Will I Have This Stomach Pain Forever? (Part 1)

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More data (Clin Gastroenterol Hepatol 2014; 12: 2026-32) helps answer the question about the persistence of functional abdominal pain from childhood into young adulthood.

Using a longitudinal study design, consecutive new pediatric patients (8-16 years) with functional abdominal pain from a subspecialty clinic were contacted on average 9.2 years (n=392) after their initial evaluation.

Key findings:

  • 41% continue to meet criteria for a functional GI disorder, most commonly irritable bowel syndrome (110 of 169 patients).
  • Severity of pain was not a predictive factor of persistence
  • Extraintestinal somatic complaints and depressive symptoms increased the risk of having persistent functional abdominal pain.

The associated editorial (pages 2033-36) comments on the strengths of the study and the potential opportunity of intervening to prevent persistence of abdominal pain.  It notes that anxiety and hypervigilance can lower the brain’s perception threshold and lead to increased pain.  “From this perspective, centrally targeted treatments such as psychological treatment or psychopharmacological treatments will likely have therapeutic value.”

Take-home message: 59% of patients resolve their symptoms with time.

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Liver Update -January 2015

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Briefly noted:

1. Gastroenterology 2014; 147: 1327-37 (editorial 1216-18).  “Probiotic VSL#3 reduces liver disease severity and hospitalization in patients with cirrhosis: a randomized, controlled trial.” 66 patients received VSL#3 (9 x 10 to the 11th bacteria), 64 patients received placebo -both groups studied for 6 months. Treatment with lactulose and rifaximin were withdrawn a week prior to study entry. Key findings: ‘fewer hospitalizations for severe encephalopathy, better quality of life, and decreases in Child-Turcotte-Pugh class and Model for End-Stage Liver Disease.’  Hazard ratio for preventing hospitalization with VSL#3 was 0.52. However, the findings did not show that VSL#3 reached a statistically-significant reduction in recurrence rate for hepatic encephalopathy. No adverse events were noted.

2. NY Times: Gilead sued over cost of Sovaldi.

3. N Engl J Med 2014; 371:2375-2382.  Link to abstract: Interferon-free Antiviral Regimen for HCV after Liver Transplantation:  “Treatment with the multitargeted regimen of ombitasvir–ABT-450/r and dasabuvir with ribavirin was associated with a low rate of serious adverse events and a high rate of sustained virologic response among liver-transplant recipients with recurrent HCV genotype 1 infection, a historically difficult-to-treat population.”

4. “Transplantation Traffic –Geography as Destiny for Transplant Candidates” NEJM 2014; 271: 2450-52.  Describes ongoing geographic inequality in organ distribution and obstacles to improving allocation.

5. Liver Transpl 2015; 21: 57-62. Immediate Extubation After Pediatric Liver Transplantation –feasible in 67% according to this retrospective review.

Local Law Office --Truth in Advertising?

Local Law Office –Truth in Advertising?

Water -Often Missing from Diet

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A recent NPR report indicates that a faction of scientists is pushing for a water icon to be added to the government’s MyPlate.

Here’s the link: Missing from MyPlate? Water

Here’s an excerpt:

“Consumption of sugary beverages is the leading contributor to added sugar in the American diet,” says Christina Hecht, senior policy adviser at the UC Nutrition Policy Institute and one of the water advocates. “If people could make that one change to drink water to quench their thirst instead of sugar beverages, that would solve a big piece of the problem.”

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Resistance to Maintenance of Certification

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For those opposed to the Board Certification process, the arguments are well-detailed in a recent editorial (NEJM 2015; 372: 106-8); the preceding editorial, in contrast, argues that maintenance of certification (MOC) is positively affecting the care of patients.

Some of this discussion has been mentioned previously on this blog: After I Passed The Test | gutsandgrowth

Key points:

  • “High-quality data supporting the efficacy of the program [MOC] will be very hard, if not impossible, to obtain.”
  • Many physicians believe “that the exam questions are not relevant to their practice or a reliable gauge of physicians’ knowledge.”
  • Many physicians believe “that closed-book tests are no longer relevant, since physicians can now easily turn to online resources.”
  • An excellent alternative to the MOC to support lifelong learning is continuing medical education (CME).
  • The authors note that the American Board of Internal Medicine (ABIM) “is a private, self-appointed certifying organization. Although it has made important contributions to patient care, it has also grown into a $55-million-per-year business, unfettered by competition, selling proprietary, copyrighted products.”

Here’s the link: “Boarded to Death –Why Maintenance of Certification is Bad for Doctors and Patients”

Another viewpoint on this issue from Bryan Vartabedian/33 charts: 33 Shorts

What’s Wrong with “I Want My Kid Tested For Food Allergies”

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Most parents, and many physicians, do not understand the limitations of food allergy testing.  As I am sure is common among physicians, I frequently receive requests for food allergy testing; parents do not realize that the strategy for food allergy testing is not straight-forward and has not advanced significantly for decades.  This information is detailed in a recent study and associated editorial (J Pediatr 2015; 166: 97-100, editorial 8-10: “Pitfalls in Food Allergy”).

The study was a retrospective review of all new patients seen at a pediatric food allergy center (2011-2012).  This involved a review of 797 new patients.

Key findings:

  • Of 284 patients who had received a food allergy panel, only 90 (32.8%) had a history warranting evaluation for food allergy.
  • Among 126 individuals who had food restrictions imposed based on food allergy panel testing, 112 (88.9%) were able to re-introduce at least 1 food into their diet.
  • The positive predictive value of food allergy testing was 2.2%.

So what can we learn from this study and editorial?

Misdiagnosis often relates to a lack of understanding regarding serum IgE-based testing.  First of all, many children with atopic dermatitis (and other atopic conditions) have elevated total IgE which results in more false positives.  In addition, a positive IgE test for a specific food indicates sensitization but not necessarily an allergy.

Strategy for testing (recommended by editorial):

  • “The key to the diagnosis of food allergy cannot be overstated; it begins with a detailed clinical history”
  • Testing should be “limited in general to the food(s) in question.”
  • When there is uncertainty, oral food challenges can be performed by specialists.
  • “If a patient is consuming a food without clinical symptoms of allergy, allergy testing should not be done to that food.”

Bottomline (from authors’ conclusion): “Food allergy panel testing often results in misdiagnosis of food allergy, overly restrictive dietary avoidance, and an unnecessary economic burden on the health system.”

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Positive Results for Probiotics in Latest Study of Colicy Infants

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While not all studies have demonstrated benefit of probiotics for infant colic, many have, particularly in breastfed infants.  The latest study (J Pediatr 2015; 166: 74-78) shows that “administration of L reuteri DSM 17938 significantly improved colic symptoms by reducing crying and fussing times in breastfed Canadian infants.”

This study was conducted between 2012-2014 and enrolled 52 infants.  These infants were randomized to either probiotics or placebo; the study was double-blind as well.

Key results:

  • For the 21 day study:  Total average crying and fussing times for probiotic group was 1719 ± 750 minutes compared with 2195 ± 764 minutes in the placebo group. (P=0.028)
  • At the end of the study, the probiotic group crying/fussing for 60 minutes per day compared with 102 minutes/day in the placebo group.  (P=0.045)

Take-home message: In breastfed infants, the probiotic L reuteri DSM 17938 reduced crying.

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Neonatal Nutrition Lecture -What We Know Right Now

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A recent terrific lecture at Northside Hospital’s neonatology conference by Reese Clark highlighted what we know about neonatal nutrition and what we should be striving to achieve.  This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Dr. Clark was willing to share slides from his talk and a related talk on necrotizing enterocolitis:

Here are a couple of key points from his talk regarding postnatal growth and feedings:

  • Every baby needs good nutrition.  While this is an obvious point, a lot of effort is focused on aspects of care needed in only a small number of neonates.
  • New target for weight gain in premature infants should be 20 gm/kg/day.  This growth is associated with better outcomes (Pediatrics 2006; 117: 1253 Ehrenkranz RA).  In this study, which controlled for a large number of variables, those in the top quartile of growth had much lower rates of cerebral palsy and neurologic impairments.  These improvements were also significant when comparing those in the top quartile to those in the 2nd and 3rd quartiles who were not sicker than those in the top quartile.
  • Most premature neonates are not achieving adequate growth with z-scores for weight and height lower at discharge from the NICU than their z-scores at birth. That is, despite advances in enteral and parenteral nutrition, premature neonates are falling behind while in the NICU. (Clark RH, et al. Pediatrics 2003; 111: 986)
  • Recognizing the supremacy of human milk has been the most important advance and has lead to much lower rates of necrotizing enterocolitis.  There is now a great case for exclusive human milk (J Pediatr 2013; 163: 1592-95; BMC Res Notes 2013; 6: 459)
  • With parenteral nutrition, higher amounts of amino acid have been associated with less issues with hyperglycemia. (Pediatrics 2007; 120: 12: 86-96; Pediatrics 2013; 163: 1278-82)
  • Insulin for hyperglycemia has been associated with poorer outcomes.
  • Does carnitine help with lipid metabolism? No one really knows –no randomized trials.
  • Continuous NG feeds are not associated with fewer signs/symptoms (e.g.. apnea, bradycardia, arching) than NG bolus feeds.
  • Acid suppression in neonates is not effective and potentially harmful
  • We need to use the best growth curves for premature infants: Fenton and Olsen growth charts

Since there are not going to be any trials randomizing neonates into groups assigned to poor growth, we will not know with certainty the impact of good nutrition on long-term outcomes.  Issues with reverse causation and selection bias make it difficult to know whether those with poor growth had other factors besides their nutritional plan which contributed to their outcomes.

Bottomline: We need to continue to optimize nutrition in premature infants; this includes using human milk and preventing necrotizing enterocolitis (which includes avoid acid blockers).  Our goal should be to have infants leave the NICU better nourished than when they arrived.

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.

 

Infliximab -Low Response in Young Kids (7 years and younger) with IBD

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 JPGN 2014; 59: 758-62. The full abstract for this reference follows but the message from this retrospective study of 33 children is clear –a much smaller percentage of the youngest children respond to infliximab compared to older children, adolescents and adults. In the discussion, the authors note that younger children may need higher dosing to maintain good infliximab levels or the disease pathogenesis may be much different (eg. underlying immunodeficiency and different gene mutations).

Here’s the abstract (from JPGN twitter feed):

Background: Infliximab (IFX) is efficacious for induction and maintenance of remission in pediatric patients with moderate-to-severe inflammatory bowel disease (IBD). It has, however, not been studied in patients 7 years old and younger. Our aim was to characterize efficacy and safety of IFX therapy in this cohort.

Methods: This was a retrospective study of patients with IBD ages 7 years and younger, treated with IFX between 1999 and 2011. Medical records were reviewed for age of diagnosis, disease phenotype, therapy, surgery, IFX infusion dates, dose, and intervals. Outcome measures included physician global assessment, corticosteroid requirement, and adverse events.

Results: Thirty-three children (ages 2.4–7 years) were included. Twenty patients had Crohn disease, 4 had ulcerative colitis, and 9 had indeterminate colitis. Maintenance of IFX therapy at 1, 2, and 3 years was 36%, 18%, and 12%, respectively. Patients of age 5 years and younger had the lowest rates of maintenance of therapy at 25% at year 1, and 10% at years 2 and 3 combined. Nine percent of all of the patients demonstrated response measured by the physician global assessment and were steroid free at 1 year. There were 8 infusion reactions. There were no malignancies, serious infections, or deaths.

Conclusions: IFX demonstrated a modest response rate and a low steroid-sparing effect in patients with IBD 7 years old and younger. Although this is a limited study, there appears to be a trend for decreased sustained efficacy with IFX in this age group, particularly in children 5 years old and younger, when compared with the previously published literature in older children.

Arsenic in Rice –New Recommendations

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Over the last two years, there has been increased concern about arsenic in rice.  This has been addressed by consumer reports, the American Academy of Pediatrics (AAP), and is being looked into by the FDA.

Due to the concerns about arsenic in rice, the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) committee on nutrition has published a consensus statement (JPGN 2015; 60: 142-145).  Pediatric gastroenterologists and pediatricians need to familiarize themselves with the report and their recommendations.

Key points:

  • Inorganic arsenic is a carcinogen.
  • “Arsenic content in raw rice varies from 0.1 to 0.4 mg of inorganic arsenic/kg of dry mass.  Rice has a much higher arsenic level than that in other grains.”
  • “Brown rice contains higher concentrations of arsenic.”
  • There is increased inorganic arsenic in products made from rice bran such as rice drinks is much higher due to the concentration of arsenic in the bran layers.
  • “Traditionally in European adults, an average of 9g of rice is consumed daily compared with 300g/day in Asian diets.”
  • “In the US population, mean childhood (1-6 years of age) dietary intake of inorganic arsenic is 3.2 mcg per day”
  • Currently, in the UK, the Food Standards Agency recommends against substitution of breastmilk, formula, or cow’s milk formula by rice drinks up to 4.5 years of age;  in contrast, in Sweden, recommendations advise no rice-based drinks for children <6 years.

Committee Conclusions/Recommendations:

  • “Inorganic arsenic intake during childhood is likely to affect long-term health”
  • “There is a lack of published data on the amount of arsenic in rice protein-based infant formula”
  • Inorganic arsenic in childhood should be as low as possible and the content in dietary products needs to be regulated
  • Rice drinks should not be used in infants and young children
  • Inorganic arsenic exposure can be reduced by including a variety of grains such as oat, barley, wheat, and maize.
  • Rice protein-based infant formulas remain an option in those with cow’s milk protein allergy,,.”the potential risks should be considered”

This is a link to the full length article (available via JPGNonline twitter feed): JGPN “Arsenic in Rice: A Cause for Concern”

This topic has been addressed by Nutrition4Kids website as well. Nutrition4Kids FDA Studying Arsenic

Bottomline: If there is an impact of arsenic in rice on long-term health, it is unclear; the amounts of these exposures are tiny in most cases.  Yet, given the availability of alternatives to rice and rice-based drinks, some changes in practice (ie. adhering to these guidelines) may be worthwhile.

 

 

HCV: When to Spike the Ball

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When a team scores a touchdown in football, often one sees a player spike the ball in celebration.  The equivalent of spiking a ball rarely happens in medicine.  That being said, a recent study (Hepatology 2015; 61: 41-45) indicates that after treatment sofosbuvir regimens, you can celebrate if you have a sustained virological response (SVR) at 12 weeks (SVR12).

The authors conducted a retrospective review of five trials with 863 patients with HCV genotypes 1-6.  “Of the 779 patients with an SVR12, 777 (99.7%) also achieved an SVR24.” Of the patients who relapsed, most (77.6%) did so within 4 weeks of completing therapy.

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