Ultra-Short Celiac Disease

Posted on July 11, 2016 by gutsandgrowth

It is well-recognized that obtaining a duodenal bulb biopsy increases the likelihood of making a diagnosis of celiac disease. Another study (PD Mooney et al. Gastroenterol 2016; 150: 1125-34) has tried to quantitate the frequency of “ultra-short” celiac disease (USCD).

In this prospective study of 1378 patients (mean age 50.3 yrs) who underwent endoscopy between 2008-2014, there was a cohort who had a high clinical suspicion of celiac disease in which quadrantic biopsies of the duodenal bulb were obtained.

Key findings:

268 (19.4%) were diagnosed with celiac disease
26 (9.7%) of celiac population had disease identified primarily in the duodenal bulb. These patients with USCD were younger (P=.03), had lower serologic titers of tissue transglutaminase antibody (tTG) (P=.001), and less frequently had diarrhea (P=.001).
In USCD, the tTG titers were a median of 4.8x ULN compared with 20x ULN in those with more extensive disease.
While the authors characterize 26 as having USCD, 19 of the 26 did have Marsh 1 (n=18, 69.2%) or Marsh 2 (n=1, 3.8%) lesions, indicating at least some involvement more distally. However, in these patients the duodenal bulb findings clinched the diagnosis.

Despite the protocol, the authors showed that a single biopsy from the bulb was sufficient to increase the diagnostic yield.

My take: This study reinforces the need for duodenal biopsies from both the bulb and more distally when the diagnosis of celiac disease is being considered.

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More Than 100 Leading Scientists: “Stop Bashing GMO Foods”

Posted on July 10, 2016 by gutsandgrowth

“Scientific and regulatory agencies around the world have repeatedly and consistently found crops and foods improved through biotechnology to be as safe as, if not safer than those derived from any other method of production,” the group of laureates wrote. “There has never been a single confirmed case of a negative health outcome for humans or animals from their consumption. Their environmental impacts have been shown repeatedly to be less damaging to the environment, and a boon to global biodiversity.”

Here’s the link: NY Times Stop Bashing GMO Foods

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Zip Code vs. Genetic Code

Posted on July 9, 2016 by gutsandgrowth

Several posts have highlighted the importance of poverty contributing to high mortality, including the following:

The following infographic shows again how your zip code is likely more important than your genetic code.

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Gastrostomy Tubes: The First 30 Days

Posted on July 8, 2016 by gutsandgrowth

A retrospective study (AB Goldin et al. J Pediatric 2016; 174: 139-45) provides a better idea about the likelihood of complications by looking for ED visits and admissions within 30 days of placement.

This study involved 38 Children’s Hospitals and 15,642 patients the Pediatric Health Information System (PHIS) database. Key findings:

8.6% had an ED visit within 30 days
3.9% had an admission within 30 days
Common reasons for return visits: infection (27%), mechanical complication (22%) and replacement (19%).

The authors note that risk factors for ED visits and admission were mainly non modifiable like race/ethnicity and medical complexity. They also note that problems in the early postoperative period are grossly underestimated due to many issues being addressed in the outpatient setting.

This study indicates that there is a tremendous opportunity for improvement. There is great variation in hospital practices with regard to the type and method of placing gastrostomy tube. In addition, there is a high variability in the determination of the need for fundoplication which is often undertaken at the time of gastrostomy tube placement.

My take: Understanding these risks is important to give families accurate information prior to placement of gastrostomy tubes. In addition, these high rates of complications indicate the need for head-to-head prospective trials comparing types of gastrostomy tube placement and education efforts.

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Even Normal Body Mass Index Could Be a Problem

Posted on July 7, 2016 by gutsandgrowth

A recent study (G Twig et al. NEJM 2016; 374: 2430-40) which had more than 42 million person-years of followup (1967-2010) showed that adolescents with a BMI in the 50th to 74th percentile (CDC values), well within the accepted normal range, had increased cardiovascular and all-cause mortality.

The study involved more than 2.3 million Israeli adolescents with up to 40 years of followup information. The study utilized data obtained from 17 year olds who were seen 1 year prior to mandatory military service. There was increasing mortality associated with higher BMI subgroups.

Key findings:

For those between the 50-74% in adolescence: the hazard ratios for coronary heart disease 1.49, for stroke 1.18, and total cardiovascular causes was 1.32.
For those ≥95% (obese) in adolescence: the hazard ratios for coronary heart disease 4.89, for stroke 2.64, and total cardiovascular causes was 3.46.

My take: this study shows that even modest increases in BMI are associated with modest increase in cardiovascular mortality over 40 years. Whether the BMI itself plays a causal role or is more of an epiphenomenon of other risk factors (eg. sedentary risk factors) is not clear.

Adverse Events Following Pediatric Endoscopy –Underestimated Previously

Posted on July 6, 2016 by gutsandgrowth

A recent study (RE Kramer, MR Narkewicz. JPGN 2016; 62: 828-33) report the frequency of adverse events that occurred within 72 hours in a prospective observational cohort of 9577 patients from a single center.

The authors characterized complications more precisely and identified a much higher rate of complications than what has previously been reported. Key findings:

The overall adverse event rate was 2.6% with 1.7% of all cases requiring unanticipated medical care.
Absolute risk of bleeding was 0.11%, infection 0.07%, and perforation 0.1% (n=12). In total, these standard measures of complications were 0.28%.
Advanced and therapeutic cases had much higher rates of adverse events. Perforations occurred after esophageal dilatation (5), esophageal food impaction (1), polypectomy (4), and primary GJ placement (2).
Adverse rate with ERCP was 11.54%
Adverse rate with PEG was 10.71%
Adverse rate with dilatation was 10.94%. It is noted that a total of 319 dilatations were reviewed. 5 had perforations.
Adverse rate with polypectomy was 6.27%. It is noted that a total of 128 polypectomies were reviewed. 4 had perforations.
The authors did not identify a significantly higher complication rate with trainee physicians.

As noted in a previous entry (see below), studies in adults have an estimated a perforation rate of 0.09% and serious complication rates (GI and non-GI complications) of 0.15% for upper endoscopy and of 0.2% for colonoscopy. In addition, a large pediatric study of endoscopies, found a perforation rate of 0.014% for EGDs and 0.028% for colonoscopies. Thus, this report identifies a higher rate (10-fold) of perforation (driven by therapeutic endoscopy) and a much higher rate of adverse events, including 2.08% in diagnostic EGD and 3.9% for diagnostic colonoscopy. Furthermore, for diagnostic EGD and for diagnostic colonoscopy, grade 2 (needing ER or unanticipated physician evaluation) or higher adverse events occurred in 1.21% and 2.31% respectively.

My take: Using a broader (and more accurate) definition of complications after endoscopy, the authors have demonstrated a much higher rate of adverse events, particularly following dilatation, PEG, polypectomy, and ERCP. This report indicates that our preop counseling needs to be modified to inform families that complications are not quite so rare.

Related blog post: High Endoscopy Complication Rate After Intestinal …

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Soap Suds Enemas & ED Management of Impactions

Posted on July 5, 2016 by gutsandgrowth

A recent retrospective single-center study (CE Chumpiitazi et al. JPGN 2016; 63: 15-18) identified 512 patients (8 mo-23 years) who were treated with soap suds enemas (20 mL/kg of water with one packet of castile soap). Key findings: No serious adverse events were identified. “82% were successfully treated.”

While this large study provides a fair amount of reassurance, the associated editorial (pg 1-2) makes some key points:

ED diagnosis of fecal impaction is unreliable. “Abdominal radiographs are often performed…[but] have shown unsatisfactory sensitivity and specificity.” In this study, only 38% had reported history of constipation; thus a high number of children developed impactions without prior constipation. Thus, either many of these children were not impacted or the history was unreliable.
“SSEs are likely to be very effective, but so are phosphate enemas and milk and molasses enemas that have fallen out of favor because of safety concerns.”
In the editorial, until prospective studies are completed, the authors advocate considering oral PEG (high-dose) or ducosate enemas, normal saline enemas, glycerin enemas, mineral oil enemas, or bisacodyl enemas.

My take: While the editorial makes some valid points, particularly making sure that treatment for an impaction is needed, I think this study provides good preliminary data on the safety of soap suds enemas. As with all pediatric treatments, more high-quality studies would be welcome.

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Apple Juice for Gastroenteritis

Posted on July 4, 2016 by gutsandgrowth

While oral rehydration solutions (ORS) are a major advance, particularly for severe diarrhea, for milder cases diluted apple juice is probably better for most children according to a recent study (Freedman SB et al. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: A randomized clinical trial. JAMA 2016 Apr 30; [e-pub]). While the balance of sugar and salt in ORS enhance fluid absorption, administration of ORS can be complicated by limited acceptance, especially in children.

From Epocrates Summary:

Juice Is Best for Treating Mild Gastroenteritis with Minimal Dehydration

Dilute apple juice for initial hydration followed by fluids of the child’s choice was superior to electrolyte maintenance solution for treating children with mild gastroenteritis and minimal dehydration…

In a single-blind noninferiority trial, researchers randomized 647 children (aged 6−60 months) presenting to a Canadian pediatric emergency department with gastroenteritis and minimal dehydration to receive either 1) half-strength apple juice for initial hydration followed by fluids of the child’s choice or 2) apple-flavored electrolyte maintenance solution. The primary outcome was treatment failure, defined as occurrence of any of the following within 7 days: intravenous rehydration, hospitalization, unscheduled visit to a physician, treating physician’s request to cross over to other study arm, weight loss ≥3% or Clinical Dehydration Scale score ≥5 at follow-up.

Treatment failure was significantly lower in the juice/preferred fluids group (16.7% vs. 25.0%); the difference met the study’s criteria for noninferiority and superiority. Significantly fewer children in the juice/preferred fluids group received intravenous rehydration at the index visit (0.9% vs. 6.8%) and within 7 days (2.5% vs. 9.0%). Juice/preferred fluids was most beneficial in children ≥24 months of age (treatment failure rate, 9.8% vs. 25.9%).

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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.

How Gut Microbes Could Lead to Atherothrombotic Disease

Posted on July 3, 2016 by gutsandgrowth

About three years ago, this blog looked at the link between gut microbes, diet, genes and heart disease (Linking diet, genes, and gut microbes to…heart disease | gutsandgrowth).

A summary of the most recent information on this topic: H Tilg. “A Gut Feeling About Thrombosis” (NEJM 2016; 374: 2494-6).

Background: Previous research has shown that certain dietary nutrients that include choline are processed by gut microbes to produce trimethylamine (TMA) which is converted into TMA-N-O (TMAO) by the liver. Particular foods that have been associated with higher TMAO include meats and eggs. It has been observed that antibiotics, presumably by their affect on gut microbes, reduce TMAO levels.

What’s new: Zhu et al (Cell 2016; 165: 111-24) “gave mice excess of dietary choline, microbe-generated TMAO enhanced platelet responsiveness in vivo, promoting a prothrombotic phenotype” was blocked by the administration of oral antibiotics. Fecal microbiota transplantation, however, elevated the risk of thrombosis when administered to germ-free mice.

This data shows more clearly a causal relationship between TMAO and thrombotic mechanisms via platelet activation and a causal relationship between gut microbes and TMAO levels. However, this data does not determine exactly how we should modify our diets and or microbes to achieve improved clinical outcomes.

Politics and Limiting Physician Speech

Posted on July 2, 2016 by gutsandgrowth

A concise review/commentary (WE Parmet et al. NEJM 2016; 374: 2304-7) of Wollschlaeger v Governor of Florida explains how attempts to support the gun lobby are likely imposing unconstitutional limits on the free speech of physicians as well as undermining good health policy.

This law “prohibits physicians from intentionally entering into a patient’s record information about firearm ownership that ‘is not relevant to the patient’s medical care or safety, or the safety of others’; prohibits physicians from asking patients (or for minors, patients’ parents) about firearm ownership unless they believe ‘in good faith’ that ‘information is relevant to patient’s medical care or safety.'”

There are good reasons for physicians to inquire about guns in the homes as there is definitive evidence that a gun in the home increases the risk of death, especially by suicide. The odds, on average from studies, is a 3-fold risk in homes with guns, but even higher for children and adolescents.

The law is counter productive as well. “Studies to date, as limited as they are, suggest that gun owners so counseled are more likely to change storage practices than to remove guns from their homes.”

While the politics with firearms is heavily influenced by well-funded lobbyists, there are other areas in which there are laws regulating physician speech, including abortion and fracking.

My take: I think it is outrageous that there are laws curtailing a physician’s free speech and efforts to dictate practice based on political philosophy. I hope they will not be upheld.

Related blog post: Can the FDA prohibit free speech? | gutsandgrowth