For the issue of fatigue and IBD, besides active IBD and anemia, the authors recommend considering medication side effects (especially from immunomodulators/corticosteroids and cannabis), mental health, sleep disorders, and nutritional concerns (?role for thiamine supplementation). Even when all these issues are addressed, many times fatigue persists.
Here is the proposed algorithm from July 24, 2020.
#MondayNightIBD has a lot of topics that they have covered including functional medicine, COVID, sexual health, utilizing social medicine, grief and pharmacology.
— Use for inflammatory conditions limited to those who fail on TNF blockers
An excerpt:
The FDA has finished its review of a large postmarketing safety study of tofacitinib (Xeljanz, Xeljanz XR), and its conclusions do not bode well for the popular drug and the larger class of JAK inhibitors.
Data from the trial revealed increased risks for serious heart-related events — including myocardial infarction (MI) and stroke — as well as a higher risk for cancer, blood clots, and death. Even the lower 5-mg dose of tofacitinib turned up an increased risk of blood clots and death in the final analysis, the agency noted.
FDA is requiring new and updated warnings for tofacitinib, as well as two other arthritis medicines in the JAK inhibitor class — baricitinib (Olumiant) and upadacitinib (Rinvoq)…
Treatment with the JAK inhibitor was associated with an increased risk for major adverse cardiac events (MACE), including MI, cardiovascular death, and stroke (HR 1.33, 95% CI 0.91-1.94), which missed criteria for non-inferiority, as well as a higher risk for cancer (HR 1.48, 95% CI 1.04-2.09).
“AGA suggests against re-instituting routine pre-procedure testing prior to elective endoscopy. The downsides (delays in patient care, burden, inaccurate results) outweigh potential benefits. Infection and transmission of SARS-CoV2 from asymptomatic individuals is rare especially among vaccinated health care workers using personal protective equipment (PPE), even with the emergence of the Delta variant.”
“If PPE is available, AGA recommends using N95 masks” for both upper endoscopy and colonoscopy”
In this study with 109 adults who were newly diagnosed with eosinophilic esophagitis (EoE), the authors consecutively performed high-resolution manometry (HRM). Key findings:
68 (62%) had normal findings from HRM
8 (7.3%) had achalasia (1 with type 1, 4 with type 2, and 3 with type 3)
9 (8.3%) had major motor disorders of esophagus (& not achalasia) and 24 (15.6%) had minor motor disorders
These findings are important because the diagnosis of EoE could result in a diagnostic delay of concurring achalasia and because the presence of esophageal eosinophilia could perhaps play a role in the pathogenesis of achalasia (or vice versa). The finding of achalasia in 7.3% of this population is exponentially higher than the estimated prevalence of achalasia in the general population (10-16 cases per 100,000).
My take: In patients with EoE, further diagnostic workup is indicated if there are persistent symptoms.
Recently, several news reports highlighted a study which among other things claimed that each hot dog one ingests could costs a person 36 minutes off their lifespan.
Olivier Jolliet, one of the lead researchers on the study, published in thejournal Nature Food, told USA TODAY that 5,800 foods were evaluated and then ranked based on their nutritional disease burden as well as their impact on the environment. Hot dogs were considered the most unhealthy...
The study found that substituting 10% of daily caloric intake from beef and processed meats for a mix of fruits, vegetables, nuts, legumes and select seafood could reduce your dietary carbon footprint by one-third and allow people to gain 48 minutes of healthy life per day...
Regardless of moderation, hot dogs are not exactly healthy. The World Health Organization’s International Agency for Cancer Research (IARC) reported ham, hot dogs and other processed meats may contribute to colorectal cancer. Hot dogs also are high in saturated fat and sodium. Just one hot dog can contain over a quarter of your day’s sodium allowance and over 14 grams of fat...while processed meats like hot dogs can inherently be unhealthy, it’s wrong to zero in on just hot dogs as the study does in highlighting the food.
Researchers classified foods into three color zones: green, yellow and red, based on their combined nutritional and environmental performances, much like a traffic light. The green zone represents foods that are recommended to increase in one’s diet and contains foods that are both nutritionally beneficial and have low environmental impacts. Foods in this zone are predominantly nuts, fruits, field-grown vegetables, legumes, whole grains and some seafood.
Based on their findings, the researchers suggest:
Decreasing foods with the most negative health and environmental impacts including high processed meat, beef, shrimp, followed by pork, lamb and greenhouse-grown vegetables.
Increasing the most nutritionally beneficial foods, including field-grown fruits and vegetables, legumes, nuts and low-environmental impact seafood.
Due to case series which have reported increased mucocutaneous bleeding and macrothrombocytopenia, the authors prospectively evaluated children (n=29) with 22q11 deletion syndrome (22q11DS) for bleeding disorders. Key findings:
In total, 17 of 29 subjects had a positive bleeding score on ISTH-BAT (International Society on Thrombosis and Hemostasis Bleeding Assessment Tool) compared with 1 of 29 control patients (P < .0001).
The most frequent bleeding symptoms reported in subjects with 22q11DS were epistaxis (69%) and bruising (52%).
Eighteen subjects had been surgically challenged, and 6 were noted to have increased perioperative hemorrhage.
My take: While this bleeding was mainly mucocutaneous, I agree with the authors that children with 22q11DS should be screened with a validated bleeding assessment tool before surgical interventions.
In the study by Wightman et al, the researchers performed a retrospective cohort analysis of children receiving a first kidney, liver, or heart-alone transplant in the United Network for Organ Sharing dataset from 2008 to 2017. Key findings:
Definite intellectual disability accounted for 594 of 6747 (9%) first pediatric kidney-alone, 318 of 4566 (7%) first pediatric liver-alone, and 324 of 3722 (9%) first pediatric heart-alone transplant recipients.
Children with intellectual disability account for 7%-9% of pediatric transplant recipients with comparable long-term outcomes to other pediatric recipients.
The article had a number of limitations including a lack of a standardized assessment of cognitive development.
In the editorial, the author “opposes the absolute exclusion of patients with intellectual disability and end-stage organ disease from transplantation waitlists provided that the candidates are expected to gain a predefined minimum benefit threshold of life-years and quality-adjusted-life years. Intellectual disability is one of many factors that should be considered in determining transplant eligibility and each candidate should have an individualized interdisciplinary assessment.”
In this commentary, it is noted that “the vast majority (85%) of individuals classified as having intellectual disability are able to live independently with minimum levels of support.” While the author would exclude those in a persistent vegetative state and those who were minimally conscious, otherwise he advocates “the candidate with intellectual disability should be given equal priority for organ transplantation.”
My view: The suitability for transplantation of individuals with intellectual disability centers on the issue of personhood; those who meet the threshold of personhood should be eligible to receive organ transplants without discrimination. Wikipedia-Personhood: “Defining personhood is a controversial topic in philosophy and law and is closely tied with legal and political concepts of citizenship, equality, and liberty.”
This useful review explains the techniques/technologies/limitations of transient elastography and provides pediatric values which correlate with liver fibrosis. Confounding factors, however, may affect elastography measurements, such as obesity, severe inflammation, nonfasting state, and hepatic congestion.
From Table 2 for Elastography (FibroScan technology) Cut-Off Values and Correlation with Outcomes :
Biliary Atresia: >15.5 kPa distinguishes METAVIR F4 fibrosis and >12.7 kPa predicts development of varices
Any Chronic Liver disease: >10.6 kPa distinguishes METAVIR F2 fibrosis
My take: Elastography is most useful when values are at the very low and very high end. Low values provide a lot of reassurance against significant fibrosis and high values indicate a high likelihood of significant liver fibrosis.
I recently had the opportunity to hear a terrific lecture by Kathleen Hoff regarding efforts to achieve continence for children, especially those with anorectal malformations. This blog entry has abbreviated/summarized the presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.
Key points (my notes followed by screenshots of some of the slides):
Data from PARC: Red color indicates use of enemas, light brown indicates use of laxativesProducts for enemasData showing increasing use of antegrade enemas in older children and those with moderate and complex malformations
gutsandgrowth 
