Clinical Evaluation Not Sensitive for Aspiration

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A recent retrospective study (in press): abstract link: Presenting Signs and Symptoms do not Predict Aspiration Risk in Children DR Duncan et al. J Pediatr 2018;  https://doi.org/10.1016/j.jpeds.2018.05.030

From Boston Children’s Hospital Notes (9/12/18):

  • More than 80 percent of aspiration was silent
  • Rosen, Duncan and colleagues also found that observed feedings, even by very skilled clinicians, are not sensitive enough to diagnose aspiration in children because of the high rates of silent aspiration. Based on statistical analyses, the degree of agreement between observed feeding and the VFSS was poor for the diagnosis of aspiration.
  • Almost a third of the patients experienced symptoms during or after meals, which may help explain why physicians frequently misdiagnose oropharyngeal dysphagia with aspiration as gastroesophageal reflux disease (GERD).

Full abstract:

Objectives

To determine if any presenting symptoms are associated with aspiration risk, and to evaluate the reliability of clinical feeding evaluation (CFE) in diagnosing aspiration compared with videofluoroscopic swallow study (VFSS).

Study design

We retrospectively reviewed records of children under 2 years of age who had evaluation for oropharyngeal dysphagia by CFE and VFSS at Boston Children’s Hospital and compared presenting symptoms, symptom timing, and CFE and VFSS results. We investigated the relationship between symptom presence and aspiration using the Fisher exact test and stepwise logistic regression with adjustment for comorbidities. CFE and VFSS results were compared using the McNemar test. Intervals from CFE to VFSS were compared using the Student ttest.

Results

A total of 412 subjects with mean (±SD) age 8.9 ± 6.9 months were evaluated. No symptom, including timing relative to meals, predicted aspiration on VFSS. This lack of association between symptoms and VFSS results persisted even in the adjusted multivariate model. The sensitivity of CFE for predicting aspiration by VFSS was 44%. Patients with a reassuring CFE waited 28.2 ± 8.5 days longer for confirmatory VFSS compared with those with a concerning CFE (P < .05).

Conclusions

Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE does not have the sensitivity to consistently diagnose aspiration so a VFSS should be performed in persistently symptomatic patients.

My take: This study provides more data indicating that clinical evaluations are not reliable in children less than 2 years of age to exclude formal swallow study evaluations and that some symptoms attributed to reflux are in fact due to aspiration.

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Fecal Microbiota Transplantation: How important is the BMI of the stool donor?

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Currently fecal microbiota transplantation (FMT) “best practices” exclude obese stool donors based on a report of germ-free mice gaining weight after FMT from mice with obesity and based on a case report of an individual with 34 pound weight gain after FMT.

A recent report (M Fischer et al. Clin Gastroenterol Hepatol 2018; 16: 1351-3) suggests that the the BMI of the stool donor does not affect recipient weight after a single FMT procedure for C difficile infection.

This analysis included 173 patients with a mean age of 57 years.  One group of 103 were from a randomized control trial; in this group, 66 (64%) received FMT from a normal weight (BMI 18-24.9) donor and 37 (36%) received FMT from an overweight (BMI 25-29.9) donor. Among an additional 70 individuals from an observational cohort, 25 received FMT from normal weight donor, 30 received FMT from overweight donor, and 15 received FMT from an obese donor.

Key finding:

  • There was no significant difference in BMI among the FMT recipients up to 48 weeks after a single FMT.  Based on data from Figure 1, patients who received FMT from normal weight donor had slightly higher mean weight gain at 48 weeks afterwards (not statistically-significant)

The authors caution that a prospective study is required to confirm these findings and in the interim, they recommend exclusion of obese/overweight FMT donors.

My take: There are plenty of willing stool donors –so who knows if this will ever be examined adequately.  This study challenges the idea that FMT from an obese donor will result in recipient obesity, presumably via changes in the microbiome.

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Exclusive Enteral Nutrition for Crohn’s Disease -Less Effective in Those with Isolated Colonic Disease

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A recent study (Y Xu. Clinical Nutrition 2018; https://doi.org/10.1016/j.clnu.2018.08.022) showed that exclusive enteral nutrition (EEN) is less effective in patient’s with Crohn’s disease with isolated colonic disease.

Abstract Link: Isolated Colonic Crohn’s Disease is Associated with a Reduced Response to Exclusive Enteral Nutrition Compared to Ileal or Ileocolonic Disease

This was a retrospective study of 241 adults: 52 patients in the cCD (isolated colonic disease) group and 189 patients in the non-cCD group.

Key findings:

  • “The rates of clinical remission differed between the two groups (cCD group: 51.9% versus non-cCD group: 68.3%, P = 0.029). Multivariate analyses indicated that isolated colonic involvement was associated with a reduced response to EEN (OR = 2.74; [CI] 95% = [1.2 –6.23], P = 0.016).”
  • “Further analysis showed that even in patients who achieved clinical remission after EEN, inflammatory serum markers declined more slowly in the cCD group than in the non-cCD group, and the time to remission was longer in the cCD group.”

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This Makes Me Mad…Immigration Policy

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When our government takes actions on behalf of our country, this reflects on all of our values.  So, earlier this year I was disgusted and angry when I learned that as part of a ‘zero tolerance’ rule, young children were separated from their parents and placed in something akin to cages.  For me, this is a stain on our country’s history that could be compared to other atrocities like the Tuskegee experiments and Japanese internment during WWII.  While this policy was more short-lived, there are still children separated from their parents and for the children involved the consequences could be life-long.  Sadly, our entire country is responsible because we elected this administration which adopted these policies.

Now, this administration which seems incapable of any shame, is planning more steps that should make decent persons upset. Additional threats to lawful immigrants are being devised (KM Perreira et al. NEJM 2018; 379: 901-3).

“Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States” and in some cases deported.  Public-charge guidelines aim to keep immigrants from relying on public charges (eg. cash-assistance programs like welfare) for the first 5 years after admission to the U.S.

“The Trump administration is proposing sweeping changes to these [public-charge] guidelines.”  One of these proposed expansions of public-charge determination is including enrollment for Obamacare, which is legally mandated and which can include subsidies.  Another target is the Children’s Health Insurance Program.  As a consequence of these guideline changes, instead of ~3% of lawful immigrants being considered as receiving a public charge, if adopted, this would increase to a range from 32% to 47%.

If these policies are adopted, this is likely to have a lot of adverse health consequences.  Immigrants, including U.S.-born children, will be less likely to receive health care and more likely to be food insecure; 25% of U.S.-born children of immigrants currently receive SNAP (supplemental nutrition assistance program) benefits. Health consequences will affect millions and include an increase in low birth infants, increased infant mortality, and increased maternal morbidity.

For health care providers and institutions, implementation of these policies is likely to result in higher costs from uncompensated care.

In related commentaries (BL Grace et al. NEJM 2018; 379: 904-5, M Martin. NEJM 2018; 379: 906-7), the authors note the following points:

  • “Current immigration policies are undermining trust in U.S institutions…and changing the way immigrants and refugees seek health care.”  Many are worried that seeking health care could lead directly or indirectly (after providing information) to deportation
  • “Even naturalized citizens fear that their status is no longer secure.”
  • “I feel sad that my colleague’s 6-year-old patient has nightmares and urinary incontinence because she is terrified her parents will be deported.  Sad that my patients fear coming to the hospital despite grave illness out of panic that someone will ask about their immigration status.”

My take: We are all accomplices (many unwitting) in the roll out of these detrimental policies that are now affecting lawful immigrants..

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“If this was celiac, why didn’t it stop when she cut out gluten?”

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Here’s a link to a well-described case report. Her Searing Gut Pain Suggested Celiac Disease. Why Didn’t Cutting Out Gluten Help?

This 57 year old with ‘presumptive’ celiac disease did not improve with a gluten-free diet.  After an initial self-diagnosis and subsequently an endoscopy that also suggested celiac disease, she did not improve.  While the doctors involved in her care had labeled her ‘noncompliant,’ it turns out she did NOT have celiac disease and improved after the right diagnosis (diagnosis noted at bottom of this post).

My take: There are several entities that can mimic celiac disease (even histologically), including Crohn’s disease, Autoimmune enteropathy, CTLA4 deficiency, and Whipple’s disease (the diagnosis in this case).  When someone is not getting better, the diagnosis needs to be reconsidered.