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

 

Celiac Disease Epidemic?

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A recent prospective study (E Liu et al. Gastroenterol 2017; 152: 1329-36) reports a very high rate of celiac disease in Denver.

The authors collected data on HAL-DR, DQ genotypes in 31,766 infants.  Among the various genotypes, a total of 1339 were followed .for 20 years (starting in 1993). The key outcomes were development of celiac disease autoimmunity (CDA) indicated by persistence of anti-TTG IgA antibody for at least 3 months or development of celiac disease (CD) with biopsies showing at least Marsh 2 histologic lesions.  The authors weighted the genotypes based on their frequency in the population to develop estimates for the entire Denver population.

Key findings:

  • 66 (of 1339) developed both CD and CDA. Another 46 developed only CDA. In this group of 46, seropositivity reverted to normal in 21 (46%).
  • Cumulative incidence for CDA at 5, 10 and 15 yrs of age: 2.4%, 4.3%, and 5.1% respectively
  • Cumulative incidence for CD at 5, 10 and 15 yrs of age: 1.6%, 2.8%, and 3.1% respectively

In their discussion, the authors note that “the 3.1% cumulative incidence of CD in Denver by age 15 is the highest to date in North America and is consistent with the 3% prevalence reported in Sweden for 12 year olds born during an ‘epidemic’ thought to be the result of early introduction…of gluten.” This theory about the epidemic is has been discounted: “timing of gluten introduction is not likely a factor” though the quantity could be a factor.

My take: These rates of CD and CDA are very high; ongoing data to determine the frequency in other parts of the country are needed.  This high rate of CD is clearly bad news for a lot of people, excepting those with commercial interests in gluten free products.

 

For 1-3 year old, AAP recommendation for maximum of 4 oz./day of 100% juice, and for 4-6 year olds a maximum of 6 oz/day.  For 7 years and older, AAP recommends a maximum of 8 oz/day

Liver Briefs May 2017

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Briefly noted:

O Jeanniard-Malet et al. JPGN 2017; 64: 524-7. This survey of 28 centers in France assessed clinical practice with regard to primary prophylaxis in portal hypertension. More than 75% use endoscopy to screen for varices in patients with chronic liver conditions. “In cases of grade 2 varices with red marks and grade 3 varices >90% of centres perform sclerotherapy or endoscopic variceal ligation.”

Y-D Ren et al. Hepatology 2017; 65: 1765-8. FMT for chronic HBV? This small study with 5 patients who received fecal microbiota transplantation in an effort to clear HBeAg.  There were 13 controls.  Patients in both group received either ongoing entecavir or tenofovir antiviral therapy (& had received for at least 3 years). FMT was given every 4 weeks (1 to 7 treatments). HBeAg declined gradually after each round.  Three patients in the FMT arm cleared HBeAg compared with none in the control arm.  Two of the three cleared HBeAg after on FMT and the third after two rounds of FMT.

Y Sun et al. Hepatology 2017; 65: 1438-50.  In this report, the authors propose to augment the liver biopsy classification in patients with Hepatitis B.  Their goal is to provide more information about dynamic changes regarding fibrosis using three terms:

  • Predominantly progressive: thick/broad/loose/pale septa with inflammation
  • Predominantly regressive: delicate/thin/dense/splitting septa
  • Indeteminate

Using this new designation, they characterized 71 paired liver biopsies before and after entecavir for 78 weeks.  Before treatment: 58%, 29%, and 13% for progressive, regressive and indeterminate; after treatment: 11%, 11%, and 78% respectively.

Rodin Museum, Gates of Hell

 

Brain-Gut Axis in 2017

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“Brain–gut interactions and maintenance factors in pediatric gastroenterological disorders. Recommendations for clinical care.” B Reed-Knight et al. Clinical Practice in Pediatric Psychology, 2017; 5: 93-105.

A summary of this review article by Sharon Berry, PhD, ABPP, Past President, Society of Pediatric Psychology:

This review article describes the brain–gut axis as a means to increase understanding of how biological mechanisms implicated in a range of pediatric GI disorders interact with psychological and contextual factors to maintain GI symptoms and (b) provide practical ways for pediatricians and other healthcare providers to  incorporate a discussion of the brain–gut axis into patient education for pediatric GI disorders.

Biological mechanisms of the brain–gut axis including alterations in pain processing, the stress response system, and gut microbiome activity are reviewed. Psychosocial factors that contribute to or maintain disturbances in the brain–gut axis are discussed with implications for clinical assessment and intervention. The authors assert that a mutual understanding by patients, families, and providers alike of the relevant brain–gut interactions and the biopsychosocial model, in general, will serve as a foundation for successful delivery of and adherence to medical and psychological interventions. Important clinical conclusions include:

  • Early discussion of the brain-gut axis may reduce resistance to integrated behavioral or psychological treatment for pediatric gastroenterological disorders.
  • Sample visual aids and descriptive scripts are available within this review to guide discussions of the brain-gut axis with patients and families for a range of pediatric GI disorders.

My take: This article serves is a useful resource for pediatric psychologists to better understand the ideas of visceral hypersensitivity, stress response, and biological triggers (eg. gut microbiome, infections) for gastrointestinal disorders. Its discussion of biopsychosocial assessment and psychological interventions are helpful for pediatric gastroenterologists to understand the psychological approaches toward treatment.

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NPR: Banana Diet for Celiac Disease

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A recent report from NPR highlights a previous diet for celiac disease -the banana diet. While celiac disease had been discovered in the 1890s by Dr. Samuel Gee, the role of gluten was not understood until WWII.

NPR: Doctors Once Thought Bananas Cured Celiac Disease

Here’s an excerpt:

a high-calorie, banana-based diet [was] invented by Dr. Sidney Haas in 1924. The diet forbade starches but included numerous daily bananas, along with milk, cottage cheese, meat and vegetables…

Haas arrived at his banana diet through an honest error — one that, unfortunately, had serious repercussions for people with celiac disease. In his 1924 paper, he wrote of a town in Puerto Rico where “dwellers who eat much bread suffer from [celiac] sprue while the farmers who live largely on bananas never.”

Haas skipped over the role of wheat and focused instead on the exotic bananas, which he thought held curative powers…

But Haas’ honest error led to serious consequences. As the children recovered, wheat was reintroduced.

It was a Dutch pediatrician, Willem Karel Dicke, who first realized that wheat might be linked to celiac disease. He noticed that in the last few years of World War II, when bread was unavailable in the Netherlands, the mortality rate from celiac disease dropped to zero. In 1952, Dicke and his colleagues identified gluten as the trigger for celiac disease, and the gluten-free diet was born.