A recent study (S Isanaka et al. NEJM 2017; 376: 1121-30) shows that a new low-cost oral rotavirus vaccine is effective and importantly, it does not require refridgeration.
Here is a link to a 1:35 min quick take video summary: Efficacy of a Low-Cost, Heat-Stable Oral Rotavirus Vaccine in Niger
“Medical Child Abuse” is the favored term for what has been called Munchausen Syndrome by Proxy (and “Factitious disorder imposed on another”). A recent case series with 36 cases (AZ Ali-Panzarella, TJ Bryant, H Marcovitch, JD Lewis. Curr Gastroenterol Rep 2017; 19: 14) provides some of the most extensive information about this troubling condition. Kudos to my colleague Jeff Lewis and his coauthors for this publication.
The authors conducted a retrospective review of all cases of medical child abuse that were confirmed by video. During a 20-year period, covert video monitoring was used in suspected cases. This study is important because most of the literature on this topic are single case reports. Furthermore, there is virtually no published follow-up outcome data available.
Key demographics:
Clinical features:
Multidisciplinary Process:
19 references are given with this report. Two references that are highlighted:
My take: Making a diagnosis of medical child abuse is crucial for these children. This report makes an important contribution to this end. Institutions that do not have covert surveillance should consider collaboration with institutions that have set up this capability.
Related blog post: A Cautionary Tale–Is it Medical Child Abuse?
Monet, Musee L’Orangerie
Briefly noted:
In the first study, Hoekman et al identified 21 studies to determine the placebo response in pediatric abdominal pain-related functional GI disorders. The authors found a pooled response to placebo of 41% (improvement) and resolution with placebo occurred in 17%.
The second study examined 289 children (55% U.S., 45% Italy) comparing the frequency of functional GI disorders in children with celiac disease on a gluten free diet compared with controls. Overall, chronic abdominal pain was present in 30.9% of subjects with celiac disease compared with 22.7% of sibling controls and 21.6% of unrelated controls. This did not reach statistical significance.
Related post: Is functional pain more common with celiac disease?
Sawnee Mountain
From Abstract:
Objective To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for celiac disease.
Evidence Review The USPSTF reviewed the evidence on the accuracy of screening in asymptomatic adults, adolescents, and children; the potential benefits and harms of screening vs not screening and targeted vs universal screening; and the benefits and harms of treatment of screen-detected celiac disease. The USPSTF also reviewed contextual information on the prevalence of celiac disease among patients without obvious symptoms and the natural history of subclinical celiac disease.
Findings The USPSTF found inadequate evidence on the accuracy of screening for celiac disease, the potential benefits and harms of screening vs not screening or targeted vs universal screening, and the potential benefits and harms of treatment of screen-detected celiac disease.
Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for celiac disease in asymptomatic persons. (I statement)
Winged Victory of Samothrace, 190 BC
A recent study (A Ermarth et al. Clin Gastroenterol Hepato 2017; 15: 396-402) retrospectively examined serology from 3555 pediatric patients who had intestinal biopsies, including 517 with celiac disease from a total of 30,413 with serologic testing These patients had their testing at a commercial lab (ARUP laboratiories). The authors note their regional prevalence of celiac disease was 1.7% of screened patients.
Table 1 lists the PPV, NPV, Sens, Spec based on the degree of elevation of the TTG IgA value.
Some examples:
Related blog links:
Sawnee Mountain
In a recent study (D Gidrewicz et al. JPGN 2017; 64: 362-7) with 228 consecutive, newly diagnosed children with biopsy-proven celiac disease, the authors followed improvement in serology. Patients were divided into tertiles based on the degree of TTG IgA/EMA abnormalities. For example, Group A had the most abnormal serology: TTG >10 times ULN and EMA ≥1:80.
My take: This data confirms the fact that it takes a long time for resolution of celiac serology, particularly in those with the most severe disease.
A recent “consensus” review on bowel management (G Mosiello et al. JPGN 2017; 64: 343-52) is available as an open access article –Link: Consensus Review of Best Practic of Transanal Irrigation in Children
The use of bowel management tube (or cone) for transanal irrigation has been around since ~1987 (B Shandling et. al. J Ped Surg 1987; 22: 271-3) and generally is considered in children older than 3 years of age with severe problems with defecation (organic and functional).
This particular review has a very good table on troubleshooting (Table 4) and a succinct summary of indications/contraindications (Table 2).
Related blog entries:
NY Times Summarizes the reasons why Canadians with Cystic Fibrosis Live Longer: Link: Canadians With Cystic Fibrosis Live 10 Years Longer Than Americans With the Disease
Cystic fibrosis is an inherited disease that causes recurrent lung infections and other problems. The average lifespan for an American with the illness is 37 years. In Canada, it is 49.
Researchers studied records of 5,941 Canadian and 45,448 American cystic fibrosis patients between 1990 and 2013. After controlling for severity of disease, age and other factors, they found that overall death rates were 34 percent lower in Canada than in the United States.
There was no difference in death rates between Canadians and Americans with private health insurance. But Canada provides universal health care coverage under a single-payer system, so every Canadian has some kind of health insurance. The Canadian death rate was 44 percent lower than that of Americans on Medicaid or Medicare, and 77 percent lower than Americans without insurance.
AL Stephenson et al. Ann Intern Med. 2017. DOI: 10.7326/M16-0858
Sainte-Chapelle, Paris
A recent review (B Weiss, O Pinahs-Hamiel. JPGN 2017; 64: 175-79) of the medical literature describes the various recommendations regarding celiac disease (CD) and type 1 diabetes mellitus (T1DM).
Key points:
The authors review recommendations for CD screening. Several guidelines have recommended soon after diagnosis (especially if >2 years of age).
Their figure 1 algorithm provides guidance on evaluation. In those patients with T1DM and positive CD serology, if they are asymptomatic, assuring that serology is persistently elevated may be worthwhile before proceeding with small bowel biopsy. In those who initially test negative for serology, there may be a role for HLA testing and/or periodic screening every few years.
Related editorial on recent article: Celiac Disease, Gut-Brain Axis, and Behavior: Cause, Consequence or Merely Epiphenomenon (A Fasano) Thanks to KT Park for this reference. Excerpt:
By assessing the psychological functioning of infants enrolled in the Environmental Determinant of Diabetes in the Young trial and followed prospectively, the authors reported that 3.5-year-old children affected by celiac disease autoimmunity (CDA), defined as positive serology in children at risk, have increased reports of depression/anxiety, aggressive behavior, and sleep disturbances. Interestingly, these symptoms were significantly greater in the 66 children with CDA whose mothers were unaware of the diagnosis compared with the 440 children with CDA whose mothers were aware of the diagnosis and the 3651 children without CDA, decreasing the chance that the reported behaviors were biased by families’ subjective assessment…Prospective studies such as that reported by Smith et al may be a key approach to shedding light on how intestinal factors can influence human behavior and to identifying possible targets to ameliorate psychological symptoms caused by inappropriate gut-brain cross-talk.
Reference article: Smith L, et al.. Psychological manifestation of celiac disease autoimmunity in young children. Pediatrics. 2017;139(3):e20162848
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.
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