From NBC news: A walk a day may keep early death away
Here’s the “skinny:” (an excerpt)
The findings that a daily, stroll of 20 minutes may reduce a person’s risk of premature death by up to 30 percent are consistent… with the physical activity guidelines for Americans.
Related blog post:
Walking with a “Z” or an “X” | gutsandgrowth
Don’t Get Run Over When You Walk
A recent study (Hepatology 2015; 61: 285 & editorial 28-31) takes a closer look at US liver organ allocation and outcomes.
The editorial notes that our allocation in the US is targeted towards “need.” Since February 2001, the MELD score was adopted with “the stated aim of reducing deaths on the waiting list.” Other potential aims:
The editorial notes that “despite the concerns the approach has been highly effective in achieving its goal in reducing waiting list mortality.”
“Like any system, it can be manipulated and, given the life-saving nature of transplantation, it is scarcely surprising that both legal and illegal methods have been adopted to artificially raise the MELD score and distort allocation.”
The study reviewed 78,595 adult liver transplant candidates (2005-2012). 27.3% of the waiting list was occupied by candidates with exceptions.
Candidates with exceptions fared much better on the waiting list compared to those without exceptions in mean days waiting (HCC 237 versus non-HCC 426), transplantation rates (HCC 79.1% versus non-HCC 40.6%), and waiting list death rate (HCC 4.5% versus non-HCC 24.6%).
The editorialists recommend that “we should consider diverting some of the resources used to develop and implement a perfect allocation scheme into increasing the number of donors and livers used for transplant and, in the longer term, finding treatments and interventions that will render liver transplantation a treatment of historic interest.” Now that’s a lofty goal.
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Carbapenem-Resistant Enterobacteriaceae (CRE) are difficult to treat infections. A recent story in USA Today noted their association with endoscopic retrograde cholangiopancreatography (ERCP)/duodenoscopes. According to the article, the FDA is working with the manufacturers to eliminate this risk. Compared to other endoscopes, the side-viewing scopes are more technically-difficult to clean because of its “elevator” mechanisms. “The biggest cases involved dozens of patients and multiple deaths.” It is likely that more frequent and easier-to-treat infections may be transmitted as well; these types of infections generally do not result in full-fledged epidemiological investigations. Here’s the link: “Deadly bacteria on medical scopes trigger infections” This link has particularly good diagrams explaining resistant organisms. It is important to emphasize that these infections, to my knowledge, have not been reported with the more common endoscopic procedures. Because of technical differences in the scopes, the standard cleaning procedures are effective for upper endoscopies and colonoscopies. Related posts:
A recent study (J Pediatr 2015; 166: 85-90, editorial 11-14) finds that children with functional gastrointestinal diseases (FGID) had more impaired “quality of life” than children with organic gastrointestinal diseases. For those of us taking care of these children, this finding does not come as a surprise, but there is a lot to learn from this study nonetheless.
Using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, the authors completed a 9-site study with 689 families for patients with physician-diagnosed GI disorders including functional problems like irritable bowel syndrome and dyspepsia as well as organic diseases like Crohn’s disease and ulcerative colitis. These patients were compared with a healthy control sample of 1114 families.
In addition to obtaining health-related quality of life (HRQOL) data, the authors reported information on school days missed, days in bed, parent missed workdays, and healthcare utilization.
Key findings:
The associated editorial tries to work through the reasons why the impact of FGID is greater than an organic disease.
The authors hypothesize that two factors play a big role:
1. Issue of control:
2. Issue of response shift:
In addition, the authors note that with many FGID, that physicians often “suspect constipation is the cause…when laxative therapy is not helpful, this leads to more frustration.” They advocate shifting the focus for these families from “finding a cure to managing day-to-day symptoms.”
In my view, there are a lot of other factors at play that may help explain why HRQOL is lower in patients with FGIDs. This can include a high incidence of emotional disturbances (eg. anxiety, depression) and poor coping skills (eg. catastrophizing). This study also is another example showing that the physical severity of the medical disease does not correlate with the severity of the impact.
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The article reviewed earlier today on this blog (Clinical Gastroenterology and Hepatology 2014; 12: 2026-32) has been reviewed on the AGA blog as well (some of this information is redundant from earlier post):
Here’s a link to a summary of the article: AGA blog on RAP and here’s an excerpt: Sara Horst et al investigated whether pediatric functional abdominal pain leads to functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) in adulthood. They performed a longitudinal analysis of 392 children (8−16 years old) initially seen at a subspecialty clinic for recurrent abdominal pain. Horst et al assessed the contribution of gastrointestinal symptoms, extra-intestinal somatic symptoms, and depressive symptoms to FGIDs 5−15 years later. They found that on average 9 years later, 41% met symptom criteria for FGID—mostly irritable bowel syndrome and functional dyspepsia. Levels of depressive symptoms in childhood correlated a greater likelihood of FGID later in life (see figure). 
More data (Clin Gastroenterol Hepatol 2014; 12: 2026-32) helps answer the question about the persistence of functional abdominal pain from childhood into young adulthood.
Using a longitudinal study design, consecutive new pediatric patients (8-16 years) with functional abdominal pain from a subspecialty clinic were contacted on average 9.2 years (n=392) after their initial evaluation.
Key findings:
The associated editorial (pages 2033-36) comments on the strengths of the study and the potential opportunity of intervening to prevent persistence of abdominal pain. It notes that anxiety and hypervigilance can lower the brain’s perception threshold and lead to increased pain. “From this perspective, centrally targeted treatments such as psychological treatment or psychopharmacological treatments will likely have therapeutic value.”
Take-home message: 59% of patients resolve their symptoms with time.
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Briefly noted:
1. Gastroenterology 2014; 147: 1327-37 (editorial 1216-18). “Probiotic VSL#3 reduces liver disease severity and hospitalization in patients with cirrhosis: a randomized, controlled trial.” 66 patients received VSL#3 (9 x 10 to the 11th bacteria), 64 patients received placebo -both groups studied for 6 months. Treatment with lactulose and rifaximin were withdrawn a week prior to study entry. Key findings: ‘fewer hospitalizations for severe encephalopathy, better quality of life, and decreases in Child-Turcotte-Pugh class and Model for End-Stage Liver Disease.’ Hazard ratio for preventing hospitalization with VSL#3 was 0.52. However, the findings did not show that VSL#3 reached a statistically-significant reduction in recurrence rate for hepatic encephalopathy. No adverse events were noted.
2. NY Times: Gilead sued over cost of Sovaldi.
3. N Engl J Med 2014; 371:2375-2382. Link to abstract: Interferon-free Antiviral Regimen for HCV after Liver Transplantation: “Treatment with the multitargeted regimen of ombitasvir–ABT-450/r and dasabuvir with ribavirin was associated with a low rate of serious adverse events and a high rate of sustained virologic response among liver-transplant recipients with recurrent HCV genotype 1 infection, a historically difficult-to-treat population.”
4. “Transplantation Traffic –Geography as Destiny for Transplant Candidates” NEJM 2014; 271: 2450-52. Describes ongoing geographic inequality in organ distribution and obstacles to improving allocation.
5. Liver Transpl 2015; 21: 57-62. Immediate Extubation After Pediatric Liver Transplantation –feasible in 67% according to this retrospective review.
Local Law Office –Truth in Advertising?
A recent NPR report indicates that a faction of scientists is pushing for a water icon to be added to the government’s MyPlate.
Here’s the link: Missing from MyPlate? Water
Here’s an excerpt:
“Consumption of sugary beverages is the leading contributor to added sugar in the American diet,” says Christina Hecht, senior policy adviser at the UC Nutrition Policy Institute and one of the water advocates. “If people could make that one change to drink water to quench their thirst instead of sugar beverages, that would solve a big piece of the problem.”
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For those opposed to the Board Certification process, the arguments are well-detailed in a recent editorial (NEJM 2015; 372: 106-8); the preceding editorial, in contrast, argues that maintenance of certification (MOC) is positively affecting the care of patients.
Some of this discussion has been mentioned previously on this blog: After I Passed The Test | gutsandgrowth
Key points:
Here’s the link: “Boarded to Death –Why Maintenance of Certification is Bad for Doctors and Patients”
Another viewpoint on this issue from Bryan Vartabedian/33 charts: 33 Shorts
Most parents, and many physicians, do not understand the limitations of food allergy testing. As I am sure is common among physicians, I frequently receive requests for food allergy testing; parents do not realize that the strategy for food allergy testing is not straight-forward and has not advanced significantly for decades. This information is detailed in a recent study and associated editorial (J Pediatr 2015; 166: 97-100, editorial 8-10: “Pitfalls in Food Allergy”).
The study was a retrospective review of all new patients seen at a pediatric food allergy center (2011-2012). This involved a review of 797 new patients.
Key findings:
So what can we learn from this study and editorial?
Misdiagnosis often relates to a lack of understanding regarding serum IgE-based testing. First of all, many children with atopic dermatitis (and other atopic conditions) have elevated total IgE which results in more false positives. In addition, a positive IgE test for a specific food indicates sensitization but not necessarily an allergy.
Strategy for testing (recommended by editorial):
Bottomline (from authors’ conclusion): “Food allergy panel testing often results in misdiagnosis of food allergy, overly restrictive dietary avoidance, and an unnecessary economic burden on the health system.”
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gutsandgrowth 