Best Approach for Identifying Eosinophilic Esophagitis

Posted on July 8, 2019 by gutsandgrowth

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.

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
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.

Related blog posts:

From NASPGHAN 2014 EoE Slide Set

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

Posted on July 7, 2019 by gutsandgrowth

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

Posted on July 6, 2019 by gutsandgrowth

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.

Related blog posts:

First Year of Life Antibiotics and Celiac Disease

Posted on July 5, 2019 by gutsandgrowth

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.

Related blog posts:

Retiro Park, Glass Palace
Madrid

50th Peachtree Road Race

Posted on July 4, 2019 by gutsandgrowth

Liver Briefs -July 2019

Posted on July 4, 2019 by gutsandgrowth

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.

“Rude Surgeons May Have Worse Outcomes”

Posted on July 3, 2019 by gutsandgrowth

NPR: When Surgeons Are Abrasive To Co-Workers, Patients’ Health May Suffer

An excerpt:
A study published Wednesday in JAMA Surgery challenges these ideas. The study, which looked at interactions between surgeons and their teams, found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. Surgeons who model unprofessional behavior can undermine the performance of their teams, the authors write, potentially threatening patients’ safety.

For the study, researchers gathered data on nearly 13,700 patients and 202 surgeons from the National Surgical Quality Improvement Program, a system designed to track and improve surgical care…

The researchers found that when surgeons had one or more reports of unprofessional behavior over the previous 36 months, their patients were 12% to 14% more likely to experience complications in a 30-day period following surgery. These complications included infections, pneumonia, stroke and kidney failure.

Full text article: Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients WO Cooper et al. JAMA Surg. Published online June 19, 2019. doi:10.1001/jamasurg.2019.1738

My take: It is interesting to speculate about why rude behavior may affect long-term outcomes. My suspicion would be that team members would be more hesitant to offer advice or to call quickly if concerns arose. Alternatively, it could be that if someone is not considerate enough to work well with their colleagues/other health professionals that they could be less attentive in their care.

Improving Obesity Trend in Young Children?

Posted on July 2, 2019 by gutsandgrowth

Link (YouTube): William Meyers Inaugural Conference Lecture

Vedolizumab More Effective Than Adalimumab for Ulcerative Colitis

Posted on July 1, 2019 by gutsandgrowth

Gastroendonews: Tea Leaves No More: Biologics Head-to-Head Produces a Winner

An excerpt:

In the first head-to-head trial of biologic treatments for inflammatory bowel disease, vedolizumab (Entyvio, Takeda) was nearly 50% more effective than adalimumab (Humira, AbbVie) in inducing clinical and mucosal remission in patients with moderate to severe ulcerative colitis…

They enrolled 771 patients with moderate to severe ulcerative colitis in the VARSITY study and randomly assigned them to receive 52 weeks of treatment with either vedolizumab or adalimumab…

They had failed other conventional therapies, including 25% in each group that had received an anti–tumor necrosis factor (TNF) agent…

31.3% of vedolizumab recipients and 22.5% of those taking adalimumab were in clinical remission after 52 weeks (P=0.0061). Clinical remission was defined as a complete Mayo score of 2 or lower and no subscore greater than 1
Nearly 40% of patients who received vedolizumab achieved mucosal healing at 52 weeks, compared with 27.7% of adalimumab recipients (P=0.0005).

My take: This study provides a rationale for vedolizumab to be used as a first-line biologic agent for ulcerative colitis.

Related posts:

Is Red Meat More Likely to Cause High Cholesterol than White Meat?

Posted on June 30, 2019 by gutsandgrowth

A recent study -full text link: N Bergeron et al. Effects of red meat, white meat, and nonmeat protein sources on atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: a randomized controlled trial. The American Journal of Clinical Nutrition, nqz035, https://doi.org/10.1093/ajcn/nqz035

This study which randomized 177 patients to 4 week trials of each protein source: red meat, white meat, or non-meat protein found no significant differences in cholesterol levels.

From CNN: White meat is just as bad for you as red beef when it comes to your cholesterol level, study says

An excerpt:

The red meat or white meat debate is a draw: Eating white meat, such as poultry, will have an identical effect on your cholesterol level as eating red beef, new research indicates.

The long-held belief that eating white meat is less harmful for your heart may still hold true, because there may be other effects from eating red meat that contribute to cardiovascular disease, said the University of California, San Francisco researchers. This needs to be explored in more detail, they added.

Non-meat proteins such as vegetables, dairy, and legumes, including beans, show the best cholesterol benefit, according to the new study published Tuesday in the American Journal of Clinical Nutrition.

From Twitter -CDC Messaging on Dangers of Smoking While Pregnant: