Animated overview of distracted driving study narrated by Editor-in-Chief Jeffrey Drazen. http://nej.md/1hVzO1t (2:43 video from NEJM)
More explanation of this study from NY Times: http://nyti.ms/1dX4lcp
“An inexperienced driver who reaches for a cellphone increases the risk for a crash by more than 700 percent, a new study found.”
J Pediatr 2013; 163: 1692-6. This retrospective study of prospectively collected data from 178 children provides data with regard to micronutrient deficiency among intestinal failure patients transitioning to enteral feeds. Figures 1 and 2 along with Table 2 provide the prevalence of micronutrient deficiency while receiving supplemental parenteral nutrition (PN) and while on full enteral nutrition (FEN). Iron deficiency was most common in both situations with prevalence of 84% and 61% respectively. With the exception of folate (0%), all of the vitamins and micronutrients had fairly high rates of deficiency. While on FEN, deficiencies were the following:
The study does not indicate that the deficiency values were adjusted based on CRP values. Instead, “low serum levels were used to define deficiencies.” This is likely to lead to numerous errors. Nevertheless, it is clear that these deficiencies are common. Another finding of the study was that normal anthropometrics did not reduce the frequency of these deficiencies. In their patient population, 57 of 136 (42%) with sufficient height and weight data had a height-for-age z-scores of <-2 by the time of FEN; where as 52 of 139 patients (37%) had weight-for-age z-scores of <-2.
A recent post on The Pediatric Nutritionist blog provides a suggested approach to the monitoring of vitamins and micronutrients based on the need for parenteral nutrition and on the need to consider inflammatory markers in the interpretation of these lab values: The Importance of Nutrition Lab Monitoring Protocols Featuring …
Bottomline: Vitamin and micronutrient deficiencies are common among intestinal failure patients. In addition, a large percentage of these kids are not large at all.
Related blog post:
What happens to micronutrient levels in the hospital setting …
A couple recent youtube videos on 22Q deletion provide helpful information:
1. An Introduction to 22q112 Deletion Syndrome – YouTube –~20 minute video which provides an overview of the various problems and presentations of patients with 22Q deletion.2. http://www.youtube.com/watch?v=34YhIYhNrdo -~ 5 minute video from the Netherlands conveys the message that kids with 22Q wanted to be treated like everyone else.
Related blog post:
Immunoglobulin deficiencies with DiGeorge Syndrome … This post lists a number of references and resources related to 22Q (aka. DiGeorge Syndrome or Velocardiac Facial Syndrome).
According to a 3 min video (and article) publicized on twitter by Dr. Sanjay Gupta, Stem Cell therapy for Crohn disease is 97% effective. ow.ly/smrJM I sent him a tweet asking for data to support this figure but have not heard back. That being said, there are very few treatments that work in 97% of patients with any chronic disease.
The context of the video regards a model who has had 75 hospitalizations for Crohn disease and is unable to tolerate standard treatment. “Thus far, there is a 97 percent success rate with this procedure, but it’s not fully covered by insurance, so Jocelyn must find the money for the procedure, her travel, and the long recovery.”
To my knowledge, stem cell therapy, while promising, for Crohn disease remains an experimental treatment without any large studies proving its effectiveness.
An abstract at DDW last year (Stem Cell Transplantation Halts Crohn’s Disease – Medscape) reported that among the 22 patients in the stem cell treatment group (who were refractory to multiple other medications), 40% had mucosal healing and 58% had segmental healing. The presenting physician, Dr. Christopher Hawkey, noted ‘there were serious adverse events and many patients were not cured…. We need controlled trials showing a long-term risk/benefit ratio.’
Another study (Blood. 2010;116:6123-6132) with 24 patients, reported that “the percentage of clinical relapse-free survival defined as the percent free of restarting CD medical therapy after transplantation is 91% at 1 year, 63% at 2 years, 57% at 3 years, 39% at 4 years, and 19% at 5 years.”
Bottomline: I think the information in the video is not accurate. Inevitably, it will lead to a lot of ill-informed questions by families. When a respected physician posts this type of unsupported information, it has the potential to undermine not just his credibility but other physicians as well. Perhaps, Dr. Gupta will consider revising this information.
Related article:
Clin Gastroenterol Hepatol 2014; 12: 64-71: “A phase 2 study of allogeneic mesenchymal stromal cells for luminal Crohn’s disease refractory to biologic therapy.” Results: among the 15 patients (of 16) who completed the study, the mean CDAI score was reduced from 370 to 203. Twelve patients had a clinical response and eight had clinical remission. All patients received 4 weekly infusions of mesenchymal stromal cells. One patient had a stage 1 adenocarcinoma (colon) but the authors think that this was likely present prior to the infusions. Why this study is important? If shown effective in larger studies, mesenchymal stromal cells are much safer than allogeneic stem cells as donor to recipient matching is not needed nor chemotherapeutic marrow conditioning.
The “DAISY” (diabetes autoimmunity study in the young) study indicates that the timing of solid-food introduction can influence the likelihood of developing type 1 diabetes (T1DM) (JAMA Pediatr 2013; 167: 808-15).
The participants were 1853 children at increased genetic risk for T1DM who were enrolled in a longitudinal observational cohort study in Denver. Early solid-food exposure was considered <4 months of age and late >6 months of age.
Results:
The study has several limitations, particularly the relatively low numbers of children who developed T1DM (n=53).
A second study (Pediatrics 2013 [doi: 10.1542/peds2012-3692]) –thanks to Ben Gold for this reference –showed that “solid foods were introduced significantly earlier among the infants with allergies, with 35% of them receiving their first solids before and including 16 weeks, compared with 14% of control infants (P=.011).” (Solid foods before 17 weeks linked to food allergy)
Bottomline: As with celiac disease (“Gluten–Related Disorders” (Part 1) | gutsandgrowth), current science suggests the introduction of solid foods between 4-6 months of age may diminish the risk of developing T1DM as well as food allergies.
I have been a fan of Arthur Caplan for a long time. In medical school, I had the good fortune to study closely with several brilliant bioethicists including Baruch Brody and Tristram Engelhardt. Since that time, I have remained interested in bioethics. Arthur Caplan has been a leading voice in bioethics for a long time and often approaches topics in a no-nonsense manner.
A recent link (from John Pohl’s twitter feed) chronicle.com/blogs/conversation/2014/01/07/distinguishing-science-from-nonsense/ … and excerpt from Arthur Caplan addresses the need for a better appreciation of science; this short opinion piece ties together brain death, vaccines, evolution, and nutritional supplements:
A key reason for the poor performance of our children with respect to science is that American culture is both ignorant of and disrespectful to science.
As I write this, two women in ICUs in the United States are on life support despite having been pronounced dead by medical experts. These women, a teenager in Oakland, Calif., and a young woman in Fort Worth carrying a 14-week-old fetus when she died, were found to be dead on the basis of brain death. Both had their bodies maintained by machines (in Oakland it was with the support of her family; in Texas it was against family wishes). Neither the news media nor the medical profession seemed to be able to explain that brain death is truly death. Nor did the public seem inclined to listen, believing that somehow a miracle might occur.
At the same time as those cases emerged, a poll was released by the Pew Research Center showing that a third of Americans do not believe in evolution. They think that “humans and other living things have existed in their present form since the beginning of time.” Twenty-four percent acknowledge evolution but believe that a Supreme Being has directly guided life on earth.
And as I write this, flu season has begun. The federal Centers for Disease Control and Prevention estimates that last year 381,000 Americans were hospitalized because of the flu. They also estimate that the flu vaccine prevented 79,000 hospitalizations and 6.6 million illnesses. Yet a tiny cabal of kooks and know-nothings has gotten so much attention that barely half of all Americans get a flu shot.
The problem does not end there. The multibillion-dollar nutritional-supplements industry has no solid evidence for the efficacy of its products, while there are plenty of instances in which death and disability have been linked to poorly manufactured or mislabeled supplements. Yet our airwaves are full of ads and endorsements for this cornucopia of malarkey.
The point ought to be clear. Children are not going to flourish at science in a society that treats science either as something you can believe in selectively, something that is simply one point of view, or something about which anyone can have a credible opinion no matter how ill-qualified, dumb, or misinformed.
If we want to have a brighter economic future, then we need to start thinking about science education outside of our schools. We need editors who refuse to put fringe points of view on the air. We need scientists who see it as their duty to engage broader audiences—not just their peers—about their work. We need the training of scholars in the public understanding of science so that more voices are heard respecting science and the scientific method.
We need our courts to better vet who can speak for science. And we need more scientists as role models rather than the athletes and entertainers so put before the eyes of kids who may find it a bit hard to take chemistry, ecology, epidemiology, statistics, and geology seriously when their home life is filled with the musings of the casts of Duck Dynasty, Here Comes Honey Boo Boo, and Long Island Medium.
And we wonder why Johnny and Jane can’t distinguish science from nonsense.
Arthur L. Caplan is a professor of bioethics and director of the division of medical ethics at NYU Langone Medical Center.
At a recent group dinner meeting, we had the opportunity to review therapeutic anti-TNF monitoring. In addition, we discussed emerging treatments for inflammatory bowel disease, like golimumab, tofacintinib and vedolizumab.
As noted in previous blog entries (see below), therapeutic anti-TNF monitoring can help adjust treatment. Namely, if a patient loses response to therapy and has low trough levels of anti-TNF (Infliximab ❤ μg/mL, Adalimumab <8 μg/mL, or certolizumab <27.5 μg/mL) without antidrug antibodies (ADAs), then increasing the dose is likely to be effective. However, if a patient has a therapeutic level and is not responding, changing to another agent and/or further investigation is worthwhile.
So, what information is new?
Outstanding questions?
Related blog links:
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. 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
A retrospective review of all serial transverse enteroplasty (STEP) procedures from Omaha provides more data on long-term outcomes (J Pediatr 2014; 164: 93-8). In total 51 patients underwent a total of 68 STEP procedures. Underlying bowel diseases: NEC (n=8), Gastroschisis (n=29), Intestinal Atresia (n=11), and Volvulus (n=4). Median length prior to STEP: 30 cm.
Results:
Bottomline: The authors philosophy is that the STEP should create uniformity of luminal diameter as the first priority rather than increased length. Based on their experience, there appears to be a learning curve to optimizing outcomes with STEP procedures.
Also noted: J Pediatr 2013; 163: 1692-6. Retrospective study of prospectively collected data from 178 children with regard to micronutrient deficiency among intestinal failure patients transitioning to enteral feeds. Figures 1 and 2 along with Table 2 provide the prevalence of micronutrient deficiency while receiving supplemental parenteral nutrition (PN) and while on full enteral nutrition (FEN). Iron deficiency was most common in both situations with prevalence of 84% and 61% respectively. With the exception of folate (0%), all of the vitamins and micronutrients had fairly high rates of deficiency. While on FEN defiencies were the following:
A recent post on The Pediatric Nutritionist blog provides a suggested approach to the monitoring of vitamins and micronutrients based on the need for parenteral nutrition and on the need to consider inflammatory markers in the interpretation of these lab values: The Importance of Nutrition Lab Monitoring Protocols Featuring …
From AGA twitter feed: http://t.co/vFwhS5YEF4 -Full text article.
From Abstract:
In a study of 30 patients with IBS and 8 healthy individuals (controls, matched for demographics and diet), we collected dietary data from subjects for 1 habitual week. Participants then randomly were assigned to groups that received 21 days of either a diet low in FODMAPs or a typical Australian diet, followed by a washout period of at least 21 days, before crossing over to the alternate diet. Daily symptoms were rated using a 0- to 100-mm visual analogue scale. Almost all food was provided during the interventional diet periods, with a goal of less than 0.5 g intake of FODMAPs per meal for the low-FODMAP diet. All stools were collected from days 17–21 and assessed for frequency, weight, water content, and King’s Stool Chart rating.
Subjects with IBS had lower overall gastrointestinal symptom scores (22.8; 95% confidence interval, 16.7–28.8 mm) while on a diet low in FODMAPs, compared with the Australian diet (44.9; 95% confidence interval, 36.6–53.1 mm; P < .001) and the subjects’ habitual diet. Bloating, pain, and passage of wind also were reduced while IBS patients were on the low-FODMAP diet. Symptoms were minimal and unaltered by either diet among controls. Patients of all IBS subtypes had greater satisfaction with stool consistency while on the low-FODMAP diet, but diarrhea-predominant IBS was the only subtype with altered fecal frequency and King’s Stool Chart scores.
In a controlled, cross-over study of patients with IBS, a diet low in FODMAPs effectively reduced functional gastrointestinal symptoms. This high-quality evidence supports its use as a first-line therapy.
Related Blog Posts:
My understanding is that shortly before my twin and I were born, a nurse used a pencil test to predict our genders. Though my mother is quite smart, she believed the nurse knew what she was doing. However, shortly thereafter, it turned out that I had a twin brother not a twin sister.
ER doctors often perform a similar service to the pencil test when they use an abdominal radiograph (AXR) to determine if their patients have constipation. A new pediatric study from Toronto highlights this phenomenon and current recommendations (J Pediatr 2014; 164: 83-8).
Background: this retrospective cohort study of children <18 years took place between 2008-2010. As part of the study, a single pediatric radiologist (blinded to participant classification, assigned Leech scores to all misdiagnosis AXRs along with 20% of the remaining AXRs. From a total of 112,381 ER visits, the review identified 3987 where constipation was the discharge diagnosis (3.5% of all visits). In the cohort diagnosed with constipation, the mean age was 6.6 years.
Key findings:
Why I think this study is important:
While the authors point out that 1 in 200 children ultimately required a surgical or radiologic intervention within 7 days, I do not think that this error rate or diagnostic delay is particularly high. What is important is that this study reiterates the fact that AXRs are not useful for the diagnosis of constipation. The authors note “reviews have concluded that there is no evidence of an association between clinical symptoms of constipation and fecal loading on AXR.” Furthermore, AXRs may lead ER physicians to a cognitive diagnostic error.
Also, the misdiagnosis rate is much greater than reported in the study due to the definition adopted by the authors. The authors did not include treatable infectious diseases (e.g.. pneumonia, urinary tract infection) as well as a large number of other medical diagnosis. Other “incipient” disease processes may have been missed including inflammatory bowel disease and celiac disease.
The authors imply that using a more standard definition of constipation would be useful, namely the Iowa criteria which requires the presence of 2 of the following:
The authors reference a study which indicated that AXRs should be restricted to patients with high-yield clinical features: prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, addominal distention, and peritoneal signs.
Bottomline: AXRs do not establish a diagnosis of constipation. Yet, after families have been told their child is constipated because of an AXR it is not easy to convince them that an AXR is about as useful as a pencil test for this diagnosis.
Related blog posts:
gutsandgrowth 