Does Reflux Really Worsen After Gastrostomy Placement in Children?

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A recent prospective longitudinal cohort study (J Franken et al. JPGN 2020; 70: e41-47) examined the development of gastroesophageal reflux (GER) in 50 children  who underwent gastrostomy tube (GT) placement between 2012-2014.

Key findings:

  • GER symptoms were present before and after GT placement: in 44% and 40% respectively.

Among the 25 who underwent pre- and post-operative impedance-pH analysis

  • there was not a significant change in acid exposure: 6.2% vs. 6.1%
  • there was not a significant change in reflux episodes
  • Prior to GT placement, 18 of 25 (72%) had pathologic reflux.  Afterwards, 18 of 25 (72%) had pathologic reflux –though this included 4 with new onset reflux and 4 with resolved reflux

My take: This study shows that reflux symptoms and documented reflux are commonplace in children undergoing GT placement.  Based on this limited sample size, it appears that GER does not appreciably change following GT placement.

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Island Ford, Sandy Springs

IBD Shorts March 2020

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Ustekinumab Predictor. At recent ACG meeting, PS Dulai presented data on 781 adult patients that was used to determine likelihood of ustekinumab response. Source: GIHepNews: New ustekinumab response predictor in Crohn’s called ‘brilliant’

Variable  & Points:

  • No prior anti-TNF agents:  2 points
  • No prior bowel surgery: 2 points
  • No smoking (current or prior): 1 point
  • No active fistulas: 1 point
  • Baseline albumin: >4.3    3 points, >3.9-4.3     2 points, >.3.2-3.9   0 points,     >2.5-3.2    -1 point, 2.5 or less   -3 points

Probability of Response Interpretation:

  • High if ≥5 points
  • Intermediate if 2-4 points
  • Low if 0 or 1 points

Infliximab outperformed golimumab for moderate-to-severe ulcerative colitis. S Singh et al. Clin Gastroenterol Hepatol 2020; 18: 424-31. Using data from three phase 3 trials (1793 patients), the authors found that infliximab worked more rapidly and with greater efficacy than golimumab.  At week 6, patient reported outcome of clinical remission was 50.0% and 38.9% (aOR 2.0).  After adjusting for patient variables, infliximab was superior in achieving clinical remission with aOR 3.01 (39% vs. 21%).

Increasing incidence of inflammatory bowel disease in Latin America and Caribbean. PG Kotze et al. Clin Gastroenterol Hepatol 2020; 18: 304-12. This systematic review examined incidence & prevalence of IBD over the last 30 years. In Brazil, for example, the incidence of Crohn’s disease jumped from 0.08 per 100,000 person-years in 1988 to 5.5 per 100,000 person-years in 2015.

IBD Passport Website: IBD Passport homepage. “IBD Passport is an award winning website that aims to provide comprehensive, practical and reliable information on all aspects of travelling with Crohn’s Disease or Ulcerative Colitis (Inflammatory Bowel Disease). IBD Passport is the first website to combine this information into one resource to make planning your trip easy. IBD Passport is a UK registered non-profit charity (Registered number: 1171268) with a global reach aimed to support IBD travellers of all nations and regions in the world.”

Adverse Effects of Low-Dose Methotrexate (≤20 mg/week). DH Solomon et al. Ann Intern Med. 2020. DOI: 10.7326/M19-3369. n=4786, median age 66 years. This was a secondary analyses of a double-blind, placebo-controlled, randomized trial. “With the exception of increased risk for skin cancer (HR, 2.05 [CI, 1.28 to 3.28]), the treatment groups did not differ in risk for other cancer or mucocutaneous, neuropsychiatric, or musculoskeletal AEs.” There were increased risks of gastrointestinal, infectious, pulmonary, and hematologic AE.

 

 

 

Could Immunotherapy (EPIT) Work For Eosinophilic Esophagitis? & Coronavirus Up-to-Date Tally

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A recent double-blind pilot study (n=20) (JM Spegel et al. Clin Gastroenterol Hepatol 2020; 18: 328-36) explored the use of epicutaneous immunotherapy (EPIT) in children with milk-induced eosinophilic esophagitis (EoE). 15 children received active treatment with a “Viaskin” milk allergen extract patch and 5 children received a placebo.

The premise of EPIT for EoE has been based on animal models (mouse & piglet) which have shown that epicutaneous desensitization to peanuts has been successful in preventing development of EoE.

The design of the study involved EPIT during a 9 month milk-free period followed by a milk-containing diet for 2 months.  Biopsies were taken and then there was an additional 11 month open-label phase in which all patients received EPIT.

Key findings:

  • No significant differences in mean eos/hpf in the two groups: 50 vs 48 in EPIT compared to placebo respectively.
  • There were 9 of 19 (47%) had a significant drop in eosinophil count with less than 15 eos/hpf at the end of the open-label phase.
  • Overall, adverse events were similar in both groups, though the EPIT group had more frequent GI adverse events than the placebo group (67% vs. 40%)

My take: The primary and secondary endpoints were not reached in this study.  However, based on the open-label phase response, further studies are warranted.

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Also, from Johns Hopkins: COVID19 Caseload & Outcomes Worldwide

This screenshot was taken at 2:53 pm on 3/7/20

 

NY Times: What’s Behind $urprise Billing

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NY Times: Who’s Behind Your Outrageous Medical Bills?

This article describes how “surprise bills are just the latest in a decades-long war between players in the health care industry over who gets to keep the fortunes generated each year from patient illness — $3.6 trillion in 2018.”

Key points:

  • “Forty years a go, …billed rates were far lower…and insurer mostly just paid them…That’s when a more entrepreneurial streak kicked in…If someone is paying you whatever you ask, why not ask for more?”
  • “Surprise bills are the latest tactic: when providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly.  For their part, insurers didn’t really care if those practitioners demanding more money left.”
  • Members of Congress can address this problem and “tackle the obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?”

My take: When physicians/hospitals and insurance companies are at odds, patients/families are the ones paying the price.

Related article: NY Times: My $145,000 Surprise Medical Bill What my brief glimpse into the financial abyss taught me about the American health care system.

Garden at UNC Chapel Hill

Abdominal Pain in Children Increases With Age and With Psychological Factors

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A recent study (MP Jones et al. Clin Gastroenterol Hepatol 2020; 18: 360-7) provides granular data on a well-recognized phenomenon: stomach pain is more common in older children than younger children and is associated with psychosocial factors.

Design: “All Babies in Southeast Sweden” Study with 1781 children (born 1997-99).  Families answered questionnaires at birth, 1 year, 2.5 years, 5 years, 8 years and 10-12 years.

Key findings:

  • Abdominal pain prevalence increased linearly with age -each year the rate increased .  At 2 yrs, the prevalence was ~6%, at 5 yrs ~8%, at 8 yrs ~9.5%, and at 12 yrs ~12% (Figure 2)
  • Psychosocial factors associated with abdominal pain included lower emotional control at 2 yrs of age, parental concern for child at 2 yrs of age, and measures of parental stress.

My take: This study reinforces the idea that psychosocial factors increase the development of non-organic abdominal pain.  If they could be addressed better, GI clinics would be less busy.

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Old Well, UNC Chapel Hill, Fall

Current Impact of Climate Change

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When I hear people say that the changes in climate are ‘just another weather cycle,’ I wonder if they understand the reasons why scientists are so worried.  It is not simply the historic increases in temperature.  The bigger concerns are the permanent changes in the environment that foster ongoing and worsening problems.  The atmosphere now has greenhouse gases that could take a 1000 years to dissipate even without further pollution (Related blog post: The Health Consequences of Climate Change).  This is akin to sleeping under more blankets except that in the middle of the night, when you are sweating, there is not a simple fix –no easy way to remove the greenhouse gases in the atmosphere.

A recent commentary (RN Salas. NEJM 2020; 382: 589-91) details the myriad ways that the climate crisis will affect clinical practice.

The climate crisis is a threat multiplier;  key points:

  • climate sensitive waterborne and foodborne illness
  • worsening mental health
  • heat strokes/heat-related hospitalizations
  • rising pollen levels
  • decreasing nutritional value of food
  • vector borne disease
  • trouble with medication storage (need to be stored at appropriate temperatures)
  • treatment disruptions by climate events
  • supply-chain disruptions by climate catastrophes
  • hospital power outages
  • rising temperatures could increase bacterial resistance to antibiotics

My take (borrowed from commentary): “Despite the irony, I often describe our current knowledge of the health effects of climate crisis as an iceberg.  Though we see a peak above the water’s surface, there is much to fear from the larger mass beneath –the effects that we haven’t yet identified.”

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Garden at UNC Chapel Hill Campus

“The Truth About Allergies and Food Sensitivity Tests”

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This is a link to a 20 minute video regarding “The Truth About Allergies and Food Sensitivity Tests” with Dr. Dave Stutkus and Dr. Mike Varshavski. (If trouble with link, then can find with quick search on YouTube.)

A couple of clarifications:

The video (~at the 3 minute mark) does not provide much nuance on “non-celiac gluten sensitivity” (see related blog posts below)

Some other points:

  • Don’t perform Food IgG testing -this is a memory antibody and does not reflect food allergy or sensitivity
  • So-called food sensitivity IgG tests do not have standardized normal values
  • Don’t perform broad-based IgE testing; there are many false-positives and false negative

Dr. Stutkus decided to undergone ‘food sensitivity’ tests and was reportedly sensitive to nearly 80 foods.

Related blog posts:

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

Have Nonprofit Hospitals Lost Their Mission?

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NY Times: Nonprofit Hospitals Are Too Profitable

An excerpt:

Seven of the 10 most profitable hospitals in America are nonprofit hospitals…

It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents…

The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, “No part of their net earnings is allowed to inure to the benefit of any private shareholder or individual.”) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent…

Additionally, hospitals should not be allowed to declare Medicaid “losses” as a community benefit. While it’s true that Medicaid typically pays less than private insurance companies, Medicaid plays a crucial role for private insurance markets by acting as a high-risk pool for patients with severe illness and disability…These large medical centers also enthusiastically accept taxpayer money for research…

Particularly in communities with a shortage of health care resources, tax exemption can make sense. In medically saturated areas, where profits and executive compensation approach Wall Street levels, tax exemption should raise eyebrows.

My take: This opinion piece makes a strong argument that many nonprofit hospitals do not deserve to be exempt from taxes. At a minimum, more transparency regarding tangible benefits is needed to assure that hospitals earn this exemption.

AJC: Georgia hospital disclosures show disparities, seven-figure salaries  According to the AJC, the Children’s Healthcare of Atlanta’s CEO made 1.9 million last year. By comparison, the Northside CEO made 4.9 million. Other tidbits: Piedmont’s chief philanthropy officer was compensated 1.2 million.

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“The problem with internet quotes is that you can’t always depend on their accuracy” ~Abraham Lincoln, 1864.

Working Together to Improve Outcomes for Children with Inflammatory Bowel Disease

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Recently, we had an “ImproveCareNow Population Management” meeting.  At these regular meetings, we typically review at least one topic of interest, review data on how patients are doing (eg. hospitalizations, clinical remission, surgeries, followup visits), and discuss patients who have challenging clinical problems.  Credit for making these meetings work go to Clair Talmadge, PA-C, Samantha Gomez (ICN coordinator), and Chelly Dykes (physician leader).  Also, with regards to depression screening, we are fortunate to have the support of Bonney Reed-Knight and Jessica Buzenski.

At the latest meeting, we discussed our recent implementation of depression screening, expanded definitions of clinical remission/sustained clinical remission, and family support projects.

With regard to depression screening, we are finding that ~30% had actionable screens indicating some level of depression and ~4% screened as suicidal (requiring urgent attention).

My take: Each of these meetings and the work that goes into them make tangible improvements in outcomes.

Some of the slides are shown below.

Related blog posts:

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.