Mediterranean Diet vs Specific Carbohydrate Diet for Crohn’s Disease

Posted on June 7, 2021 by gutsandgrowth

It appears that the Mediterranean diet works as well as the specific carbohydrate diet for adults with Crohn’s disease.

A Randomized Trial Comparing the Specific Carbohydrate Diet to a Mediterranean Diet in Adults with Crohn’s Disease (in press -thanks to Kipp Ellsworth for this reference) JD Lewis et al. Gastroenterol 2021; https://doi.org/10.1053/j.gastro.2021.05.047

Abstract:

Background & Aims

This study compared the effectiveness of the Specific Carbohydrate Diet (SCD) to the Mediterranean Diet (MD) as treatment for Crohn’s disease (CD) with mild to moderate symptoms.

Methods

Adult patients with CD and with mild-moderate symptoms were randomly assigned 1:1 to consume the MD or SCD for 12 weeks. For the first 6-weeks, participants received prepared meals and snacks according to their assigned diet. After 6-weeks, participants were instructed to follow the diet independently. The primary outcome was symptomatic remission at week 6. Key secondary outcomes at week 6 included: fecal calprotectin (FC) response (FC <250 μg/g and reduction by >50% among those with baseline FC >250 μg/g) and C-Reactive Protein (CRP) response (high-sensitivity CRP (hsCRP) <5 mg/L and >50% reduction from baseline among those with hsCRP >5mg/L).

Results

194 patients were randomized, and 191 were included in the efficacy analyses. The percentage of participants who achieved symptomatic remission at week 6 was not superior with SCD (SCD 46.5%, MD 43.5%; P = .77). FC response was achieved in 8/23 participants (34.8%) with SCD and 4/13 participants (30.8%) with MD (P = .83). CRP response was achieved in 2/37 participants (5.4%) with SCD and 1/28 participant (3.6%) with MD (P = .68).

Conclusions

SCD was not superior to MD to achieve symptomatic remission, FC response and CRP response. CRP response was uncommon. Given these results, the greater ease of following the MD, and other health benefits associated with MD, the MD may be preferred to the SCD for most patients with CD with mild to moderate symptoms.

Related blog post:

Trial by Diet Approach for Crohn’s disease in children (this blog post has link to 16 other dietary therapy posts)

“Enteral Ventilation via Anus”

Posted on June 6, 2021 by gutsandgrowth

A good Sunday read: Full text: Mammalian enteral ventilation ameliorates respiratory failure (R Okabe et al. Med (2021), https://doi.org/10.1016/j.medj.2021.04.004) -thanks to a friend for forwarding the study.

Background: Several aquatic organisms such as loaches have evolved unique intestinal breathing mechanisms to survive under extensive hypoxia. Scientists hope that the approach could one day be used to treat people with low oxygen, without risking the lung damage that can be caused by mechanical ventilators. To date, it is highly controversial whether such capability can be adapted in mammalian species as another site for gas exchange. This study reports the advent of the intestinal breathing phenomenon in mammalians by exploiting EVA (enteral ventilation via anus).

This study showed that administration of oxygen-rich perfluorochemical liquid via the rectum could “increase oxygenation in several mammals including pigs. The level of arterial oxygenation, if scaled for human application, is likely sufficient to alleviate patients with severe respiratory failure. The administration of 200–400 mL PFD to pigs weighing 10–20 kg improved PaO₂ by 13 mm Hg (from 57.2 ± 13.5 to 70.8 ± 6.22 mm Hg) and SaO₂ by 7% (from 84% to 91%).”

NY Times review of this study: Breathing Through the Rectum Saves Oxygen-Starved Mice and Pigs

My take: It is good that this study was not published on April 1st! Perhaps, if this advances, this will be more work for our aerodigestive team.

Graphical Abstract Figure from Mark Pochapin Twitter Feed

Genetic Diagnostic Tools for Cholestasis

Posted on June 5, 2021 by gutsandgrowth

Several articles in a recent JPGN (May issue) delve into the topic of using genetic tools for the diagnosis of cholestatic conditions. The most important, in my view, of these articles is JPGN 2021; 72: 654-660. (Use of a Comprehensive 66-Gene Cholestasis Sequencing Panel in 2171 Cholestatic Infants, Children, and Young Adults); congratulations to the lead author, my colleague Saul Karpen.

Key findings:

Between February 2016 and December 2017, 2171 results were reported. Median turnaround time was 21 days.
583 pathogenic (P) variants, 79 likely pathogenic (LP) variants, and 3117 VOUS; 166 P/LP variants and 415 VOUS were novel.
The panel’s overall diagnostic yield was 12% (n = 265/2171) representing 32 genes with mutations identified (the panel tested up to 66 genes).
The top five genetic diagnoses for the group, in order: JAG1 + NOTCH2 (Alagille syndrome), ABCB11, SERPINA1, ABCB4, and POLG. (Table 3 lists all of the findings)

Other reports in the same issue describe a normal-GGT cholestasis due to USP53 deficiency

LN Bull et al. JPGN 2021; 72: 667-73. Cholestasis Due to USP53 Deficiency,
G Porta et al JPGN 2021; 72: 674-676. Progressive Familial Intrahepatic Cholestasis Associated With USP53 Gene Mutation in a Brazilian Child
An associated editorial by RH Squires et al. Progressive Familial Intrahepatic Cholestasis: Is It Time to Transition to Genetic Cholestasis?

My take: Genetic cholestasis panels and/or whole exome sequencing are very useful and are being incorporated earlier into diagnostic workups.

Related blog posts:

ACG Clostridium Difficile Guidelines Plus One

Posted on June 4, 2021 by gutsandgrowth

CR Kelly et al. Am J Gastroenterol 2021;00:1–24. https://doi.org/10.14309/ajg.0000000000001278; published online May 18, 2021. Full text PDF: ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

Key points:

Guideline recommends AGAINST using probiotics for prevention of C difficile infection (CDI)
Guideline cautions AGAINST testing individuals at low risk for CDI (eg. not having diarrhea)
Guideline recommends either vancomycin or fidaxomicin (lower CDI recurrence) for all cases of CDI and consideration of metronidazole for nonsevere cases. Fidaxomicin is recommended for CDI recurrence after vancomycin or metronidazole.
Guideline recommends combination of highly sensitive test and highly specific test for diagnosis of CDI. “CDI-related complications are rare in NAAT-positive, toxin EIA-negative patients, who, even when untreated, may have clinical courses similar to those without CDI…If both are positive, the diagnosis of CDI can be made reliably. If both are negative, CDI is unlikely. Discordant results when NAAT or GDH is positive and toxin EIA is negative require clinical evaluation and consideration of the possibility of colonization or that the patient has CDI but toxin levels are below the limits of detection (see below).

Related blog posts:

Also, I recommend this article in the NY Times about a liver/intestinal transplant surgeon (who has taken care of some of our patients): ‘I Had Never Faced the Reality of Death’: A Surgeon Becomes a Patient

Magnet Safety

Posted on June 3, 2021 by gutsandgrowth

Some screenshots from a recent (5/19/21) ‘tweetorial’ on Magnet Safety:

More information on this topic from a previous Bowel Sounds Podcast with Bryan Rudolph (June 2020)

Also there’s a GIF (from Bryan Rudolph’s twitter feed):

https://twitter.com/USCPSC/status/1398286842718474244

Related blog posts:

Preventing Fistulas and Improving Radiologic Remission with Infliximab

Posted on June 2, 2021 by gutsandgrowth

Two recent studies show how infliximab improves outcomes in Crohn’s disease.

P Bossuyt et al. Clin Gastroenterol Hepatol 2021; 19: 947-954. Infliximab Exposure Associates With Radiologic Evidence of Healing in Patients With Crohn’s Disease
AAM Singer et al. Clin Gastroenterol Hepatol 2021; 19: 1071-1073. Factors Associated With Development of Perianal Fistulas in Pediatric Patients With Crohn’s Disease (see previous blog: Early Treatment with Anti-TNFs and Development of Perianal Fistulas)

The first study by Bossuyt et al was a substudy (n=36) of the TAILORIX trial. Key findings:

At week 54 of treatment, 36.4% of patients had a radiologic response, 30.3% of patients were in remission, and 71% had endoscopic features of remission
Radiologic remission correlated with infliximab trough level at week 14 (P = .049) when the infliximab trough level cut-off value was set at 7.8 μg/mL (area under the curve, 0.74; 75% sensitivity; 86% specificity; 90% negative predictive value; 57% positive predictive value)
Radiologic response was also associated with continuous infliximab trough levels above 5.0 μg/mL at all time points) (P = .034)
Among patients with both radiologic and endoscopic remission, the median infliximab trough level was 8.5
In this study, one interesting finding was that only half of patients with endoscopic remission achieved radiologic remission, especially since the cohort had a short disease duration at the onset of treatment (median duration of 1.5 months)

In the second study by Singer et al with 208 pediatric patients with Crohn’s disease, all patients had baseline cross-sectional imaging. Key findings:

26% had perianal fistulas at baseline
14/136 (10%) developed perianal fistulas within 3 years
Non-white race increased the risk of perianal fistula
Non-penetrating perianal lesions (NPLs) increased the risk of perianal fistulas (20% in patients with NPLs vs. 4% in those without NPLs)
Anti-TNF treatment was associated with a decreased risk of perianal fistulas (HR 0.11); this risk reduction was seen in patients with NPLs also (HR =0.14)

My take: Good infliximab levels correlate with better outcomes.

Related blog posts:

And from The Onion:

Acute Viral Hepatitis in Spain

Posted on June 1, 2021 by gutsandgrowth

J Llaneras et al. Clin Gastroenterol Hepatol 2021; 19: 1030-37. Etiologies and Features of Acute Viral Hepatitis in Spain

This prospective study of adults collected data from an emergency room of an academic hospital in Barcelona (2014-2018).

Key findings:

The most common etiologies of acute hepatitis were HBV infection (28%), HEV infection (18%), HCV infection (17%), and HAV infection (14%)
Approximately one-third of acute hepatitis cases were in immigrants
The main risk factors of the cohort were sexual risk contact and intravenous drug use; 79% of cases of HAV had sexual risk behavior
Chronic infections developed in 5/28 patients (18%) with acute HBV infection and 7/17 patients (41%) with acute HCV infection

The graphical abstract breaks down features for the most common etiologies:
HBV (blue) 28%, HEV (purple-pink) 18%, HCV (maroon) 17%, and HAV (light green) 14%.

Prospective Pediatric Study of the Persistence and Progression of Recurrent Abdominal Pain

Posted on May 31, 2021 by gutsandgrowth

J Sjolund et al. Clin Gastroenterol Hepatol 2021; 19: 930-938. Prevalence and Progression of Recurrent Abdominal Pain, From Early Childhood to Adolescence

Using a prospective, population-based Swedish cohort (1994-1996) (BAMSE project), the authors analyzed data from 2455 children with complete follow-up evaluation at ages 1, 2, 12, and 16 years.

Key findings:

RAP was reported by 26.2% of children on at least 1 of 3 assessment points, of which 11.3% reported symptoms more than once
Children with RAP at 12 years had persistent symptoms at 16 years in 45% of cases and increased risks for RAP (relative risk, 2.2; 95% CI, 1.7–2.8), any AP-FGID (relative risk, 2.6; 95% CI, 1.9–3.6), and IBS (relative risk, 3.2; 95% CI, 2.0–5.1) at 16 years
Figure 3 summarizes the overlap of RAP at different time points:
**In early childhood (1-2 years of age), 149 (6%) had RAP per parental reports. Only 27 in this group, had RAP noted at 16 years of age which accounted for 7% of the total 16 year old cohort with RAP
**At 12 years of age, 98 (4%) had RAP. 44 (45%) of this group continued with pain at 16 years which accounted for 11% of the total 16 year old cohort with RAP

My take: Most children (84%) with RAP at 16 years of age did NOT report RAP at younger ages; however, in children with RAP at 12 years of age, 45% continued to have RAP at 16 years of age.

Related blog posts:

This and That: Ear Tubes and Addiction Medicine

Posted on May 30, 2021 by gutsandgrowth

Interesting articles from recent NEJM:

A Hoberman et al. NEJM 2021; 384: 1789-99. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media

A quick read of this article suggested very bad news for our ENT colleagues. In this prospective, randomized trial (n=250), the authors did not find a significant advantage of tympanostomy tubes over medical management of acute otitis media (OM) among 6-35 month olds with recurrent OM in an intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P=0.66).

In an associated editorial (pg 1859-60), (Ellen Wald notes that only 55% of children in the medical management group were actually treated medically throughout the trial making the sample size too small. Her advice: “In a child older than 2 years of age, we can forecast that infections will be fewer in the coming year and that medical treatment should be continued. In the younger child, there is a nearly 50% likelihood that the frequency of infections will continue; the child is likely to have fewer and less severe episodes of acute otitis media with less exposure to antibiotics if tympanostomy-tube placement is undertaken.”

Time to first recurrent episode of acute otitis media (Figure 2). Cumulative percentage of children with recurrent OM with one minus Kaplan-Meier survival estimates according to trial group.

E Poorman. NEJM 2021; 384: 1783-1784. The Number Needed to Prescribe — What Would It Take to Expand Access to Buprenorphine?

This article describes how many physicians are reluctant to treat opioid use disorder. The author notes that “prescribing buprenorphine is one of the most effective ways to save a life. In one study, buprenorphine treatment was associated with a 37% reduction in all-cause mortality during the year after a nonfatal overdose. This reduction is larger than the reduction in mortality associated with any blood-pressure medication, diabetic agent, or statin….But much…will depend on physicians believing that people with a substance use disorder aren’t just “addicts” but are people with a chronic medical disease that we can and should treat.”