“For the Moderna study, researchers looked at blood samples taken from eight people who had received the recommended two doses of the Moderna vaccine. The findings are yet to be peer reviewed, but suggest immunity from the vaccine recognises the new variants. Neutralising antibodies, made by the body’s immune system, stop the virus from entering cells.
Blood samples exposed to the new variants appeared to have sufficient antibodies to achieve this neutralising effect, although it was not as strong for the South Africa variant as for the UK one. Moderna says this could mean that protection against the South Africa variant might disappear more quickly.”
Transabdominal ultrasound is recommended as a first-line noninvasive imaging modality for suspected AP
If ultrasound is negative for AP and an imaging diagnosis of AP is needed, either CT or MRI is recommended
“MRI, particularly MRCP, has also been shown to be more sensitive than CT for biliary etiologies of pancreatitis”
“In clinical practice, MRI is often used for assessment and monitoring of late complications of AP, such as fluid collections, to time and guide therapeutic interventions.”
Acute Recurrent Pancreatitis:
MRI is recommended to identify structural or obstructive causes for ARP
Chronic Pancreatitis:
MRI is the recommended modality for imaging of suspected CP
When imaging is needed to assess a suspected or known episode of AP in a child with CP, transabdominal ultrasound is the preferred first-line imaging modality
My take: This report provides a great deal of detail regarding the imaging modalities, terminology and diagnostic considerations for pediatric pancreatitis.
Table 1 provides a summary of the recommendations and indicates a threshold for which routine pre-procedure testing may not be needed:
“For endoscopy centers where the prevalence of asymptomatic SARS-CoV-2 infection is low (<0.5%), the AGA suggests against implementing a pretesting strategy.”
Conditional recommendation, very low certainty evidence
Rationale: “In low-prevalence settings, a pretesting strategy may not be informative for triage due to the high number of false positives, thus PPE availability may drive decision-making.”
My take: Particularly after the rollout of vaccination to health care providers, routine testing for SARS-CoV-2 is not likely to be needed once the prevalence drops to low levels.
The authors investigated the effects of tumor necrosis factor superfamily member 14 (TNFSF14, also called LIGHT) on fibroblasts in EoE.
Key findings:
LIGHT was up-regulated in the esophageal tissues from patients with EoE, compared with control individuals
Stimulation of esophageal fibroblasts with LIGHT induced inflammatory gene transcription
My take: The authors show that patients with EoE had proinflammatory fibroblasts in the epithelium. Further, they show that eosinophil-fibroblast interaction was dependent on intact LIGHT signaling.
Yesterday, Evan Anderson (infectious disease) shared some updates on COVID-19 vaccines.
Dr. Anderson noted that more research is needed in children, pregnant women and immunocompromised populations. Immunocompromised patients may have a lower response rate to vaccination.
The South African 501Y.V2 COVID-19 variant may be less responsive to neutralization from donor plasma and the vaccines may be less effective in this variant.
He reviewed ACIP recommendations -available from CDC website as well
Dr. Anderson noted there is a good response to vaccination even in those with a lack of adverse effects with vaccination
Immunity after vaccination: data has been published showing good antibody levels at 3 months. Moderna has stated that they expect vaccine will provide immunity for at least a year
Immunity after infection with COVID-19: at least 3 months. Those with milder infection are more likely to get reinfected.
Antibody testing after vaccination to assess for immunity is not recommended
In the article, they note “the exception is for any live-attenuated virus vaccines or replication-competent viral vector vaccines that come to market.” Currently, all of the vaccines are inactivated (not live-attenuated).
These recommendations apply to approved populations which currently do not include pediatric patients or patients who are pregnant.
As noted in previous posts, I tend to favor isotonic IV fluids due to risk of hyponatremia with hypotonic fluids. A new study (below) indicates that some isotonic fluids are associated with an increased risk of electrolyte disturbances. Thanks to Ben Gold for this reference.
In this unblinded, randomized clinical trial with 614 children, participants were randomized to receive commercially available plasmalike isotonic fluid therapy (140 mmol/L of sodium and 5 mmol/L potassium in 5% dextrose) or moderately hypotonic fluid therapy (80 mmol/L sodium and 20 mmol/L potassium in 5% dextrose).
Key findings:
Clinically significant electrolyte disorder was more common in children receiving plasmalike isotonic fluid therapy:
Hypokalemia developed in 57 patients (19%) and hypernatremia developed in 4 patients (1.3%) receiving isotonic fluids; in total, this group had 61 of 308 patients [20%]) with electrolyte disturbance, compared with 9 of 306 patients [2.9%] of those receiving hypotonic fluid therapy (P < .001)
“Severe” hypokalemia (<3.0 mmol/L) was significantly more common in patients receiving isotonic fluid therapy 8 of 308 patients (2.6%) compared with 1 of 306 patients ( 0.3%) patients receiving hypotonic fluid therapy
My take: In the U.S., this suggests that fluids like lactated ringer’s which also has a low amount of potassium should not be routinely used. When choosing an isotonic fluid in children, D5 Normal Saline (0.9%) with added potassium may be more suitable..
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. 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 recent commentary (JM Perrin et al. NEJM 2020; 383: 2595-2598. Medicaid and Child Health Equity) describes what is happening with Medicaid and the Children’s Health Insurance Program (CHIP).
Key points:
Over the past 20 years, the proportion of pediatric health care coverage provided by Medicaid and CHIP has been increasing. In 1997, these programs represented about 15% of health care coverage compared to ~35% in 2018. This corresponds to reductions in employer-provided coverage
Unlike private insurance, Medicaid is always available as it doesn’t have fixed enrollment periods
State funding of Medicaid creates challenges. “States have routinely used strategies for limiting enrollment”
“Medicaid’s low physician payment rates, which average about two-thirds of rates paid by Medicare for the same services, depress physician participation…Lack of access to specialists poses additional problems in many communities”
The authors recommend the following:
Medicaid should be expanded to cover all children from birth through 21 years of age
The federal government should assume full financial responsibility
Medicaid payments should parallel national Medicare standards
Beginning at 1 year after a diagnosis of CD, 29 patients (0.06%) received a diagnosis of small bowel adenocarcinoma vs 45 reference individuals (0.02%).
HRs were small bowel adenocarcinoma 3.05, carcinoids 0.59, and adenomas 5.73.).
Overall, there was 1 extra case of small bowel adenocarcinoma in every 2944 patients with CD followed for 10 years.
There was an inverse association between mucosal healing risk of future small bowel adenocarcinoma (HR, 0.18; 95% CI, 0.02–1.61), although the HR failed to attain statistical significance.
It is important to note that lymphoma is much more common malignancy than adenocarcinoma in celiacdisease. The authors, in their discussion, state: “compared with lymphomas, small bowel adenocarcinomas were approximately 10 times less common in patients with CD.” At the same time, with the discovery of milder cases of Celiac disease, lymphoma risk is not nearly as high as previously suggested. A large cohort study (Clinical Gastroenterology and Hepatology 2012; 10: 30-36) of ~45,000 did not see an increased risk of GI cancers beyond the first year after diagnosis. In addition, another study (Gastroenterology 2010; 139: 763), found that mortality NOT worsened in undiagnosed celiac disease (identified by review of serology) in Olmstead County, though bone density decreased. n=129 of 16,847. (?milder cases undiagnosed). Related post: Good News For Celiac Disease
My take (mostly borrowed from authors): There is a tiny increase in risk of “small bowel adenomas and adenocarcinomas in patients with diagnosed CD, but only a very marginal increase in terms of absolute risk. Our results do not imply a need for surveillance but celiac individuals with signs or symptoms of malignancy should merit further investigation for small bowel adenocarcinoma. Mucosal healing was strongly associated with lower risk of small bowel adenocarcinoma, although the association failed to reach statistical significance.’ Lymphoma is a more common malignancy associated with CD but the absolute risk remains low.
gutsandgrowth 