PPIs NOT Linked to Cognitive Decline/Dementia & PPIs NOT Linked to Heart Attacks

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In a prospective study (M Wod et al. Clin Gastroenterol Hepatol 2018; 16: 681-89), data on middle-aged (n=2346, 46-67 yrs) and older individuals (n=2475) were collected in the Longitudinal Study of Aging Danish Twins.  This study showed that there was no difference in cognitive decline between PPI users and non-users.

The second study (SN Landi et al. Gastroenterol 2018; 154: 861-73) used a large administrative database and reviewed more than 5 million new  users of prescription PPIs and prescription H2RAs.  The authors found no significant difference in myocardial infarctions (MIs) between PPIs and H2RAs over a 12 month period.

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Lots of Allergy & Autoimmunity Issues Following Solid Organ Transplantation

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A recent retrospective cross-sectional cohort study (N Marcus et al. J Pediatr 2018; 196: 154-60, editorial page 10) identified 273 transplant recipients with a median followup of 3.6 years. This cohort included 111 liver transplant recipients, 103 heart transplant recipients, 52 kidney transplant recipients, and 7 multivisceral transplant recipients.

Key findings:

  • 92 (34%) developed allergy or autoimmunity after transplantation.
  • Allergic problems included eczema (n=44), food allergy (n=22), eosinophilic gastrointestinal disease (n=11), and asthma (n=28)
  • Autoimmunity problems developed in 6.6% (18) including autoimmune cytopenias (n=10). Two patients died due to autoimmune hemolytic anemia and hemophagocytic lymphohistiocytosis.
  • Allergic problems typically developed during the first year after transplantation and rarely after 5 years following transplantation.
  • ~20% required a change in immunosuppression
  • ~50% improved with time

In the editorial, the Dr. Helen Evans notes that the increasing reporting of atopic/allergic disorders could be due to recognition but could also be due, in part, to the widespread adoption of tacrolimus instead of cyclosporine for immunosuppression.

My take: Many have said that organ transplantation, which is life-saving, substitutes one problem for another.  This is an example of an additional burden, often related to immunosuppression, that patients and families have to manage afterwards.

Chattahoochee River, Island Ford

Low-Value Care: IBD Serologies for Diagnosis of IBD

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A recent high-value care series (MD Long, BE Sands. Clin Gastroenterol Hepatol 2018; 16: 618-20) explains why “clinicians should not use IBD serologies as a test to diagnose inflammatory bowel disease.”

Here are the key points:

  • “Benoir et demonstrated that a 7-marker serology panel had a lower predictive value than routine laboratory tests in diagnosis of IBD among symptomatic pediatric patients.”
  • “Studies on the accuracy of these serologies for diagnosis included populations with a high prevalence of IBD (42%-62%), rather than the low-prevalence populations in primary care settings” (or even in for routine GI office visits)…”When the disease is rare, a greater proportion of the positive tests represent false positives and the PPV [positive predictive value] is low.”
  • The authors also recommend against using serologies to predict a more aggressive course because “no data exist that modifications based on these serologies improve outcomes.”

My take: When I highlight this article, there is an element of confirmational bias as I have held a dim view of their value for a long time. While there is some academic interest in IBD serology results, to me, it is a disturbing trend to see patients with nonspecific abdominal pain referred who have already had these serological markers.

Increased Organ Availability for Transplantation Related to Opioid Epidemic

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A letter to the editor (MR Mehra et al. NEJM 2018; 378: 20: 1943-45) provides a perspective on the increasing availability of organs for transplantation from drug overdoses/opioid epidemic from 2000 to 2016.

Key findings:

  • “The drug-abuse epidemic has been associated with a sharp increase in the recovery of organs from brain-dead donors in the United States but not in Europe. “
  • “The U.S. data indicate that survival among recipients from donors who died from drug intoxication is similar to survival among recipients from donors who died from other causes.”

My take: Opioid use is more likely to place one at risk for needing a liver transplantation due to increase acquistion of hepatitis C infection and is more likely to make a donor available due to drug overdoses.

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More on Time to Split (2018)

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As noted in a blog last year (More on its Past Time to Split), increased use of split livers can reduce liver transplantation waitlist mortality in children.  Further justification for this approach is evident from a new study (DB Mogul et al. J Pediatr 2018; 196: 148-53, editorial pg 12) indicated that outcomes following split liver organs are equivalent to whole organ liver organs.

The authors examined two time periods: 2002-2009 and 2010-2015 using the Scientific Registry of Transplant Recipients. n=5715

Key findings:

  • 1-year survival from split liver transplant (SLT) improved during the later period compared to the initial period: 95% versus 89%. n=1626 (28.5% of all transplants)
  • 1-year survival from living donor liver transplant (LDLT) improved during the later period compared to the initial period: 98% versus 93%. n=661 (11.6% of all transplants)
  • 1-year survival from whole liver transplant (WLT) was essentially unchanged during the later period compared to the initial period: 95% versus 94%. n=3428 (60% of all transplants)

These data show that survival after transplant is no longer worsened by SLT and may be higher for LDLT than WLT.

The editorial by Dr. Bae Kim and Dr. Vakili note that there have been several proposals to encourage more use of SLTs.  One that was developed “would prioritize children <2 years old before local/regional adults except for those who were status 1 or who had a MELD score above 30.”  At this point, these efforts to favor SLT allocation have not been adopted by UNOS Board of Directors.

My take (borrowed from editorial): “The question should no longer be ‘To split or not to split?’ but rather ‘Why should we let children die when we can now split livers safely?'”

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Chattahoochee River

 

 

Canakinumab for Recurrent Fever Syndromes

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A recent study (F de Benedetti et al. NEJM 2018; 378: 1908-19) presents data on canakinumab, an anti-interleukin-1β monoclonal antibody, for three hereditary periodic fever syndromes in the so-called “CLUSTER” trial.  Canakimumab is administered as a subcutaneous injection. The three periodic fevers were the following:

  • Familial Mediterranean Fever (colchicine-resistant)
  • Mevalonate kinase
  • Tumor necrosis factor-receptor-associated periodic syndrome (TRAPS)

Are Long-Term Liver Transplant Survivors Destined to Have Low Bone Density? (No)

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Briefly noted: A recent study (L Ee et al. JPGN 2018; 66: 797-801) provides some good news for children who have had liver transplantation (LTx).

Among 42 patients (64% with biliary atresia) who had undergone LTx at a median age of 2.2 years and were long-term survivors (median time since LTx 10.1 yrs), mean bone mineral density (BMD) were normal.  Lumbar BMD z-score -0.15 and total body BMD -0.76.  Pathologic fractures were noted in 2 patients; these occurred within 18 months of transplantation.

My take: this study indicates that over time, most patients are not likely to have very low bone density.

Low Fiber Diet During Bowel Prep

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A recent prospective, randomized trial (A Mytyk et al. JPGN 2018; 66: 720-24) compared a low fiber diet with a clear liquid diet during a polyethyylene glycol prep prior to colonoscopy. N=184, Median age 15 yrs (range 6-18 yrs).

Low fiber diet included milk, dairy products, some soups, bread and rolls, sandwiches, meat, fish, eggs, pasta, and honey.

Children in both groups were asked to fast for a minimum of 6 hours prior to colonoscopy and their bowel prep was assessed with the Boston Bowel Preparation Scale (BBPS). Bowel prep consisted of PEG 4000 with electrolytes dosed at 66 mL/kg to max of 4 liters.

Key findings:

  • There was no significant difference in BBPS between the two groups
  • Overall, 95.4% of patients had good bowel cleanness (BBPS ≥5)

My take: This study indicates that with a good volume of bowel prep, a less-rigorous diet change may be effective for a cleanout.

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.

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Big Creek Greenway -not far from McFarland

 

ADMIRE Study: Use of Stem Cell Therapy for Complex Perianal Fistulas in Crohn’s Disease

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A recent phase 3 randomized, double-blind, placebo-controlled study (J Panes et al. Gastroenterol 2018; 154: 1334-42) examined the use of stem cell therapy for the treatment of complex perianal fistulas in Crohn’s disease (CD).

They used a single local injection of 120 million Cx601, a suspension of allogeneic expanded adipose-derived stem cells, and compared to a placebo injection.  This study comprised 212 patients from 49 centers. The primary endpoint, labelled “combined remission,” was based on absence of draining fistulas and MRI findings.

Key Findings:

  • As noted in Figure 1 (below), combined remission occurred in 51.5% of Cx601-Rx patients compared with 35.6% for placebo at week 24; at week 52, combined remission occurred in 56.3% of Cx601-Rx patients compared with 38.6%

My take: This local therapy improved outcomes for 1 year after a single injection and appears promising for refractory perianal fistulas.  It may help avoid surgery or systemic immunosuppression.

 

Closer Look at Data Then Image Below