Our recent ImproveCareNow group meeting focused on very early onset IBD. Much of the information has been covered on previous posts, including Patterns and Puzzles with very early onset IBD.
Some of the slides -which at the time of presentation were attributed in part to a recent conference in Philadelphia.
A recent AGA perspectives issue provides two viewpoints on when to start/resume anti-TNF therapy after Crohn’s disease surgery:
Dr. Bressler states that he considers anti-TNF therapy for patients with ongoing immune dysfunction after surgery who are at high risk for recurrence. Attributes of high risk disease include the following:
His commentary indicates that a “‘wait and see’ approach is appropriate for most patients. He frequently will measure a calprotectin three months postoperatively and every three months and perform a colonoscopy typically 6-9 months postoperatively. Those with endoscopic recurrence will be placed on anti-TNF therapy.
Dr. Requiero states:
My take: I tend to favor Dr. Reguieiro’s approach in my patient population.
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August 21, 2017 eclipse (2 days ago) caused unusual shadows:
This shadowing was minutes after the peak eclipse with narrow crescents
This shadowing was a few minutes later and with broader crescents
“Little belly-achers grow up to be big belly-achers and big belly-achers beget little belly-achers” –John Apley
John Apley’s monographThe Child with Abdominal Pains indicates that children with recurrent abdominal pain often grow up to be adults with abdominal pains. A recent study indicates the same type of phenomenon with picky eaters.
A summary of this study in Research Digest: The first study to see if fussy-eating children grow into fussy-eating adults (Thanks to Bonney Reed-Knight for this link.)
An excerpt:
60 per cent of fussy eating children in the study were also fussy eaters at age 23, but fussy eating young adults were no more likely to report signs of eating disorder than their non-fussy peers.
The researchers led by Meredith Van Tine at Stanford University School of Medicine managed to catch up with 61 individuals, now aged 23, who’d participated as children in a long-running study in which their eating habits had been scored by their parents at ages 2, 7, 9.5 and 11, including any signs of fussy eating (being a “selective eater”, having strong likes and dislikes, and only eating a limited variety of foods etc). The participants were now asked to rate themselves on whether they were selective or fussy eaters, and they answered questions about whether they engaged in behaviours related to eating disorders.
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A personal pet peeve is having to explain to so many parents that their child is not constipated. The typical scenario is that their child went to the ER for abdominal pain and had an abdominal radiograph (AXR); then, the parents are informed that their child is constipated based on ‘fecal loading’ noted on the AXR. In this scenario, it is common for the child to have the following:
So, I like to see publications that support my viewpoint that this approach is misguided. Two recent studies provide some insight into this topic:
Freedman et al performed a retrospective cohort study (children <18 yrs) who were diagnosed with constipation at 23 EDs from 2004-2015. This study used the PHIS database. Key findings:
Recognizing that AXRs are “unnecessary and potentially misleading,” Ferguson et al aimed to decrease AXR utilization in low-acuity patients who were suspected of having constipation. Using quality tools, the authors performed four plan-do-study-act cycles which included holding grand rounds, sharing best practices, metrics reporting, and academic detailing. Key finding:
My take: These studies support my view that routine use of AXR in the diagnosis of constipation is a mistake and can be misleading.
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The enthusiasm for probiotics is generally greater than expected based on the data available to support their use for many indications. This has been discussed several times on this blog (see below). The reasons why probiotics are sometimes not effective can be related to being poorly regulated/lack rigorous production standards; even in conditions in which there is some effectiveness (eg. antibiotic-associated diarrhea [AAD]), the number of persons needed to treat for one person to benefit is fairly high. Furthermore, as a recent study (A Olek et al. J Pediatr 2017; 186: 82-6) shows, even in conditions like AAD in which probiotics have proven efficacy, the effects may be strain-specific and/or dose-related.
Olek et al showed that Lactobacillus planatarum DSM9843 (LP299V) was NOT beneficial compared to placebo in reducing the incidence of loose/watery stools or mean number of stools among 438 children receiving outpatient antibiotic therapy.
Specifics: This was a prospective, double-blind, randomized, placebo-controlled parallel-group study. The treatment group received LP299V during antibiotic therapy and for 1 week afterwards. In addition to monitoring the number of stools, the authors determined the frequency of AAD which they defined according to WHO guidelines (>3 loose/watery stools/24 hours after initiation of antibiotics). In this study, AAD was confined to study duration rather than over 2 months.
The authors note that LP299V has been effective in studies involving adult hospitalized patients. They question whether healthy children, therefore, may be less likely to benefit from probiotics and whether a higher dose could have been more effective.
My take: “Data from clinical studies on probiotics are conflicting” for many conditions, including antibiotic-associated diarrhea.
Lovers Leap, near Ashville (Appalachian Trail)
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Our hospital switched to a new rectal suction biopsy device. This ~ 9 minute YouTube video, rbi2 rectal suction, explains how it is assembled and provides pointers on its use –thanks to Steven Liu for this link.
I have no financial stake in this product.
FDA Warning: Five Die While Using Obesity Devices (Intragastric Balloons)
An excerpt:
At least five people have died soon after being fitted with balloons aimed at helping them lose weight, the Food and Drug Administration said Thursday.
The FDA says it doesn’t know if the devices or the surgery to implant them is to blame but issued an alert to doctors to closely monitor patients who get them.
Related blog post: In the News: Weight Loss Intragastric Balloons
A recent commmentary (D Patel, KT Park. JPGN 2017; 134-6) explains the topic of interchangeability and its relationship to biosimlars. While biosimilars are expected to reduce the cost of biologic therapy, there are concerns regarding immunogenicity and whether switching to these products could reduce therapeutic sustainability.
The authors explain that some products are truly interchangeable and produce the same clinical result. An interchangeable medicine (eg. typical generic) does not increase safety risk and switching from originator drug can be done by pharmacists or government payers without intervention of the prescribing health provider.
CT-P13 (Inflectra) has been approved as a biosimilar but has not been deemed an interchangeable product. This is important. Biosimilars “could have clinical consequences and repeated switches may increase immunogenicity.” Also, biosimilar products are much more complicated products than typical generic drugs.
Other key points:
My take: We still have a lot to learn. Until more studies are available, switching stable patients could increase risk of losing response.
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Dry Falls, Highlands NC
The AGA has made several recommendations regarding biosimilars –#2 and #6 are particularly of interest to pediatric gastroenterologists. More on this topic will follow tomorrow.
Link: AGA Makes Six Recommendations to FDA on Interchangeable Biosimilars
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