Best Tweets from Postgraduate Course: #NASPGHAN15

Posted on October 9, 2015 by gutsandgrowth

Since I am not at this year’s national meeting, I have followed some of the information on social media. Here are some of the best tweets:

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The Slow March of the Digital Health Revolution

Posted on October 8, 2015 by gutsandgrowth

A recent commentary (SD Dorn. Gastroenterol 2015; 149: 516-20) provides insight on the digital health revolution.

Key points:

“Amara’s law –that ‘we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run’–seems to apply to digital health. Expect short-term gains to be incremental.”
The promise of ‘big data’ has not translated into big changes yet. “Many systems are not interoperable owing to cost, competition, privacy concerns, and technical barriers.”
Mobile health, mHeath, “is skewed toward those who need the least help: the young, the fit, and the educated.” And, there is “no evidence supporting the effectiveness of the vast majority of mHealth tools.”

What’s wrong with electronic health records?

“The overall evidence that EHRs improve safety and quality is spotty. Cost savings remain elusive.” Some reasons include that more time is needed and/or flaws in EHR design.
EHRs are not very usable –excessive clicks and scrolling.
EHRs “reduce productivity and can add hours to the busy clinician’s day”
Physicians “now spend up to two-thirds of a typical outpatient visit documenting.”
Clinical records may be more legible, but they are often less useful. “Template-generated notes frequently lack coherent narratives, are bloated with extraneous and repetitive information, and sometimes contain obvious errors that are copied forward from one note to another.”
“Physicians suffering from ‘alert fatigue’ may ignore potentially valuable clinical alerts.”
EHRs require frequent sign-ins and computers often have to be unlocked.
EHRs are expensive.
“In total, EHRs significantly worsen physician satisfaction.“

From a patient vantage, EHRs offer the possibility of patient portals to send physician messages, obtain test results, request medication refills, and schedule appointments. Telehealth offers the potential for expert advice from great distances.

Some integrated health systems, including the Veteran’s Health Administration and Kaiser Permanente, have shown that EHRs can be successful.

My take: The transition to digital technologies has great promise but could lead to a less personal approach. So far, the transition to digital health has been a bumpy slow road.

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Why D5 1/2NS was the Right Choice in the 1950s!

Posted on October 7, 2015 by gutsandgrowth

For many, a frequent practice is to order D5 1/2NS intravenous fluids for maintenance IVFs. An expert review (ML Moritz, JC Ayus. NEJM 2015; 2015: 373: 1350-60) of this topic explains why this was right in the 1950s but is usually the wrong choice today.

Key points:

Use of hypotonic maintenance fluids (sodium concentration <130 mmol per liter), “has been associated with a high incidence of hospital-acquired hyponatremia and more than 100 reports of iatrogenic deaths or permanent neurologic impairment related to hyponatremic encephalopathy.”
Acutely ill patients have “disease states associated with excess arginine vasopressin.”
Recommendations on the use of hypotonic fluids were “based on theoretical calculations from the 1950s, before the syndrome of inappropriate antidiuresis was recognized as a common clinical entity.”
“More than 15 randomized, prospective trials involving more than 2000 patients have evaluated the safety and efficacy of isotonic fluids…most of these studies involved children…isotonic fluids were superior.” Limitations: these studies were typically <72 hours and excluded patients with renal disease, heart failure, and cirrhosis.
The authors also note potential problems with 0.9% NS for rapid infusion, perhaps related in part to the polyvinyl chloride bags which lowers the pH. “0.9% saline, as compared with balance salt solutions, may produce a hyperchloremic metabolic acidosis, renal vasoconstriction, an increased incidence of acute kidney injury requiring renal-replacement therapy, and hyperkalemia.”
Hypotonic fluids may be appropriate in the setting of established hypernatremia or a clinically significant renal concentrating defect (with free-water losses).

My take: D5 1/2 NS and other hypotonic fluids should not be used commonly as a maintenance fluid.

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Nutrition Support for Intestinal Failure

Posted on October 6, 2015 by gutsandgrowth

A recent blog post by Kipp Ellsworth (The Pediatric Nutritionist) highlights a recent lecture by Conrad Cole that provides several useful points. The post includes a link (embedded talk) to 76 slides. Here are a few:

Iodine deficiency: Dr. Cole “typically orders a TSH level every six months, also ordering a spot urine iodine if a significant TSH uptrend emerges.”
Lipids: “Dr. Cole reviewed evidence revealing the restriction of soy-based lipids to 0.5 gm/kg/day as nearly efficacious as the use of fish-oil infusion (Omegaven) in preventing PNALD.” Daily use of 0.5-1 gm/kg/day is less error-prone than using lipids 3-4 times/week.
Formula: “breastmilk constitutes the touchstone of enteral nutrition choices for the intestinal rehab patient, conferring a host of benefits beyond those associated with formula alone… the medium-chain triglyceride component of many oligomeric and monomeric formulas constitutes a therapeutically valuable source of nutrition, increasing the proportion of calories absorbed.”
Formula for toddlers: “Dr. Cole continues transitioning his patients to oligomeric and monomeric formulas such as Elecare Junior, Pediasure Peptide, and Peptamen Junior upon reaching toddlerhood.”
Fiber: “Dr. Cole recommended the use of a sc-FOS product such as NutraFloraas optimal for the short bowel syndrome population. Dr. Cole initially doses soluble fiber at 1 gm/100 mL of formula and advances as tolerated to a maximum of 2 gm/100 mL formula. He typically does not use supplemental fiber to control ostomy output in patients without a colon in continuity”
Enteral fish oil: “Dr. Cole remains unconvinced of the therapeutic value of enteral fish oil supplementation pending further research studies on the subject.”

Funding for his talk was provided by Abbott Nutrition.

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Medical Progress for Intestinal Failure Associated Liver Disease

Posted on October 5, 2015 by gutsandgrowth

A recent review (WS Lee, RJ Sokol. J Pediatr 2015; 167: 519-26) provides a good explanation of the role of various intralipids and intestinal microbial dysbiosis in the setting of intestinal failure-associated lipid disease (IFALD).

The review discusses criteria for IFALD (e.g. conjugated bilirubin ≥2 mg/dL & parenteral nutrition ≥14 days), the epidemiology, and the pathogenesis. Potential risk factors and level of evidence for these risk factors is noted in Table 1.

Table 2 describes the evidence supporting suggested strategies for the prevention of IFALD. The effectiveness and recommendation levels for these strategies are generally very low and weak based on reviews by ASPEN and the American Pediatric Surgical Association. Among the strategies, reduction of lipid emulsion to ≤ 1 g/kg/day has some of the strongest support in this table but is still regarded as level III evidence and described as “probably effective.” Other strategies reviewed included ethanol locks, multidisciplinary team management, use of ursodeoxycholic acid/bile acid supplementation, cycling of parenteral nutrition, use of prokinetics, removal of manganese and copper from parenteral nutrition, and antibiotic use to prevent bacterial overgrowth.

With regard to alternative intravenous lipids (eg. fish oil, or SMOF mixture):

“Although a properly powered randomized controlled trial has not been conducted, current evidence suggests that the use of FO-ILE [fish oil -intravenous lipid emulsion] is effective in reversing the established cholestasis associated with IFALD, but there is insufficient evidence for a preventative effect in neonates.”
“Most studies have been retrospective, used a historical comparison group, used different doses of lipid, and were conducted in patients with quite advanced IFALD.”
Use of FO-ILE improves biochemical parameters, but has not been shown to “improve other important long-term clinical outcomes, such as severity of hepatic fibrosis.”
In addition, reduced ILE and FO-ILE may result in other sequelae such as cognitive developmental delay. “Recently, lower brain weight and alterations of brain PUFA content were demonstrated in newborn piglets receiving total PN with reduced dose SO-ILE or FO-ILE compared with normal dose SO-ILE.”

My take: This review underscores how little is known about the approaches often recommended for management of IFALD.

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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.

Why We Vaccinate: Life after Polio

Posted on October 4, 2015 by gutsandgrowth

Phase 3 Trial of Sebelipase Alfa for Lysosomal Acid Lipase Deficiency

Posted on October 3, 2015 by gutsandgrowth

A recent report (BK Burton et al. NEJM 2015; 373: 1010-20, editorial 1071-1) provides preliminary evidence of efficacy of Sebeliplase Alfa for lysosomal acid lipase deficiency.

In this multicenter, randomized, double-blind, placebo-controlled study of 66 patients, enzyme replacement therapy with Sebelipase alfa was examined (1 mg intravenously every other week). After 20 weeks, all patients were treated by open-label. Of the 32 patients who had had liver biopsies, 10 (31%) were noted to have cirrhosis.

Findings:

Alanine aminotransferase normalized in 11 (36%) of treated patients compared with 2 (7%) of controls
Improvement in lipid levels and reduction in hepatic fat content were evident in treated patients (P<0.001 for all comparisons, except P-0.04 for triglycerides

The editorial provides a schematic explaining how sebelipase alfa targets the hepatocyte (Figure 1). The authors note that “longer-term follow-up in a larger number of patients will be required for confirmation.”

How Much Morphine Should Be Prescribed?

Posted on October 2, 2015 by gutsandgrowth

In comparison to other medications, opioid pain medications are more carefully regulated, have the potential for more severe adverse reactions, and written prescriptions are needed for dispensing. So, trying to provide the right amount is a little tricky. With this background, a recent study (M Aboud-Karam et al. J Pediatr 2015; 167: 599-604) examines the use of morphine after pediatric surgery.

This prospective study included 243 subjects. Findings:

56% of participants who received a scheduled (“regular basis”) prescription administered the medication as ordered. The most common reason for deviation was a lack of pain or mild pain relieved by acetaminophen. 33 of the 104 patients who received a scheduled prescription did not even pick up the medication from the pharmacy.
85% of participants in the “as needed” prescription group were administered morphine as ordered; however, 76% of this group took two or fewer doses. In this “as needed” group, a subset of 77 participants had precise data about the amount of morphine that they received. Less than 10 % of the prescription doses available were administered.

The authors note that morphine is covered in Canada by both private and government-based insurance plans such that there are unlikely to be financial constraints limiting medication usage. They note that the unused medication is a safety hazard due to potential for accidental ingestions.

My take: this study suggests that prescriptions with fewer doses of morphine may be warranted.

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HCV Update -Fall 2015

Posted on October 1, 2015 by gutsandgrowth

Briefly noted:

S Naggie et al. NEJM 2015; 373; 705-13. Among patients coinfected with HIV-1 and HCV (genotypes 1 and 4), 12 weeks of ledpasvir and sofosbuvir resulted in a 96% sustained HCV virological response.

DL Wyles et al. NEJM 2015; 373; 714-25. Among patients coinfected with HIV-1 and HCV (genotype 1), 12 weeks of daclatasvir plus sofosbuvir resulted in a 97% sustained HCV virological response.

HA Innes et al. Hepatology 2015; 62: 355-64. Review of a Scottish HCV clinical database showed that a sustained viral response was associated with a reduced liver mortality (adjusted Hazard Ratio 0.24), a reduced non liver mortality (aHR 0.24) and reduced behavioral events (eg. violence-related injury aHR 0.51). The latter improvement suggests that HCV eradication leads to healthier lives.

Also, seeing as today is ICD-10 Rollout: ICD-10: Source for humor? | gutsandgrowth

View from Signal Lodge, Grand Tetons

Useful Information on Eosinophilic Disorders

Posted on September 30, 2015 by gutsandgrowth

A review (JB Wechsler et al. J Asthma Allergy 2014; 7: 85-94) provides practical advice on dietary management of eosinophilic esophagitis (EoE); the section on food reintroduction from elemental diets for patients with EoE is particularly helpful. They start with typically less allergenic foods (group A) to most allergenic (group D) -from their Table 2:

Group A:

Vegetables (nonlegume): carrots, squash, sweet potato, white potato, string beans, broccoli, lettuce, beets, asparagus, cauliflower, Brussel sprouts
Fruit (noncitrus, nontropical) apples, pear, peaches, plum, apricot, nectarine, grape, raisins
Vegetables: tomatoes, celery, cucumber, onion, garlic, and other vegetables

Group B

Citrus fruit: orange, grapefruit, lemon, lime
Tropical fruit: banana, kiwi, pineapple, mango, papaya, guava, avocado
Melons: honeydew, cantaloupe, watermelon
Berries: strawberry, blueberry, raspberry, cherry, cranberry

Group C

Legumes: lima beans, chickpeas, white/black/red beans
Grains: oat, barley, rye, other grains
Meat: lamb, chicken, turkey, pork

Group D

Fish/shellfish
Corn
Peas
Peanut
Wheat
Beef
Soy
Egg
Milk

Also, this review includes a long list of “freebie” foods allowed while on elemental diet, including artificial flavors/colors, corn syrup, oils, salt, crystal lite, and many others.

The authors note that “in our practice, the period of exclusive elemental formula is limited to 4 weeks prior to therapeutic assessment by endoscopy and reintroduction…Single foods are introduced every 5-7 days” within a group and then endoscopy after 3-4 foods are clinically tolerated.” Foods from groups C and D are introduced more cautiously.

Also noted: HM Ko et al. Am J Gastroenterol 2014; 109: 1277-85. This retrospective study of 30 children with severe gastric eosinophilia (mean age 7.5 years) provides a good deal of useful information. Key point: “the disease is highly responsive to dietary restriction therapies.” 82% of patients responded to dietary restrictions and 78% had a histologic response as well. Dietary treatments included amino acid-based diet in 6 (n=6), 7-food group empiric diet (n=6), and empiric avoidance of 1-3 foods (n=5). Pharmacologic treatments (proton pump inhibitor or cromolyn) were attempted in a total of four patients in this series with half responding clinically and one of four responding histologically.

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