Increasing Rates of Abdominal Wall Birth Defect (Gastroschisis)

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From NY Times summary of recent study, “Rate of Birth Defect of Abdominal Wall Increasing, CDC Says“:

The prevalence of gastroschisis has increased by about 30 percent, to 4.9 births out of 10,000 during the period from 2006 to 2012, from 3.6 per 10,000 live births from 1995 to 2005, according to the Centers for Disease Control and Prevention.

My take: This epidemiology is definitely concerning.  Though most children with gastroschisis do well over time, some have serious problems and many require prolonged hospitalizations after birth.

 

Weight Gain in Preemies, Neurodevelopmental Outcomes, and Reverse Causation

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Since a trial which randomizes premature infants into groups that are well-nourished and poorly-nourished and then following them prospectively is never going to happen, it is difficult to know with certainty the effects of optimal nutrition are with respect to long-term neurodevelopmental outcomes.

An article I enjoyed reading on this subject (MB Belfort et al. J Pediatr 2016; 168: 30-5) pushes back on the correlation between good weight gain, as a surrogate marker for nutritional status, and neurodevelopmental outcomes.

In this study, 1070 infants between 23-27 weeks gestational age were followed with weights on days 7-28 along with weights at 12 and 24 months.  This data was compared with several indices on neurodevelopmental outcome.  Here is the key finding:  “Weight gain in the lowest quartile from 7-28 days was not associated with higher risk of adverse outcomes.”

In commentary on their findings, the authors point out that “we found no evidence to suggest that faster weight gain from 7 to 28 days of life reduced the risk of adverse outcomes…almost all of the associations between low weight gain..were attenuated or eliminated when we restricted our analysis to those children able to walk independently.”

“Overall, it appears that low weight in children with severe neurodevelopmental impairments may be caused by factors closely related to the impairments themselves…reverse causation may be at play.” Thus, underlying brain damage may limit body weight gain, rather than poor nutrition limiting brain development.”

My take: I may be apt to ‘confirmational bias’ as this study reinforces my view that improved nutrition may not change outcomes appreciably.  To be clear, I still believe that efforts to optimize the nutrition of premature infants are a good idea but we need to be skeptical about the magnitude of benefit that we will derive.

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A Few Years Ago in Yosemite

A Few Years Ago in Yosemite

Living Liver Donors: 97% Would Do It Again

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A recent study (VR Humphreville et al. Liver Transpl 2016; 22: 53-62) indicates that living liver donors report a high satisfaction following donation.

The authors examined a cohort of 127 living liver donors from the University of Minnesota; donation had occurred between 2 years and 16 years previously.  In addition to a donor-specific survey (DSS) completed by 107, the participants completed the short-form 36 health survey to assess health-related quality of life.

Key findings:

  • Almost all donors reported that they would donate again (97.2%)
  • Satisfaction rate correlated with the outcome of the liver transplant recipient along with pain after donation and vitality after donation. 91.6% rated their satisfaction with the donation process as >8 on a 10 -point scale, with 10 being “extremely satisfied”
  • Health-related quality of life was higher among donors than the general population (though they likely had higher scores than the general population at baseline)

The study elaborates on the potential complications with the most frequent  being incisional discomfort in 34%.

My Take: this information on high satisfaction will be useful for transplant programs and those considering living liver donation.

 

“A Healthy Diet’s Main Ingredient? Best Guesses”

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A recent commentary from the NY Times (A Healthy Diet’s Main Ingredients? Best Guesses) explores some of the failed efforts to improve health by reducing fat or eliminating eggs and explains why these are no longer recommended.  The article has a 12 minute video which reviews some of the confusion regarding dietary recommendations.

Here’s an excerpt:

Conventional wisdom held that fat was bad, period, with relatively few Americans distinguishing between saturated fats (meat, eggs, dairy products) and healthier unsaturated fats (fish, vegetable oils, nuts). Typically, people turned to breads, cereals and potatoes — and to sugary soft drinks — for the calories they no longer got from protein-rich foods…The result? Carbo-loading Americans grew fatter. “We put the whole country on a low-fat diet,” Mr. Taubes said, “and, lo and behold, we have an obesity epidemic.”…

New guidelines are expected to be issued this month by the Departments of Agriculture and of Health and Human Services, which tend to follow the recommendations of an advisory committee. One likely eye-catcher is a new assessment of cholesterol, long an archvillain. It seems destined for rehabilitation to some degree. Months ago, the advisory committee concluded that the dietary intake of cholesterol (the body produces this waxy, artery-obstructing matter on its own) had no real effect on blood levels of LDL, the so-called bad cholesterol. “Cholesterol,” the committee said, “is not a nutrient of concern for overconsumption.”

There is a conspicuous American tendency to cling to a favored diet as the gateway to good health, keeping weight down, staving off cancers and banishing heart attacks. A consequence is an abundance of regimens — vegan, gluten-free, Paleolithic, fruitarian and many more — each promoted by its adherents as the one true path.

But nutrition experts, including those in this Retro Report, caution that life is complex, and that we are more than what we eat.

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Good Press for PPIs

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A lot of medical publications focus on infrequent complications of medications.  This is problematic for many who have trouble understanding absolute risks and relative risks.  If a medication increases the relative risk of a rare problem, the absolute risk to the individual remains quite low.

For proton pump inhibitors, there has been a fair amount of focus on potential complications.  In my view, some of this is due to the fact that there are many taking these medications who may not be receiving much benefit.   Many of the adverse effects for most patients would result in a low absolute risk. In fact, stopping PPIs in those who have indications for their usage could result in significantly greater harm.

For those who’ve been thinking that proton pump inhibitors (PPIs) have been getting a ‘bum rap,’ here are a few publications have highlighted their success in problems other than ulcers and gastroesophageal reflux disease.

  • AJ Lucendo et al. Clin Gastroenterol Hepatol 2016; 14: 13-22.
  • RMM van Aerts et al.  Clin Gastroenterol Hepatol 2016; 14: 147-52.

The first study, a systemic review and meta-analysis of PPIs in inducing remission for eosinophilic esophagitis (EoE).  In all 33 studies (11 prospective) of adults and children were included with 619 patients. Key findings:

  • Clinical response was noted in 60.8%
  • Histologic remission (<15 Eos/hpf in this study) in 50.5%
  • In prospective studies, once-daily therapy had similar effectiveness to twice daily (55.9% vs. 49.7%)
  • pH monitoring did not predict response to PPI therapy

My take: While the conclusion from this study (by the authors) is that PPIs should be considered a first-line therapy for EoE, they also indicate that the findings need to interpreted cautiously due to poor-quality evidence, heterogeneity of the studies, and publication bias.  Despite these limitations, most experts agree that PPI therapy should be undertaken prior to use of other treatments like diets or topical steroids for EoE.

The second study showed that patients with hereditary hemochromatosis needed less phlebotomy if they were taking PPIs.  The study was a retrospective study which divided patients into 3 groups, including a paired group of 12 patients who had ferritin levels and number of phlebotomies compared for 3 years prior and 3 years after the start of PPI therapy.  In this group, phlebotomies were needed 3.16 times per year prior to PPI and only 0.5 per year subsequently (to keep ferritin less than 100 mcg/L).  The authors note that studies have shown that PPIs reduced postprandial iron absorption.  PPIs effect on iron metabolism “acts at cellular level in the endosomes and in the stomach, and it seems to have no influence on the hepcidin regulation.”  For PPI fans, the editorial (pgs 153-55) comments that “an attractive aspect of this strategy is the safety of PPIs, which has been shown even with long-term use.’ [Aliment Phamacol Ther 2015; 41: 1162-74]

My take: While this study is not recommending that patients with hereditary hemochromatosis start PPI therapy, those who are taking PPI therapy may need less frequent phlebotomy.

So, in addition to patients with gastroesophageal reflux disease and peptic ulcer disease, patients with eosinophilic esophagitis and those with hereditary hemochromatosis often benefit from PPI therapy.

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Half Dome, Yosemite

Half Dome, Yosemite

Eating the Right Foods and Weight Loss

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In a recent NY Times article, Rethinking Weight Loss and the Reasons We’re ‘Always Hungry’, the idea that too many calories causes obesity is challenged:

“…overeating doesn’t make you fat. The process of getting fat makes you overeat.”

Here’s an excerpt:

Dr. Ludwig, an obesity expert and professor of nutrition at the Harvard T.H. Chan School of Public Health, argues that weight gain begins when people eat the wrong types of food, which throws their hormones out of whack and sets off a cycle of cravings, hunger and bingeing. In his new book, “Always Hungry?,” he argues that the primary driver of obesity today is not an excess of calories per se, but an excess of high glycemic foods like sugar, refined grains and other processed carbohydrates…

Simply cutting back on calories as we’ve been told actually makes the situation worse. When we cut back on calories, our body responds by increasing hunger and slowing metabolism. It responds in an effort to save calories…

It’s the low fat, very high carbohydrate diet that we’ve been eating for the last 40 years, which raises levels of the hormone insulin and programs fat cells to go into calorie storage overdrive.

My take: The idea of changing the types of foods that we consume is not new in the fight against excessive weight gain.  Some of the best data on healthy eating is associated with the Mediterranean diet.

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Another review (from the NY Times) of the book ‘Happy Gut’ describes a diet promoted by a NY internist to help with problems like irritable bowel: Seeking a ‘Happy Gut’ for Better Health. “Cutting out dairy and gluten reversed many of his symptoms. Replacing processed foods with organic meats, fresh vegetables and fermented foods gave him more energy and settled his sensitive stomach.”

Banning Mills

Banning Mills

 

About Mentors

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I found a recent perspective (Y Tache. Gastroenterol 2015; 149: 1662-65) on mentoring of interest, particularly on the historic basis which I had forgotten.

“In Homer’s book, the Odysseus, Mentor was a loyal friend and adviser to Odusseus (Ulysses), King of Ithaca.  When Ulysses left his kingdom to participate in the Trojan War, he entrusted Mentor with the education of his son, Telemachus…This character of Greek mythology became famous only at the beginning of the 18th century in the context of the didactic French novel entitled “Les Aventures de Telemaque.”

My take: it is interesting to understand where the term “mentor” comes from.  I feel fortunate to have had some terrific mentors.

 

 

Continuous Feeds versus Bolus Feeds

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Briefly noted:

Another study (JB van Goudoever et al. JPGN 2015; 61: 659-64) indicates that bolus feeds are likely as safe as continuous feeds in preterm infants; though, the “continuous” feeding was atypical.  In this study, the bolus group received their feedings every 3 hours via gravity whereas the “continuous” feeding cohort received feedings by gravity by giving one-fourth of the hourly feeding every 15 minutes.

Key finding: In a study of 246 infants (<1750 g & <32 weeks gestational  age), there was no significant difference in reaching full enteral feedings between the group assigned to continuous feedings compared with bolus feedings

Related blog post:  Which is Safer -Drip Feeds or Bolus Feeds in Healthy Preterm …

 

Expect More on Microbiome Modulation with Enteral Nutrition

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Similar to a study reviewed on this blog (Why Does Enteral Nutrition Work for Crohn’s Disease? Is it due to the Microbiome?), another publication has shown decreased microbiome diversity associated with exclusive enteral nutrition (C Quince et al. Am J Gastroenterol 2-15; 110: 1718-29 -thanks to Ben Gold for this reference). The overall findings suggest that enteral nutrition makes the gut microbiome more ‘dysbiotic’ (more dissimilar to healthy controls) than prior to enteral nutrition.  This study examined 23 children with Crohn’s disease and 21 healthy children.

My take: Due to the increased ease and fascination of studying our stools, a lot more of this research is going to be published.  At some point, hopefully, these observational studies will transition to hypothesis-driven studies regarding which microbial species need to be modulated to improve inflammatory bowel disease.

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Salvage Therapy and Standard Therapy for H pylori

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A recent review (thanks to KT Park for reference) provides helpful resource for treating H pylori infection; this is becoming more important in this era of frequent antibiotic resistance. While this blog has reviewed expert recommendations for treatment, this article provides more insight into salvage treatments.  Table 1 reviews standard quadruple and triple regimens. Table 2 (below) provides dosing in adults for salvage therapy.

Thung, I., et al. (2015), Review article: the global emergence of Helicobacter pylori antibiotic resistance. Alimentary Pharmacology & Therapeutics. doi: 10.1111/apt.13497

Full link: Review article: the global emergence of Helicobacter pylori antibiotic resistance

 

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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.