CDC Warns of Cryptosporidium in Pools

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July 1, 2019: Washington Post: CDC warns swimmers about ‘Crypto,’ a parasite that can live for days in pools

An excerpt:

The Centers for Disease Control and Prevention published a report last week about the increased number of outbreaks caused by the fecal parasite Cryptosporidium, more commonly known as “Crypto.”…

The warning came from the CDC’s recent Morbidity and Mortality Weekly Report, which highlighted an average 13 percent increase in cryptosporidiosis outbreaks each year from 2009 to 2017.

The CDC said that over the past decade, there have been more than 400 reported outbreaks in the United States, leading to nearly 7,500 people becoming sick. Of those, more than 200 people were hospitalized, and one person died as a result of the disease, according to the report…

In about 35 percent of the outbreaks, sicknesses were linked to swimming pools and playgrounds, according to the report.

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Bear and the Strawberry Tree, Puerta del Sol, Madrid

Vitamin D Supplementation Did Not Improve Postsurgical Outcomes in Patients with Crohn’s Disease

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Link from Kipp Ellsworth Twitter Feed: Healio Gastro: Vitamin D does not prevent Crohn’s recurrence after resection

Re: Duijvestein M, et al. Abstract 144. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.

Background: “Researchers conducted a placebo-controlled trial comprising 143 patients with CD to assess the potential anti-inflammatory effects of vitamin D. Patients were randomly assigned to receive either 25,000 International Units of vitamin D3 (n = 72) or placebo (n = 71) weekly for 6 months after their first or second ileocolonic resection.”

Key Finding: “While serum vitamin D levels increased in the vitamin D group and remained unchanged in the placebo group, investigators found no difference in the incidence or severity of endoscopic recurrence at week 26 between the two groups. Cumulative clinical recurrence rates at week 26 were also comparable.”

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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

Madrid view from Círculo de Bellas Artes

 

 

IBD Articles -Briefly Noted

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A Dige et al. Gastroenterol 2019; 156: 2208-16. This study evaluated the efficacy of freshly collected autologous adipose tissue injection for healing of perianal fistulas in Crohn’s disease.  The overall healing rate was 57% and the treatment had a good safety profile.

HK Somineni et al. Gastroenterol 2019; 156: 2254-65. The researchers found that DNA methylation patterns (from ~850,000 sites) in blood samples from pediatric patients with Crohn’s disease  (n=164) were associated with inflammation and resolved with treatment of inflammation; thus, the changes in DNA methylation are less likely to be a causative agent in disease development or progression and more likely a biomarker of inflammation.

OB Kelly et al. Inflamm Bowel Dis 2019; 25: 1066-71. Among 316 patients who underwent A/P CT scan for any reason, 49 (16%) had evidence of sacroilitis, indicating this is underdiagnosed in patients with IBD.

BG Feagan et al. Inflamm Bowel Dis 2019; 25: 1028-35. In a post hoc analysis of GEMINI 1 trial (n=769 patients: 149 placebo, 620 vedolizumab), a randomized placebo-controlled trial of vedolizumab for ulcerative coliis, compared to placebo ~40% more patients receiving a full induction of vedolizumab had a sustained clinical remission after 52 weeks of therapy.  Of patients in clinical remission at week 14, 66.5% achieved a sustained clinical remission at week 52 compared with 267% of placebo-treated patients based on partial Mayo score..  Sustained clinical remission was based on partial Mayo score and rectal bleeding subscore..

PPIs: Good News on Safety

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When someone gets bitten by a shark, it often makes the news.  Yet, the frequency of shark attacks is rare and it is probably much more dangerous driving to the beach than getting into the water.

For proton pump inhibitors, it seems that they get similar press coverage as shark bites.  Many times potential adverse effects are covered heavily by the media even though many of these effects are unproven or very infrequent.

A recent study (“Safety of Proton Pump Inhibitors Based on a Large, Multi-year, Randomized Trial of Patients Receiving Rivaroxaban or Aspirin” Moayyedi, Paul et al. Gastroenterology DOI: https://doi.org/10.1053/j.gastro.2019.05.056) shows that 3 years of pantoprazole had an excellent safety profile.

Here is the abstract:

Background & Aims

Proton pump inhibitors (PPIs) are effective at treating acid-related disorders. These drugs are well tolerated in the short term, but long-term treatment was associated with adverse events in observational studies. We aimed to confirm these findings in an adequately powered randomized trial.

Methods

We performed a 3×2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease randomly assigned to groups given pantoprazole (40 mg daily, n=8791) or placebo (n=8807). Participants were also randomly assigned to groups that received rivaroxaban (2.5 mg twice daily) with aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg) alone. We collected data on development of pneumonia, Clostridium difficile infection, other enteric infections, fractures, gastric atrophy, chronic kidney disease, diabetes, chronic obstructive lung disease, dementia, cardiovascular disease, cancer, hospitalizations, and all-cause mortality every 6 months. Patients were followed up for a median of 3.01 years, with 53,152 patient years of follow up.

Results

There was no statistically significant difference between the pantoprazole and placebo groups in safety events except for enteric infections (1.4% vs 1.0% in the placebo group; odds ratio, 1.33; 95% CI, 1.01–1.75). For all other safety outcomes, proportions were similar between groups except for C difficile infection, which was approximately twice as common in the pantoprazole vs the placebo group, although there were only 13 events, so this difference was not statistically significant.

Conclusions

In a large placebo-controlled randomized trial, we found that pantoprazole is not associated with any adverse event when used for 3 years, with the possible exception of an increased risk of enteric infections. Clinicaltrials.gov identifier: NCT01776424 (https://clinicaltrials.gov/ct2/show/NCT01776424)

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Madrid view from Círculo de Bellas Artes

Best Approach for Identifying Eosinophilic Esophagitis

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A recent study (K Radicic, RF Stokes. Clin Gastroenterol Hepatol 2019; 1408-9) indicated that taking biopsies from three esophageal areas (proximal, mid, and distal)  improved the likelihood of identifying eosinophilic esophagitis (EoE).

Key findings:

  • In their study, among 96 patients with EoE, 55.2% were positive (>15 eos/hpf) in only 1 of the 3 levels.
  • 17 patients (17.7%) were positive in the mid-esophagus alone, and 6 patients (6.3%) were positive in the proximal esophagus alone.

The authors state that a 2-level biopsy protocol missed the diagnosis of EoE in roughly 1 of 5 patients.

My take: This study is provocative. However, the reasons why 3 levels improved their yield could be related to other factors rather than location.

  1. Prior studies have shown higher yield when taking 5 or 6 biopsies rather than fewer biopsies; thus, the location of biopsies may not be as important as the number of specimens
  2. Prior studies have shown that having another pathologist review the slides can increase the yield by ~20%; this indicates that careful review of specimens by itself is helpful.  Perhaps, more specimen containers will increase the time that a pathologist reviews the biopsies.

My view is that if adequate numbers of biopsies are taken from several locations, a single jar for all the specimens should suffice (& reduce costs) –though a formal study could be beneficial to confirm this.

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From NASPGHAN 2014 EoE Slide Set

Is It Worse to Be Sitting at Work or Sitting at Home?

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A recent report indicates that sitting at home is more problematic for health than sitting at work and may be bad news for the manufacturer’s of standing desks.

Time: This Type of Sitting is the Worst for Your Health

Background: For the study, [published in the Journal of the American Heart Association: JM Garcia et al. Full text link Types of Sedentary Behavior and Risk of Cardiovascular Events and Mortality in Blacks: The Jackson Heart Study. https://doi.org/10.1161/JAHA.118.010406] “almost 3,600 African American adults reported the amount of time they’d spent sitting at work, watching television and exercising over the previous year. They also provided demographic, lifestyle and health-history information. The researchers monitored the participants’ health over eight years, during which 129 had a cardiovascular issue and 205 died.”

Key findings:

  • “After adjusting for health and lifestyle factors, the researchers found that “often or always” sitting at work was not associated with a heightened risk of death and heart disease”
  • “But those watching four or more hours of television per day had a 50% higher risk of heart issues and death, compared to those watching two hours or less per day.”
  • From Today: Sitting while watching TV, but not sitting at work, linked with higher health risk: “The health risk of watching lots of TV vanished when people spent 150 minutes or more per week doing moderate-to-vigorous exercise— like brisk walking, running, swimming and cycling.”

Commentary from Time report:

  • “People who spend a good chunk of their free time watching television likely do so at the expense of exercising.”
  • “Vegging in front of the TV may also inspire other unhealthy habits” –like snacking, consuming alcohol, and disrupting sleep patterns.

My take: This study suggests that sitting a lot at work is mainly a problem only for those who sit a lot when they leave work.

Retiro Park, Madrid

 

Rising ER Costs & Changes in Billling Codes

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USAToday: ‘Really astonishing’: Average cost of hospital ER visit surges 176% in a decade, report says

An excerpt:

The average emergency room visit cost $1,389 in 2017, up 176% over the decade. That is the cost of entry for emergency care; it does not include extra charges such as blood tests, IVs, drugs or other treatments…

In 2008, 17% of hospital visits were charged the most expensive code. That surged to 27% of visits in 2017, the report said. The average price for the most expensive code more than doubled from $754 in 2008 to $1,895 in 2017.

Hospitals also increased billings for the second most expensive code, but they billed the three least expensive codes less often compared to a decade ago.

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First Year of Life Antibiotics and Celiac Disease

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Briefly noted:

A recent study (SD Sander et al. Gastroenterol 2019; 156: 2217-29) found an association between antibiotics in the first year of life and celiac disease.

The authors “collected medical information on 1.7 million children, including 3346 with a diagnosis of celiac disease” using nationwide register-based cohorts from Norway and Denmark.

Key finding:

  • “Exposure to systematic antibiotics in the first year of life was positively associated with diagnosed celiac disease,” pooled odds ratio 1.26.  Furthermore, there was a dose-dependent relationship with increasing number of exposures increasing the risk of celiac disease.

My take: The increase in prevalence of celiac disease over that past few decades is likely related to changes in our environment.  These changes affect nearly everyone, but some are more susceptible to immune-related disease that may be triggered by these environmental changes.  This study shows that early exposure to antibiotics is likely to be one of the environmental factors that increase the risk of celiac disease.

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Retiro Park, Glass Palace
Madrid

Liver Briefs -July 2019

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NH Ebel et al. JPGN 2019; 68: 788-92.  Hepatic venous pressure gradient (HVPG) did not correlate with the risk of complications from portal hypertension in this pediatric cohort (n=41); this is in contrast to studies in adults showing the utility of HVPG measurements.

AG Singal et al. Gastroenterol 2019; 156: 2149-57. AGA Practice Update on Direct-Acting Antivirals for Hepatitis C and Hepatocellular Carcinoma. There are 12 best practice advice –here are the first three:

  • BEST PRACTICE ADVICE 1: DAA treatment is associated with a reduction in the risk of incident HCC. The relative risk reduction is similar in patients with and without cirrhosis.
  • BEST PRACTICE ADVICE 2: Patients with advanced liver fibrosis (F3) or cirrhosis should receive surveillance imaging before initiating DAA treatment.
  • BEST PRACTICE ADVICE 3: Patients with advanced liver fibrosis (F3) or cirrhosis at the time of DAA treatment represent the highest-risk group for HCC after DAA-induced sustained virologic response. These patients should stay in HCC surveillance

N Hamdane et al. Gastroenterol 2019; 156: 2313-29. This study found that chronic HCV infection induced specific genome-wide-changes in H3K27ac which correlated with expression of mRNAs and proteins.  These epigenetic changes persisted after an SVR to DAAs or interferon-based therapies. These changes could explain some of the reason why HCC remains a risk after successful treatment with DAAs.

DT Dieterich et al. Gastroenteroloy & Hepatology 2019; 15S: 3-11 Link: “A simplified algorithm for the management of Hepatitis C Infection”  An excerpt:

“The algorithm begins with universal HCV screening and diagnosis by testing for HCV antibody with reflex to polymerase chain reaction to detect HCV RNA. The pretreatment evaluation uses platelet-based stratification to initially assess fibrosis, and the pan-genotypic regimens glecaprevir/pibrentasvir or sofosbuvir/velpatasvir are recommended for treatment. Unless clinically indicated, on-treatment monitoring is optional. Confirmation of cure (undetectable HCV RNA 12 weeks posttreatment) is followed by harm-reduction measures, as well as surveillance for hepatocellular carcinoma every 6 months in patients with advanced fibrosis/cirrhosis.”  My take: This algorithm is much simpler than the expanded recommendations from HCVguidelines.org website, though these agents, to my knowledge, do not yet have a pediatric indication.