Briefly noted: C Ma et al. Inflamm Bowel Dis 2017; 23: 833-9. This retrospective study examined the response to ustekinumab in 104 patients with Crohn’s disease. All patients had achieved a steroid-free ustekinumab induction. 92.3% had failed anti-TNFα therapy.
Key findings:
C Ma et al. Inflamm Bowel Dis 2017; 23: 833-9. This retrospective study examined the ongoing response to ustekinumab in 104 patients with Crohn’s disease. All patients had achieved a steroid-free ustekinumab induction. 92.3% had failed anti-TNFα therapy.Key findings:
Related blog post: Closer Look at Ustekinumab Data
O Truffinet et al JPGN 2017; 64: 721-25. This small study with 8 children with Crohn’s disease examined the use of tacrolimus. Six of eight showed a response to tacrolimus (target 8-15) with a clinical response at 2 months and 4 of 8 in clinical remission. Adverse effects were common, occurring in 6 of 8. These included renal dysfunction, diabetes, paresthesia and tremor.
J Adler et al. JPGN 2017; 64: e117-e124. Using ImproveCareNow registry, the authors identified perianal disease (PD) in 1399 of 6679 cases (21%). PD was more common in blacks than whites: 26% vs. 20%. Overall, this study showed a higher rate of PD than previously recognized.
J Amil-Dias et al JPGN 2017; 64: 818-35. This is an ESPGHAN IBD Porto Group guideline for surgical Crohn’s disease management in children. There are 25 graded statements. Here are a few:
Related blog post:
Musee d’Orsay
Breifly Noted:
From MedPage Today: Fecal transplant success may depend on bile acid metabolism
An excerpt:
the transplants change patterns of bile acid metabolism in the gut, making the environment inhospitable to C. diff colonization.
In three studies reported at Digestive Disease Week (DDW) 2017, it was demonstrated that individuals with C. diff who respond to fecal transplant showed a different pattern of microbiota species composition compared with baseline and/or with those who fail to respond. But that’s not all: the responders also showed distinct, altered profiles of those elements involved in bile acid metabolism.
Vincent Van Gogh; Hopital Saint-Paul (1889)
Many of our patients use Farrell bags to help with their enteral feedings; though, this decompression system is often used incorrectly. The following is a link to the company’s instructions on how to use this product correctly. Halyard Health: Farrell System
Note: I do not have commercial ties.
From NASPGHAN -Celiac resource: NASPGHAN Clinical Guide For Celiac Disease
I reviewed this website. Overall, this is a useful resource. There are multiple links that address some of the nuances with celiac disease. Interestingly, the website is not entirely consistent in its recommendations. For example, under the link “my parent/child has celiac” recommendations for screening family member are for TTG IgA and IgA (if asymptomatic) whereas under the health professional area, after diagnosis, the website recommends much more extensive testing of family members: HLA DQ2/DQ8 genetics, TTG IgA, IgA, and anti-DGP IgG testing
Reading a recent study (A Alioto et al. J Pediatr 2017; 185: 155-9) reminded me of “My Cousin Vinny.” In a crucial scene, Mona Lisa Vito (Marisa Tomei) proves that the accused killers were not the killers by identifying tire tread marks that were inconsistent with the defendants’ car simply by looking a photograph.
Similarly, the authors of this retrospective report highlight the extensive cost of that children undergo for evaluation of rumination when simple observation might suffice.
Key findings:
Limitations:
Other comments:
My take: Not every doctor is as good at doctoring as Vinny Gambini is at lawyering. That being said, the authors note “for patients who present with repeated effortless regurgitation and vomiting of food that begins soon after they eat or drink, is not preceded by retching, and does not occur during sleep, there are very few other diagnoses to be considered.”
Related blog posts:
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.
Omaha Beach 2017
In a recent retrospective study (JT Krill et al. Clin Gastroenterol Hepatol 2017; 15: 675-81), the authors reinforce the notion that surgery works best for reflux patients whose symptoms respond best to medical therapy.
Background: In this study, 196 patients with normal anatomy were identified, though 81 had inadequate follow-up at 1 year. This left 115 patients (median age ~52). This study examined patients with typical reflux symptoms (regurgitation, heartburn) (n=79 of 115, 68.7%) and extraesophageal symptoms, like cough, hoarseness, and throat clearing (n=36 of 115, 31.3%). It is noted that 2/3rds of those with extraesophageal symptoms had coexisting typical GERD symptoms. Most patients had a Nissen fundoplication but some underwent a Toupet fundoplication.
Key findings:
Limitations: retrospective study, 81 of 196 patients were excluded due to lack of followup
My take: This study is consistent with other studies in suggesting that reflux surgery is less effective in those who do not respond to medical therapies and who have atypical symptoms.
Related blog post:
From Pitts Street Bridge, Mt Pleasant
The most recent data in adults has indicated that dilatation for eosinophilic esophagitis (EoE) likely does not have increased risk compare to esophageal dilatation for other causes. A recent pediatric retrospective study (C Menard-Katcher et al. JPGN 2017; 64: 701-6) reaches a similar conclusion.
In this study over a 5-year period, there were 68 dilatations among 40 patients with EoE.
Dilatation was considered complete if a diameter of 15 mm (45 French) was reached or if a deep rent in the mucosa was evident; small (<0.5 cm) shallow rents were “not considered criteria for cessation of dilations.”
Methods:
Some of the key findings:
My take: Overall, this study indicates that dilations are fairly safe in the EoE population. That being said, in my view, all dilations carry a small but significant risk.
Related blog posts:
Musee d’Orsay, Naissance de Venus, Alexandre Cabanel, 1863
A recent study (A Assa et al. Inflamm Bowel Dis 2017; 23: 791-97) indicates that after surgery, anti-TNFα treatment is worth another try.
In this retrospective study with 53 children, 18 had “pharmacodynamic failure” with anti-TNFα medications (PK group) and 35 were controls. “Phamacocynamic failure is characterized by either a lack of improvement of CD symptoms or loss of response after initial improvement in the setting of adequate serum drug levels without ADAs” [antidrug antibodies].
Key findings:
The authors propose an explanation: “A plausible explanation for this finding is that in severely inflamed tissue with high inflammatory burden, local high levels of TNFα serves as a sink for anti-TNFα antibodies and that tissue injury and local hypoxia might further limit drug penetrance to its target.”
My take: This information is useful. Many patients who have surgery may respond to anti-TNFα therapy subsequently. The unanswered question: Could more frequent dosing of anti-TNFα therapy have averted surgery in some patients by overcoming areas of intense disease?
A recent study (J Sheu et al. JPGN 2017; 64: 671-8 Full Text link (courtesy of JPGNonline twitter feed): Outcomes from Pediatric GI MOC Modules) examined outcomes associated with NASPGHAN sponsored web-based quality improvement activities. This study showed that these modules, designed for Maintenance of Certification (MOC) for American Board of Pediatrics, improved quality care outcomes. What I found most interesting were some of the quality metrics that were targeted. Here are some of them:
My take: While this study showed the potential utility of these MOC modules, the larger point is that if you set specific measurable goals, you have a good chance of improving performance. This article is a good place to start when thinking about improving pediatric endoscopy quality.
Related blog posts:
I really don’t get modern art. This art (a collection of newspapers) is from Centre Pompidou. Robert Gober “Newspaper” 1992
A recent prospective study (E Liu et al. Gastroenterol 2017; 152: 1329-36) reports a very high rate of celiac disease in Denver.
The authors collected data on HAL-DR, DQ genotypes in 31,766 infants. Among the various genotypes, a total of 1339 were followed .for 20 years (starting in 1993). The key outcomes were development of celiac disease autoimmunity (CDA) indicated by persistence of anti-TTG IgA antibody for at least 3 months or development of celiac disease (CD) with biopsies showing at least Marsh 2 histologic lesions. The authors weighted the genotypes based on their frequency in the population to develop estimates for the entire Denver population.
Key findings:
In their discussion, the authors note that “the 3.1% cumulative incidence of CD in Denver by age 15 is the highest to date in North America and is consistent with the 3% prevalence reported in Sweden for 12 year olds born during an ‘epidemic’ thought to be the result of early introduction…of gluten.” This theory about the epidemic is has been discounted: “timing of gluten introduction is not likely a factor” though the quantity could be a factor.
My take: These rates of CD and CDA are very high; ongoing data to determine the frequency in other parts of the country are needed. This high rate of CD is clearly bad news for a lot of people, excepting those with commercial interests in gluten free products.
For 1-3 year old, AAP recommendation for maximum of 4 oz./day of 100% juice, and for 4-6 year olds a maximum of 6 oz/day. For 7 years and older, AAP recommends a maximum of 8 oz/day
gutsandgrowth 