A recent NY Times article (yesterday) discussed ways to reduce patient suffering and improve physician/hospital evaluations: Doctors Strive to Do Less Harm
Related blog posts:
A summary from the AGA Journals Blog of a recent article highlights the increased use of chronic narcotics, not related to surgery, in pediatric patients with IBD.
Here’s a link: Chronic Use of Narcotics in Children with IBD and here’s an excerpt:
Jessie P. Buckley et al used data from a large insurance claims database, collected from 2010 through 2011, to compare the prescription narcotic use among children (younger than 18 years old) with and without IBD who were not undergoing surgery. Buckley et al also searched for factors associated with narcotic treatment of pediatric patients with IBD.
Of 4344 children with IBD during the study period, 63% had Crohn’s disease, and 37% had ulcerative colitis.
Buckley et al found that 5.6% among children with IBD vs 2.3% in the general population received chronic narcotic therapy. Associations between IBD and narcotic use revealed a particularly high burden among children with concomitant anxiety or depression.
Cover of Clinical Gastroenterology & Hepatology –The pills look cool but wrong age depicted
A recent NY Times article reviewed a JAMA study looking at the 10 new devices geared at measuring activity. Better Fitness Through Your Phone
N of 1: As a personal aside, since I know that big brother (ie. my phone) is watching and I want to compare favorably to my wife, I definitely am taking more steps and using the stairs a bit more.
Here’s an excerpt:
The pedometer and the accelerometers were generally quite accurate, but one of the wristbands, the Fuelband, underreported the number of steps the volunteers had taken by more than 20 percent.
Others of the monitors were more accurate but, by and large, no more so than the smartphone apps, which cost much less and would likely be more convenient for many people.
The upshot, said Dr. Mitesh S. Patel, an assistant professor of medicine at the University of Pennsylvania who oversaw the study, is that smartphones could offer “an easy, less expensive, but still accurate” means for people to track their activity.
But the broader issue, as Dr. Patel and his colleagues pointed out in a related commentary published recently in JAMA, is that no fitness tracker of any kind has yet proved able to motivate people disinclined to exercise to start moving
From USA Today: Limiting Dietary Cholesterol May Not Be Needed
Here’s an excerpt:
In a draft report issued in December, an influential federal panel — the Dietary Guidelines Advisory Committee — scrapped longstanding guidelines about avoiding high-cholesterol food…The committee will send its final recommendations to the Department of Health and Human Services and the U.S. Department of Agriculture, which issue the dietary advice. Those departments are expected to issue Dietary Guidelines for Americans, 2015 later this year…
“It’s the right decision,” said Steven Nissen, chairman of cardiovascular medicine at the famed Cleveland Clinic. “We got the dietary guidelines wrong. They’ve been wrong for decades.”
He noted that only 20% of a person’s blood cholesterol — the levels measured with standard cholesterol tests — comes from diet. The rest comes from genes, he said.
“We told people not to eat eggs. It was never based on good science,” Nissen said.
Advice to avoid foods high in fat and cholesterol led many Americans to switch to foods high in sugar and carbohydrates, which often had more calories. “We got fatter and fatter,” Nissen says. “We got more and more diabetes.”
Related blog posts:
This blog has posted a number of favorable reports on coffee, even though I’m not a coffee enthusiast. In general, coffee has favorable health effects when it is not paired with alcohol or tobacco.
A recent coffee study (Gastroenterol 2015; 148: 118-25) shows an association between coffee intake and reduced incidence of liver cancer and death from chronic liver disease in the U.S.
Here’s a link to a summary of the article: GastroHepNews Coffee and Liver Disease
Related blog posts:
More liver-related news: Man with infected hepatitis C sentenced to 3 years for spitting in officer’s face (from The Republic/AP News)
Does Anyone Know Why This Toilet is in our Office Parking Garage?
For many years, ethanol locks have been promoted as a way to reduce central catheter-associated bloodstream infections (CCABSI). A recent study (Ardura M I, et al. JAMA Pediatr.doi.10.1001/jamapediatrics.2014.3291 -published online Feb 2, 2015, thanks to Ben Gold for this reference) showed a dramatic reduction in CCABSI among 24 children with intestinal failure.
This study examined outcomes from January 2011-Jan 2012 with the outcomes from February 2012-December 2013. In the latter period, ethanol lock prophylaxis was added to the CCABSI “prevention bundle” both in inpatient and outpatient settings.
Key finding: Rates of CCABSI decreased from 6.99 per 1000 catheter days to 0.42 per 1000 catheter days.
One aspect of this study that is very important is that the QI team included a specialized CVC nurse who evaluated and performed all CVC care and teaching.
Their protocol is detailed in their methods section. Some of the details:
Bottomline: Ethanol locks have the potential to reduce CCABSI by 90%; this can reduce hospitalizations, prevent complications, and possibly improve survival.
Related blog posts:
Heart-Shaped Polyp (from ACG twitter feed -recommends screening colonoscopy)
Since residency, I have understood that patients with cystic fibrosis patients could present with rectal prolapse. Yet, I can recollect only one instance in which a family told me that rectal prolapse was a presenting feature in the diagnosis of their child. It turns out that rectal prolapse is a little less common as a presenting feature, at least these days, and that the majority of cases occur in individuals with cystic fibrosis who have already been diagnosed (JPGN 2015; 60: 110-12).
In this retrospective study (2000-2010), there were 262 patients with rectal prolapse identified: 65% were male and mean age was 4 years 8 months. Newborn screening for cystic fibrosis(1994 in Wisconsin) had preceded the study period.
The most common reason for rectal prolapse was constipation (52.1%), and then acute diarrhea (12%). Only 3.6% had cystic fibrosis. Two patients were diagnosed with cystic fibrosis based on testing performed due to rectal prolapse; the remaining five had already been diagnosed.
The authors note that among their cystic fibrosis population that 3.5% also had rectal prolapse.
Take-home message: In patients with rectal prolapse, testing for cystic fibrosis has a low yield in the era of newborn screening but is probably still necessary.
Boat in Chicago Marina –Like the Name?
“It is on shaky ground that one defines a disease by a response to therapy rather than by its clinical and mechanistic characteristics.” This is noted in a recent editorial (Clin Gastroenterol Hepatol 2014; 12: 2023-25, study: 2015-22).
The editorial makes this comment because the related study finds that the esophageal tissue from eosinophilic esophagitis (EoE) patients with proton-pump responsive EoE (PPI-REE) was indistinguishable from patients with EoE who do not respond to PPIs.
The study examined 196 consecutive patients and performed immunohistochemistry to examine major basic protein (MP), eotaxin-3, and tryptase. Key finding: none of these markers were able to distinguish EoE from PPI-REE; however, these 3 assays did identify EoE with 100% accuracy compared with controls.
From the editorial: “We can approach EoE as a disease in which use of PPIs is the first step in treatment, and diet and steroids represent step-up therapy…We may not understand why some patients with EoE respond to PPIs yet others do not.” It is possible that genetic testing in the future will allow us to distinguish which patients will benefit from PPIs, topical steroids or diets.
Bottomline: Now that it is well-recognized that a substantial portion of EoE patients benefit from PPIs, is it necessary to try to use a separate label for this subset? Probably not.
Related blog posts:
A recent study (Patel RM et al. NEJM 2015; 372: 331-40) provides prospectively collected data on 6075 deaths among 22,248 live births with gestational ages 22-29 weeks from the U.S NICHD Neonatal Research Network. between 2000 thru 2011:
Key findings:
Bottomline: While there has been improvement, being born premature is associated with high mortality.
According to a recent study highlighted in Gastroenterology & Endoscopy News, gum chewing immediately prior to anesthesia is probably safe.
Here’s an excerpt:
Patients who are fasting before upper endoscopy can safely chew gum up until the time of the procedure, researchers have found…
The prospective randomized controlled study evaluated the effect of gum chewing on volume and pH of gastric contents in 67 patients scheduled to receive IV conscious sedation for upper endoscopy. The night before the procedure, patients were randomly assigned to chew gum until the start of sedation…—or to not chew gum, with no limit on the number of pieces or how long they could chew.
The median volume suctioned from the gum chewers was 13 mL, compared with 6 mL for non-gum chewers. Similarly, gastric fluid also was greater for gum chewers—0.35 versus 0.11 mL/kg for patients who did not chew gum. “The 0.35 mL/kg is still under 0.4 mL/kg, which is where the risk for aspiration comes into effect,” he noted…The pH also did not change.
Take-home message: While this study provides some reassurance, I suspect that asking families to give nothing before an endoscopy will be easier than trying to explain the nuances and risks for aspiration. For those who have only had gum, though, it may not be necessary to cancel their case.
From Atul Gawande’s Twitter Feed
gutsandgrowth 