Ethics Test for Neonatal Care Providers

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An interesting study ( CL Cummings et al. J Pediatr 2018; 199: 57-64) examined performance levels on a reliable ethics knowledge questionnaire (TEK-Neo). They found that  out of 36 questions:

  • Medical students answered 25.9 correctly
  • Neonatal nurses/practitioners answered 27.7 correctly
  • Neonatal attendings answered 28.8 correctly
  • Neonatal fellows answered 29.8 correctly
  • Clinical ethicists answered 33.0 correctly

While the overall take-home from this study is that the TEK-Neo provides a reliable gauge of neonatal ethic knowledge, I was more interested in some of the specific questions.  Here are three true-or-false questions:

  • #20. “Medically provided fluids and nutrition constitute a medical intervention that may be withheld or withdrawn for the same reasons that justify the medical withholding of other medical treatments.”
  • #21. “Parents of a critically ill 3-day old infant in the NICU born at 26 weeks on noninvasive positive pressure ventilation decline reintubation in the setting of respiratory failure and new grade 3 IVH B/L. Their informed decision to refuse further life-sustaining medical treatment ought to be respected.”
  • #24. “A 14 day-old full-term boy has sustained severe anoxia perinatally and has severe hypoxic-ischemic encephalopathy confirmed on continuous electroencephalogram by persistently low -voltage isoelectric activity. He is unresponsive to his environment. In this situation, the patient’s enteral nutrition (administered via oral gavage tube) may be ethically withdrawn.”

Though the correct answer to these three questions is true, my experience is that parents rarely are interested in withholding or withdrawing care in these type of scenarios.

 

Is it really necessary to check for Cytomegalovirus in Children with Inflammatory Bowel Disease?

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A recent retrospective study (W El-Matary et al. JPGN 2018; 67: 221-24) examined the practice of looking for Cytomegalovirus (CMV) in children with a flareup of their inflammatory bowel disease (IBD) which is currently recommended by expert consensus (JPGN 2018; 67: 292-310 –recommendation #3).

Key findings:

  • “Four of 61 patients encounters (6.6%) with UC/IBD-U, two with corticosteroid refractory disease, had positive biopsies for CMV by PCR but negative H&E and IHC.  They responded to escalated medical therapy, without needing anti-viral therapy.”
  • All children who had colectomy during the study did not have CMV detected in colonic mucosa.

The authors note that the rationale for looking for CMV is derived mainly from adult populations.  Since age is a known risk factor for CMV reactivation, the risk of CMV causing refractory IBD in children is less.

My take (borrowed in part from authors): “The low frequency of CMV in our study challenges current guidelines that recommend assessment for CMV in all pediatric patients with acute severe UC refractory to corticosteroids.”  This issue would be another that would benefit by collecting the experience of a large cohort (eg. ICN).

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

Impedance Measurements with Eosinophilic Esophagitis

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Briefly noted: MA Lowry et al. JPGN 2018; 67: 198-203.  This study showed that active eosinophilic esophagitis (EoE) was associated with much lower impedance values that inactive EoE, NERD, and controls.  At 2, 5 and 10 cm above the squamo-columnar junction, median values of impedance with active EoE were 1069, 1368, and 1707 respectively.  In comparison, inactive EoE had median values were 3663, 3657, and 4494, respectively.  My take: Since impedance was also performed during endoscopy with sedation, this does not represent a significant advance in current management.

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Long-term Use of Proton Pump Inhibitors for Eosinophilic Esophagitis

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A prospective pediatric eosinophilic esophagitis (EoE) study (C Gutierrez-Junquera et al. JPGN 2018; 67: 210-6) examines the use of proton pump inhibitors (PPIs) for long-term management for this disorder.

After diagnosis of EoE, children received esomeproazole (1 mg/kg/dose BID).  For those with a response (<15 eos/hpf), they were maintained on 1 mg/kg/day for one year.

Key findings:

  • Of the initial cohort of 109, 72 (66%) had response to esomeprazole.
  • 57 of these responders were subsequently followed in this study.  At the lower daily esomeprazole dose, 70.1% (n=40) continued with <15 eos/hpf and 29.9% (n=17) had relapse.
  • Maintaining response was more common among those who achieved an initial response (with BID esomeprazole) of <5 eos/hpf compared to those who had achieved an initial response of 6-14 eos/hpf.  At 1 year, in those with who had a more complete response, 81% maintained eosinophil count <15/hpf compared with only 50% in those with a lesser initial response.
  • Adverse events with prolonged treatment were uncommon and included self-resolving diarrhea in three, headache in one and urticaria in one; the latter two adverse effects responded to change to lansoprazole

My takes: 

  1. PPI treatment is effective in probably 40-50% of individuals with EoE (though higher response in this study)
  2. Some individuals need higher doses of PPIs
  3. Due to the high response rate, this underscores the need to diagnose EoE prior to using PPIs or after they have been discontinued.

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Why Shopping for Health Care Does Not Work and What Can Be Done About That

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From NY Times:  Shopping for Health Care Simply Doesn’t Work. So What Might? (Thanks to Ben Enav for pointing out this article)

An excerpt:

What this latest study suggests, in the context of other studies, is that if people can’t shop for elective M.R.I.s, there’s hardly a chance they are going to do so with other health care procedures that are more complicated and variable.

Even if 40 percent of health care is shoppable, people are not shopping. What seems likelier to work is doing more to influence what doctors advise.

For example, we could provide physicians with price, quality and distance information for the services they recommend. Further, with financial bonuses, we could give physicians (instead of, or in addition to, patients) some incentive to identify and suggest lower-cost care.

Leaving decisions to patients, and making them spend more of their own money, doesn’t work.

Is there a link between fitness and academic performance?

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Briefly noted:  A Muntaner-Mas et al. J Pediatr 2018; 198: 90-7.  This cross-sectional study with 250 Spanish children  (10-12 year olds) examined obesity measures, physical fitness measures and academic performance.  Key finding: “Children considered fit had better academic performance than their unfit peers…the association between body mass index and GPA was mediated by cardiorespiratory fitness and speed-agility.”  The design of this study precludes establishing this association as a causal relationship.

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U-Sniff Test

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I remember back to college chemistry when one of my professors pondered what type of person would purposely delve into sulfur-related research. Similarly, I have wondered how some of my colleagues can put their nose right in the middle of a heavy-soiled diaper and use their olfactory sense to narrow the differential diagnosis.

Now, more research involving the olfactory sense has been published: “The development of an international odor identification test for children: the Universal Sniff Test” also called the U-Sniff test (VA Schriever et al. J Pediatr 2018; 198: 265-72) and fortunately it does not involve any offensive odors.

This multicenter (19 countries) with 1760 children age 5-7 years, validated the U-sniff with twelve odors.  Key finding: The U-Sniff “enabled discrimination between normoosmia and children with congenital anosmia with a sensitivity of 100% and specificity of 86%.”

Specific odors that are part of U-Sniff: lemon, banana, coffee, flower, strawberry, fish, cut grass, orange, onion, butter, apple, peach, chocolate, tomato, cheese, biscuit, and honey.

Clostridium difficile and Inflammatory Bowel Disease

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My view is that Clostridium difficile infection (CDI) in children with inflammatory bowel disease is often overdiagnosed due to detection of a carrier state in many when tested by PCR assays and the overlapping clinical features.  This is particularly important when considering fecal microbiota transplantation (FMT) due to the potential risks of this treatment.

Recently, I had a letter to the editor (J Pediatr 2018; 199: 283) on this topic that was accepted:

The author’s reply suggested that their approach followed IDSA guidelines by checking CDI with PCR in those who were clinically-symptomatic.  Yet, the IDSA guidelines (link here: IDSA C diff guidelines) do not focus on the issue of IBD flare-ups which cause identical symptoms.  Expert IBD specialists have recommended the following for identifying CDI in patients with IBD:

“Start with enzyme immunoassay-based tests with a reflex to PCR test for discordant enzyme immunoassay results.”  Rationale: “PCR is quite sensitive for the presence of toxigenic C difficile, it may increase the detection of asymptomatic colonization and shedding.” (K Rao, PDR Higgins. Inflamm Bowel Dis 2016; 22: 1744-54.)

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Long-term Bone Health of Children with Celiac Disease

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In a recent study (C Canova et al. J Pediatr 2018; 198: 117-20) from Padua, Italy compared 1233 individuals with celiac disease to a comparison group of 6167 (from a population-based cohort of >200,000 individuals).  In this longitudinal study with a maximum followup of up to 23 years, the authors found no increase risk of fractures in youths diagnosed with celiac disease (HR of 0.87).

Findings:

  • 22 individuals had fractures compared to 128 in the reference population
  • Median age of celiac diagnosis was 6 years

Significance:

  • While celiac disease is linked to osteoporosis, “the vast majority of individuals with childhood celiac disease are likely to heal shortly after the introduction of a gluten-free diet.”

My take: Institution of a gluten-free diet for children with celiac disease likely removes the risk of osteoporosis.

Related blog posts:

  • Good News for Celiac Disease  –Gastroenterology 2010; 139: 763. 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)
  • Common to be ‘D-ficient

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Cumberland Island 2018

IBD Reviews: Role of Antibiotics and Data on Biomarkers

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A clinical review, “Antibiotics in IBD: Still a Role in the Biological Era?” (O Ledder, D Turner, Inflamm Bowel Dis 2018; 24: 1676-88).  While this article provides a detailed review of the use of antibiotics for Crohn’s (including perianal disease), Ulcerative colitis and the effects on the microbiome, the potential use for very early onset (VEO) IBD caught my attention:

“We have recently begun considering oral vancomycin and gentamicin as sole firstline therapy in the rare form of infantile (ie <2 years of age) mild to moderate IBD, with promising success…this is merely investigational” at this time.  (Ref: Lev-Tzion R et al. Digestion 2017; 95: 310-13).

My take: Antibiotics can be a helpful adjunct therapy in both Crohn’s disease and Ulcerative colitis. It is unclear what role antibiotics will have for VEO-IBD.

A recent commentary (R Khanna et al, Inflamm Bowel Dis 2018; 24: 1619-23) examines the role of biomarkers.  While much of this topic has been reviewed extensively, I found the part about calprotectin helpful.  One of the topics with discrepant data has been the negative predictive value of calprotectin for detecting inflammatory bowel disease.  The data in this review:

  • From a meta-analysis in patients with symptomatic ulcerative colitis, calprotectin had a sensitivity of 0.88 and specificity of 0.79 compared to endoscopic inflammation.  For Crohn’s disease, the respective values were 0.87 and 0.67.
  • For histologic remission in ulcerative colitis, a study found that with a threshold of 155 mcg/g, calprotectin had a sensitivity of 78% and specificity of 71%.
  • Another study suggested that values <100 mcg/g indicate quiescent disease, values 100-250 suggest possible active inflammation, and values >250 mcg/g suggest active inflammation.
  • A cross-sectional study indicated that calprotectin ≥57  mcg/g had a sensitivity of 91% and specificity of 90% to identify endoscopically-active disease (Gastroenterol 2016; 150: 96-102)

My take: Sensitivity/specificity vary greatly based on the likelihood of disease; in populations at lower risk for IBD, a calprotectin has a high level of excluding active inflammation/IBD. In populations with IBD, levels more than 250 mcg/g indicate a high likelihood of active inflammation whereas levels between 100-250 are indeterminate.

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