Costs of Rumination

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Reading a recent study (A Alioto et al. J Pediatr 2017; 185: 155-9) reminded me of “My Cousin Vinny.”  In a crucial scene, Mona Lisa Vito (Marisa Tomei) proves that the accused killers were not the killers by identifying tire tread marks that were inconsistent with the defendants’ car simply by looking a photograph.

Similarly, the authors of this retrospective report highlight the extensive cost of that children undergo for evaluation of rumination when simple observation might suffice.

Key findings:

  • Consecutive patients (n=68, 2009-2015) admitted to their inpatient rumination treatment program had undergone an average of 8.8 tests at a cost of $19,795.
  • Few tests were beneficial. Most common tests were esophagogastroduodenoscopy, upper gastrointestinal series, and abdominal ultrasound scan.

Limitations:

  • The cohort is derived from a quaternary center
  • The number of tests may be underestimated as the tests were done by the referring center; thus, the authors were reliant on data provided to them

Other comments:

  • A good clinical history can suffice to establish the diagnosis. “Observing the patient eat and/or drink and then ruminate is perhaps even more useful.”
  • “We strongly suggest that if a patient meets the symptom-based criteria for rumination syndrome, no further diagnostic testing is warranted. That said, …various phenotypes of the syndrome may make the diagnosis less clear-cut” and some testing could be needed.
  • Rumination may be “symptomatic for over 2 years before the diagnosis is established” (Pediatrics 2003; 111: 158-62)

My take: Not every doctor is as good at doctoring as Vinny Gambini is at lawyering. That being said, the authors note “for patients who present with repeated effortless regurgitation and vomiting of food that begins soon after they eat or drink, is not preceded by retching, and does not occur during sleep, there are very few other diagnoses to be considered.”

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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.

Omaha Beach 2017

Surgery for Reflux Works Best in Those Who Need it the Least

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In a recent retrospective study (JT Krill et al. Clin Gastroenterol Hepatol 2017; 15: 675-81), the authors reinforce the notion that surgery works best for reflux patients whose symptoms respond best to medical therapy.

Background: In this study, 196 patients with normal anatomy were identified, though 81 had inadequate follow-up at 1 year.  This left 115 patients (median age ~52).  This study examined patients with typical reflux symptoms (regurgitation, heartburn) (n=79 of 115, 68.7%) and extraesophageal symptoms, like cough, hoarseness, and throat clearing (n=36 of 115, 31.3%).  It is noted that 2/3rds of those with extraesophageal symptoms had coexisting typical GERD symptoms.  Most patients had a Nissen fundoplication but some underwent a Toupet fundoplication.

Key findings:

  • 91.5% of those with typical reflux symptoms (who  had responded to medical therapy) were in remission at 1 year; in comparison, only 33.3% (P <.01) of those with extraesophageal symptoms along with poor response to acid suppression therapy exhibited remission following fundoplication.
  • “The severity of acid reflux on pH monitoring and larger hiatal hernia size were associated with a more favorable outcome at 12 months.”  All patients had either abnormal pH monitoring or endoscopic esophagitis prior to surgery.  Only those with severe reflux had increased likelihood of response to surgery.

Limitations: retrospective study, 81 of 196 patients were excluded due to lack of followup

My take: This study is consistent with other studies in suggesting that reflux surgery is less effective in those who do not respond to medical therapies and who have atypical symptoms.

Related blog post:

From Pitts Street Bridge, Mt Pleasant

Favorable Fish Oil Outcomes in High Risk Preterm Infants

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Briefly noted: M Sorrell et al. JPGN 2017; 64: 783-88. In this small study with 13 infants (mean gestational age of 28 weeks) who had short bowel syndrome or severe dysmotility and direct bilirubin ≥4 mg/dL (mean 9.8 at enrollment), patients received a fish oil-based lipid emulsion (1 g/kg/d). They were compared with 119 GA-matched controls.

Overall, the authors found the fish oil supplement to be safe.  All patients had resolution of cholestasis. They note the difficulty of proving effectiveness and performing studies in this population.  “Neonatologists…find themselves faced with …a growing body of uncontrolled data that suggests benefits of an unapproved treatment…An attempt to perform a randomized controlled comparison of a plant-based lipid emulsion to FishLE in preventing PNALD in infants at risk was terminated early after an interim analysis revealed much lower than expected incidence of PNALD…[making] trials ethically problematic.”

My take: The data remain incomplete and make it difficult to use a therapy like Omegaven that is quite expensive (not covered) and not FDA approved.  The availability of SMOFlipid is likely to result in less usage of plant-based soy products.

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Rodin Museum

Dilatation for Eosinophilic Esophagitis -Pediatric Data

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The most recent data in adults has indicated that dilatation for eosinophilic esophagitis (EoE) likely does not have increased risk compare to esophageal dilatation for other causes.  A recent pediatric retrospective study (C Menard-Katcher et al. JPGN 2017; 64: 701-6) reaches a similar conclusion.

In this study over a 5-year period, there were 68 dilatations among 40 patients with EoE.

Dilatation was considered complete if a diameter of 15 mm (45 French) was reached or if a deep rent in the mucosa was evident; small (<0.5 cm) shallow rents were “not considered criteria for cessation of dilations.”

Methods:

  • In their institution, areas of narrowing >5 cm in length were typically treated with Maloney dilators and shorter narrowings were managed with balloon dilators (through the scope).
  • For Maloney bougie dilators, often dilations started at 24 French; typically 30 French if scope could traverse narrowing.
  • For balloon, often dilations started at 10 mm.  Fluoroscopy was often used at initial dilation (12 of 19).
  • 17 of 40 required more than one dilation in the study period

Some of the key findings:

  • Approximately 5% of their EoE patients needed dilations.
  • Patients with EoE who needed dilations were older than EoE patients who did not need this: 13.8 vs 8.2 years
  • Postoperative chest pain was most common adverse event, affecting 15% of dilations. In this small series, there were no perforations.
  • At this institution, half of the patients had dilation at their diagnostic endoscopy before starting EoE-specific therapy. However, as noted in their commentary, medical management may obviate the need for dilations.
  • Medical management consisted of “swallowed steroids (62%), dietary therapy (12%) or both (24%).”

My take: Overall, this study indicates that dilations are fairly safe in the EoE population. That being said, in my view, all dilations carry a small but significant risk.

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Musee d’Orsay, Naissance de Venus, Alexandre Cabanel, 1863

 

 

 

 

Acute Liver Failure -Pediatric ICU Management

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Full Text Link: Intensive Care Management of Acute Liver Failure

This article provides a very good overview of this topic starting withe diagnosis, epidemiology and proceeding to specific management issues/outcomes.

Table 1 reviews etiologies –indeterminant is most common. Table 2 shown below reviews management principles and Table 3 reviews specific treatments based on etiology. Table 4 reviews grades of encephalopathy.

My take (from authors): “Despite recent advances in supportive care and the improvements in outcomes observed…the practical intensive care management of PALF remains poorly defined…Current treatment options are merely supportive and based on incomplete adult data and local institutional experience.”

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NPR: Handshake-Free Zones to Decrease Spreading Germs

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NPR recently detailed a study to reduce germs by implementing a handshake-free zone at a neonatal intensive care unit.

Here’s the link: Handshake-Free Zones Target Spread of Germs

An excerpt:

In a survey of staff and family members about the experience, Sklansky and his colleagues found that establishing handshake-free zones does reduce the frequency of handshakes. And most health care workers support the idea.

The findings were published in the American Journal of Infection Control. The survey didn’t determine whether avoiding handshakes actually reduced the rate of infections, but Sklansky hopes to answer that question in a future study.

The formal experiment is now over, but the signs in the NICUs remain. And doctors and nurses still discourage handshakes.

It’s is an effective way to decrease the spread of germs, says Maureen Shawn Kennedy, editor-in-chief of the American Journal of Nursing…

Although there is no data to prove that reducing handshakes limits hospital infections, one study showed that bumping fists was more hygienic than shaking hands.

However, some infectious disease specialists believe health care workers don’t need to stop shaking hands. They just need to scrub better.

“The problem isn’t the handshake: It’s the hand-shaker,” says Herbert L. Fred, a Houston physician and associate editor of the Texas Heart Institute Journal.

In a 2015 editorial he urged doctors to ensure their hands are clean before touching patients. After all, he wrote, “If we ban the handshake, we might as well ban the physical examination. Both practices can spread germs,” — if you don’t wash your hands properly.

My take: The bigger message of this article is that hand hygiene needs to be improved to decrease the spread of infections.  I doubt stopping handshakes will be particularly helpful.

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Musee d’Orsay

Lipid Emulsions and Unbound Bilirubin in Preterm Infants

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Happy birthday Stan!

In previous work, it had been shown that free bilirubin (Bf) and unbound free fatty acids (FFAu) were increased in extremely low birth weight infants who received intralipid (soybean) at 3 g/kg/d.  A recent study (T Hegyi et al. J Pediatr 2017; 184: 45-50) showed that Bf and FFAu are increased with increasing intralipid dosage (1 to 3 g/kg/d) in all gestational ages (23-34 weeks).

The concern with Bf and FFAu is that elevated concentrations could have adverse neurologic effects; intralipids may act to displace bilirubin from binding to albumin. For most infants in this study, the levels “would not be expected to pose a neurotoxic risk” (per editorial pg 6-7).  Factors that enhance the generation of FFAu include infection, steroids, carnitine deficiency, and low albumin conditions. Phototherapy, in this study, reduced total serum bilirubin but not Bf in those receiving 2-3 g/kg/d of intralipid.

My take: This study does not provide any information regarding neurotoxicity.  It shows that potentially toxic levels of Bf & FFAu can occur in infants born <28 weeks who receive 2 g/k/day or more of intralipid.  While this is a concern, we also know that poor growth is associated with worsened neurocognitive outcomes (Nutrition Week: Downside of Lipid Reduction)

Surgical Reset for Anti-TNF Therapy with Crohn’s Disease

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A recent study (A Assa et al. Inflamm Bowel Dis 2017; 23: 791-97) indicates that after surgery, anti-TNFα treatment is worth another try.

In this retrospective study with 53 children, 18 had “pharmacodynamic failure” with anti-TNFα medications (PK group) and 35 were controls. “Phamacocynamic failure is characterized by either a lack of improvement of CD symptoms or  loss of response after initial improvement in the setting of adequate serum drug levels without ADAs” [antidrug antibodies].

Key findings:

  • Mean age at time of intestinal resection was 14.8 years
  • Median time from resection to anti-TNF initiation was 8 months
  • Compared to the control group, the PK group had similar response to anti-TNF therapy.   “Similar proportions of patients from both groups were in clinical remission on anti-TNF treatment after 12 months and at the end of follow-up (1.8 years)”
  • At 12 months, remission rates were 89% (PK) versus 88.5% (control)

The authors propose an explanation: “A plausible explanation for this finding is that in severely inflamed tissue with high inflammatory burden, local high levels of TNFα serves as a sink for anti-TNFα antibodies and that tissue injury and local hypoxia might further limit drug penetrance to its target.”

My take: This information is useful.  Many patients who have surgery may respond to anti-TNFα therapy subsequently.  The unanswered question: Could more frequent dosing of anti-TNFα therapy have averted surgery in some patients by overcoming areas of intense disease?

 

Pediatric Endoscopic Quality Metrics

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A recent study (J Sheu et al. JPGN 2017; 64: 671-8 Full Text link (courtesy of JPGNonline twitter feed): Outcomes from Pediatric GI MOC Modules) examined outcomes associated with NASPGHAN sponsored web-based quality improvement activities. This study showed that these modules, designed for Maintenance of Certification (MOC) for American Board of Pediatrics, improved quality care outcomes. What I found most interesting were some of the quality metrics that were targeted.  Here are some of them:

  • Performance of time out
  • Documentation of duodenal biopsies (eg. location/number)
  • Documentation of prep quality
  • Communication of endoscopy report to primary care providers
  • Documentation of biopsy results to family within 1 week
  • % of procedures that resulted in change in management
  • % successful terminal ileum intubation

My take: While this study showed the potential utility of these MOC modules, the larger point is that if you set specific measurable goals, you have a good chance of improving performance.  This article is a good place to start when thinking about improving pediatric endoscopy quality.

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I really don’t get modern art. This art (a collection of newspapers)  is from Centre Pompidou. Robert Gober “Newspaper” 1992

 

 

NAFLD Adult Prospective MRI Study: 42% Prevalence

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From Jeff Schwimmer Twitter feed:

Prevalence of Fatty Liver Disease in NE Germany Based on MRI RSNA Radiology, http://dx.doi.org/10.1148/radiol.2017161228

Excerpt from abstract:

From 2008 to 2013, 2561 white participants (1336 women; median age, 52 years; 25th and 75th quartiles, 42 and 62 years) were prospectively recruited to the Study of Health in Pomerania (SHIP). Complex chemical shift–encoded magnetic resonance (MR) examination of the liver was performed, from which PDFF and R2* were assessed…

Prevalence of fatty liver diseases was 42.2% (1082 of 2561 participants); mild, 28.5% (730 participants); moderate, 12.0% (307 participants); high content, 1.8% (45 participants).

Vincent Van Gogh, Portrait de l’artiste, Musee d’ Orsay