushing the Boundaries on Dietary Therapy for Crohn’s Disease: CD-TREAT
- Postion Paper: Nutrition in Pediatric IBD
- Use of Gluten-Free Diet with Inflammatory Bowel Diseases | gutsandgrowth
- The Search for a Dietary Culprit in IBD
- Disappointing Results from SCD Diet (small study)
- Crohn’s Disease with Isolated Colonic Involvement Less Responsive to EEN
- Practical Advice on Enteral Nutrition | gutsandgrowth
- Top Lecture: Enteral Nutrition (for CD)
- FODMAPs for IBS
- An Unexpected Twist for “Gluten Sensitivity”
- Specific Carbohydrate Diet
AGA website for patient information: Low FODMAPs diet
Quebec City
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. 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
Year in Review: My Favorite 2019 Posts
Yesterday, I listed the posts with the most views. The posts below were the ones I like the most.
General/General Health:
- William Meyers
- The Health Consequences of Climate Change
- David Brooks: “Kindness is a Skill”
- No Exaggeration: Too Many Children are Dying in the U.S.
- High Toll of Sudden Infant Death
Nutrition:
- The Paramount Health Challenge for Humans in the 21st Century
- Food Safety Lecture –It’s Still a Jungle Out There
- Ensuring Safe Infant Formula Use –More Complicated Than You Think
Liver:
- Blood Test is Better Than a Liver Biopsy for Biliary Atresia
- #NASPGHAN19 Liver Symposium (part 3)
- Low Free Sugar Diet for NALFD
Endoscopy:
- Our Study: Provider Level Variability in Colonoscopy Diagnostic Yield
- #NASPGHAN19 Postgraduate Course (part 3)
Intestinal Disorders:
- Safety of Senna-Based Laxatives
- Management of Acute Severe Colitis
- Dietary Therapy for IBD
- Oral Antibiotics for Refractory IBD (link on page for post with full text of article: October 2019 IBD Shorts)
- PPIs: Good Safety News
- Aprepitant for Cyclic Vomiting
- ESPGHAN Recommendations for Juvenile Polyposis Syndrome (position paper)
- How (Un) Helpful is AD Manometry in Children with Orthostatic Intolerance?
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. 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.
Most Popular Posts of 2019
The following are the most viewed posts from the past year:
- Preliminary Recommendations from NASPGHAN on Zantac/Ranitidine Warnings
- Which Proton Pump Inhibitor is Most Potent?
- William Meyers
- Diet or Drugs for Cyclic Vomiting Syndrome
- Blood Test is Better Than A Liver Biopsy for Biliary Atresia
- When Should a Spleen Guard Be Recommended
- “The 10 Steps to Successful Breastfeeding” Infographic
- Therapeutic Drug Monitoring: Ustekinumab (Stelara)
- Eosinophilic Esophagitis: An Update
Wishing friends, family and colleagues a healthy and happy New Year.
Morning in Sandy Springs, GA
Primary Prevention of Cow’s Milk Allergy
A recent randomized clinical study (M Urashima et al. indicates that avoiding cow’s milk formula in the first 3 days of life may prevent the development of cow’s milk allergy. Thanks to Ben Gold for this reference.
Link to full Abstract (article behind paywall): Primary Prevention of Cow’s Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow’s Milk Formula at Birth
The Atopy Induced by Breastfeeding or Cow’s Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. The primary outcome was sensitization to cow’s milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant’s second birthday.
Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid–based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).
If the mother, allocated to the BF/EF group, added more than 150 mL/d of EF to BF for 3 consecutive days, EF was switched to CMF after the fourth day. Thus, offspring allocated to BF/EF could avoid CMF for at least the first 3 days of life.
Key Finding:
- “In this randomized clinical trial involving 312 newborns, risks of sensitization to cow’s milk and immediate-type food allergy, including cow’s milk allergy and anaphylaxis, were decreased by avoiding supplementation with cow’s milk formula for at least the first 3 days of life.”
- “The primary outcome occurred in 24 infants (16.8%) in the BF/EF group, which was significantly fewer than the 46 infants (32.2%) in the BF plus CMF group (relative risk [RR], 0.52; 95% CI, 0.34-0.81).”
- “The prevalence of food allergy at the second birthday was significantly lower in the BF/EF than in the BF plus CMF groups for immediate (4 [2.6%] vs 20 [13.2%]; RR, 0.20; 95% CI, 0.07-0.57) and anaphylactic (1 [0.7%] vs 13 [8.6%]; RR, 0.08; 95% CI, 0.01-0.58) types.”
This study is interesting in that it suggests that exposure to cow’s milk in the first three days of life potentially increases the risk of CMA, whereas a previous study (*see below) showed showed that early exposure to CMF within 14 days after birth reduces the risk of CMA. In this previous study, exposure to small quantities of CMF for the first 3 days of life was not monitored. “Thus, the results of that observational study are not necessarily in contrast to those of the present trial.”
My take: This type of study is difficult to complete. It is difficult to understand why exposure to cow’s milk in the first two weeks of life is helpful and why exposure in the first three days of life is detrimental with regard to the development of cow’s milk allergy.
*Katz Y, Rajuan N, Goldberg MR, et al. Early exposure to cow’s milk protein is protective against IgE-mediated cow’s milk protein allergy. J Allergy Clin Immunol. 2010;126(1):77-82.e1. doi:10.1016/j.jaci.2010.04.020)
Related blog posts:
- Overdiagnosis of Cow’s Milk Protein Allergy in Infants and Formula Industry Influence
- Ensuring Safe Infant Formula Use -More Complicated Than You Think
Quebec City
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. 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.
Promoting Poorly-Equipped Medical Students
An interesting commentary (SA Santen et al. NEJM 2019; 381: 2287-9): “Kicking the Can Down the Road –When Medical Schools Fail to Self-Regulate”
Key points:
- Medical schools have only a ~3% attrition rate
- Some students, perhaps 1 or 2 per class, matriculate even though the dean(s) “would not allow [them] to care for their family” due to either academic limitations or unprofessional behavior
- The authors note that there is a low likelihood of legal liability of dismissal as long as there is adequate documentation and as long as schools do not deviate from due-process
My take: This concern of advancing the medical careers of problematic individuals is limited to a small number. However, it is NOT limited to medical school but applies as well to residency & fellowship programs. In addition, of course, promoting suboptimal individuals is not limited to the field of medicine.
Related blog posts:
Briefly noted: Mortality in Acute Severe Ulcerative Colitis
C Dong et al. AP&T 2019 https://doi.org/10.1111/apt.15592
Link: Systematic review with meta‐analysis: mortality in acute severe ulcerative colitis
Key point:
- “Six population‐based studies with 741,743 patients and 47 referral centre‐based studies with 2556 patients were included. The pooled 3‐month and 12‐month mortalities were respectively 0.84% and 1.01%”
Related blog posts:
- Management of Acute Severe Colitis | gutsandgrowth
- Management of Pediatric Ulcerative Colitis -ECCO Recommendations
- Tofacitinib -Where Does it Fit in Treatment Algorithm for Ulcerative Colitis?
- An Overlooked Finding in A Recent Severe Colitis Study
- Accelerated Infliximab Dosing in Acute … – gutsandgrowth
- Predictors of colectomy in pediatric UC | gutsandgrowth
- Predicting Remission in Pediatric Ulcerative Colitis …
Quebec City
