From NASPGHAN twitter feed
In addition to being a choking hazard, some fidget spinners have button batteries to light up. Button batteries are particularly dangerous if lodged in the esophagus.
Related blog post: Foreign bodies in children -expert guidance
A small retrospective study (R Bolia et al. JPGN 2017; 65: 86-88) with 497 patients (626 biopsies) found that all complications were identified within 8 hours. Thirty (48%) had complications, with a subcapsular hematoma being most common (n=14). Less common adverse events included fever (n=5), skin site ooze (n=3), intraperitoneal bleeding (n=3), hemobilia (n=2), anaphylaxis to gelfoam (n=2), and sepsis (n=1). In this study, the majority of biopsies were performed by interventional radiology (n=492); though, the complication rate was similar in both groups.
The authors conclude that their data support the outpatient liver biopsies in children.
My take: I disagree with the authors’ conclusion to some extent. Their population is too small to detect rare but severe complications. Our empiric practice is watch children older than 6 years of age for 6 hours and watch younger children (or others deemed at increased risk) for 24 hours.
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Prague
A recent study (AN Zizzo et al. JPGN 2017; 65: 6-15) performed a systematic review and meta-analysis of pediatric autoimmune hepatitis (AIH) studies.
The most remarkable finding was that there were only 76 patients from 15 qualifying studies.
Other findings:
The article has an associated editorial (N Kerkar, pg 2-3). “The adverse event profile of cyclosporine with gingival hyperplasia, hypertrichosis, nephrotoxicity, and neurotoxicity made it challenging for long-term use in children.” Besides the small number of patients, “the studies that were included were largely “observational”‘ which limits their findings as well. The study authors recommend MMF as the preferred option for 2nd-line therapy.
My take: Fortunately, most patients with autoimmune hepatitis respond to first line therapy with azathioprine/steroids. It is unclear what is the optimal 2nd-line treatment for refractory patients.
Related blog entries:
Egret, Shem Creek
With non-alcoholic steatohepatitis (NASH), there are currently no established medical therapies. However, several candidate medications look promising. However in recent years, many new medications have come with an impressive price tag and this has led to questions about whether emerging therapies for NASH will be affordable.
A recent article looked at the medication Obeticholic Acid, which was approved for treating primary biliary cholangitis. It is possible that it will be helpful for NASH. Yet, its cost , currently, is about $70,000 per year
GIHepNews: Despite clinical promise, obeticholic acid may be too expensive for treating NASH
Here’s an excerpt:
In the 72-week Phase II trial, called FLINT, 273 men and women with NASH were randomly assigned to receive OCA or placebo (Lancet 2015;385:956-965). Liver histology improved in 45% of those receiving OCA versus 21% in those receiving sham therapy (P=0.002). An increased risk for pruritus was the most notable adverse event among patients taking OCA (23% vs. 6% for placebo), according to the researchers. Based on the favorable benefit–risk results of the Phase II study, a Phase III trial is ongoing…
The expected benefit of OCA over lifestyle modifications for all the major long-term outcomes, such as decompensated cirrhosis (10% vs. 9.4%), liver-related mortality (9% vs. 8.1%) and transplant-free survival (72.2% vs. 71.5%), were relatively modest, the researchers reported. Those differences resulted in a cost per quality-adjusted life-year saved of $5.2 million with the assumption that 16% of patients would relapse…
“If the efficacy compared to placebo is of the same order found in the FLINT trial, the current cost of the drug would be prohibitive in a population-based context,” said Dr. Lavine, who was a co-investigator on the trial.
My take: Given the growing burden of NASH, new effective treatments are needed. In my view, though, cost-effectiveness has to be a consideration.
Prague Castle
Full text from ACG article: NASH: What Helps Beyond Weight Loss?
The article reinforces the value of weight loss and exercise for nonalcoholic steatohepatitis (NASH). It suggests that Vitamin E and/or pioglitazone may be helpful. Many more medications are being evaluated.
My take: As of now, losing weight and exercise remain the cornerstone for NASH treatment.
Another study (NZ Borren et al Inflamm Bowel Dis 2017; 23: 1234-9) has shown detrimental outcomes due to distance from the health care team.
In this study with 2136 patients with IBD (1197 Crohn’s disease, 9393 ulcerative colitis) with mean age of 41 years, the distance from the hospital (Massachusetts General) was compared with need for IBD-related surgery and secondary outcomes of needing biological and immunomodulator therapy.
Key findings:
According to the authors, with other indications besides IBD, “over three-quarters of the examined studies demonstrated a distance-decay association with worse outcomes in individuals living further away from health care facilities. Limitation: it is possible that patients who travel a greater distance have more disease severity and that those who have milder diseases are more likely to receive care closer to home.
My take: When highly qualified subspecialists are far away, the associated reduced access likely counters this potential benefit. Early effective therapy is important in reducing complications.
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Shem Creek, SC
It is said that “absence makes the heart grow fonder.” This expression certainly cannot be extrapolated to the liver. A recent study (DS Goldberg et al. Clin Gastroenterol Hepatol 2017; 15: 958-60) showed that increased distance to a liver transplant center was associated with higher mortality for patients with chronic liver failure (CLF).
This study examined 16,824 patients with CLF. In the cohort (879, 5.2%) who lived >150 miles from the closest LT center there was a 20% higher mortality rate (Hazard ratio of 1.20; P <.001). According to the authors, mortality with distance “modeled as a continuous variable per unit increase in 50 miles.”
From the discussion:
My take: This study, though with some limitations, bolsters the view that patients with chronic liver disease (and probably other chronic diseases) live longer if in proximity to specialized care.
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Exquisite windows in St. Vitus Cathedral, Prague
A large observation study provides some bad publicity for proton pump inhibitors (PPI):
BMJ Open Access: Risk of death among users of Proton Pump Inhibitors: a longitudinal
observational cohort study of United States veterans (Y Xie et al BMJ Open
2017;7:e015735. doi:10.1136/bmjopen-2016-01573) Thanks to Ben Enav for this reference.
This study selected ~350,000 patients from a database which identified more than 1.7 million PPI users. These patients were ‘new’ PPI users.
Key finding: Over a median follow-up of 5.71 years, PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28).
The authors note the limitations of this observational study; however, they suggest that the findings cannot be fully explained by residual confounders. They recommend limiting PPI use to “instances and durations where it is medically indicated.”
My take: As noted in a recent post (see below), some risks attributed to PPIs in observational studies do not pan out. Yet, PPI therapies need to be better-targeted to those who will truly benefit from them.
Related blog posts:
The Battery, Charleston, SC
From Axios: This is what Washington has been fighting about
An excerpt:
Every time you hear the Trump administration or Congress fight about rising Affordable Care Act premiums, or what will happen to people with pre-existing conditions, just remember — we’re talking about issues that affect 7 percent of the population. That’s how many people are in the individual health insurance market, or the “non-group” market…
But when you hear about those sky-high rate hikes because of “Obamacare,” chances are, they’re not your sky-high rate hikes — unless you happen to be in that market…
The spending limits that have been proposed for Medicaid really do matter, and they affect a larger group — 20 percent of the population.
A recent study (C AM Zar-Kessler et al. JPGN 2017; 65: 16-21) retrospectively reviewed a single center’s 8 year experience (2005-2013) using antidepressant medications to treat nonorganic abdominal pain. Of 531 cases, 192 initiated treatment with either a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).
Key findings:
In the discussion, the authors note that “all patients who experienced GI adverse effect were prescribed medications that would worsen their underlying bowel complaint…these issues may have been mitigated if more attention was paid” to this. “Specifically, TCAs should be used cautiously in those with constipation, whereas SSRIs should be avoided in those with diarrhea.”
My take: This study shows that both classes of antidepressants were associated with improvement. The conclusions about effectiveness are limited as this is a retrospective study and could not control/evaluate many variables. That being said, particularly if there is coexisting anxiety, as was frequent in this study population, a SSRI may be more effective.
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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.
Tynn Church, Prague
gutsandgrowth 