Scarier than Ebola -the Flu

Posted on by

Scarier than Ebola  — From NY Times (an excerpt)

“Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one….

On CNN on Monday night, a Dallas pediatrician was asked about what she had advised the families she sees. She said that she urged them to have their children “vaccinated against diseases that we can prevent,” and that she also stressed frequent hand-washing. Ebola or no Ebola, it’s a responsible — and frequently disregarded — way to lessen health risks.

So are these: fewer potato chips. Less sugary soda. Safer sex. Tighter restrictions on firearms. More than 30,000 Americans die from gunshots every year. Anyone looking for an epidemic to freak out about can find one right there.”

Early Antibiotics and Obesity

Posted on by

A recent JAMA Pediatrics study showed that early and frequent antibiotics were associated with an increase risk of obesity.  Here’s a link to the LA Times summary of this article:  Antibiotics and Obestiy (LA Times)

Here’s an excerpt:

Broad-spectrum antibiotics — including amoxicillin, tetracycline, streptomycin, moxifloxacin and ciprofloxacin — are intended for treatment of major systemic infections, in cases where the bacteria causing the illness has not been identified, or where a patient is under attack by a strain of bacteria resistant to standard antibiotics. While they can be highly effective, their antibiotic action is indiscriminate, and beneficial bacteria in the body are often killed off as collateral damage.

The latest study tapped the medical records of 64,580 babies and children in and around Philadelphia. It was published Monday [Sept 29, 2014] in the journal JAMA Pediatrics.

The heightened risk of obesity linked to antibiotic use was not huge: Babies who got wide-spectrum antibiotics in their first two years were about 11% more likely to be obese between 2 and 5 than were those who got no such drugs. Babies who had four or more courses of any antibiotics in the first two years were also 11% more likely to be obese in early childhood than those who’d had fewer exposures to antibiotics.

Related blog post:

IBD in Ontario: 1 in 200

Posted on by

A recent study notes an increasing incidence of and high prevalence of inflammatory bowel disease (IBD) in Ontario, Canada (Inflamm Bowel Dis 2014; 20: 1761-69).

This article notes that between 1999-2008, there was an increased incidence of IBD from 21.3 to 26.2 per 100,000.  This affected most age groups less than 65 years, but increased most rapidly in children younger than 10 years (increased 9.7% per year).  The highest incidence remained in adults aged 20 to 29 years. The overall prevalence in Ontario was estimated to be 1 in 200 overall, which is among the highest in the world.  This study relied on a validated health administrative data consisting of all Ontario residents.

The potential for misclassification bias is discussed and the potential difficulties with administrative health data is detailed in three related editorials (pages 1777-79, 1780-81, 182-83).  The editorials are helpful, in part, because a separate study in the same journal (Inflamm Bowel Dis 2014; 20: 1770-76) indicates that the incidence of Crohn’s disease and Ulcerative Colitis declined in Quebec between 2001-08. However, the authors of this study used less-rigorous methods and had a much shorter “washout” period (two years versus eight years).

At the end of the day, with conflicting studies, there remains some uncertainty with regard to IBD epidemiology.  That being said, the first study notes that “75% of CD studies and 60% of UC studies had reported increased incidence in the adult populations.”

This leads back to the question of what environmental exposures are leading to these changes in incidence.

Bottomline: This article and the associated editorials helps highlight the difficulties of using administrative health data and why many data points are needed to assess the epidemiology of IBD.  In all likelihood, the incidence of IBD is increasing.

Related blog post: Global increases in IBD incidence | gutsandgrowth

 

Deriving Measures of High Value Pediatric Care

Posted on by

A recent article titled, “How does a gastroenterologist demonstrate value?” (linked to full text) DOI: http://dx.doi.org/10.1016/j.cgh.2014.08.021 provides some insight into what is in store for gastroenterologists as the shift from fee-for-service is influenced by value care initiatives.

Key points:

  • Value = Outcome/Cost
  • Healthcare value = Health of population/Cost
  • “AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/quality-initiatives/performance-measures.”This website provides several measures for hepatitis C, inflammatory bowel disease, endoscopy, and others.
  • For example, endoscopy measures:Measure # 1: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMeasure #2: Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate UseMeasure # 3: Comprehensive Colonoscopy Documentation

As a pediatric gastroenterologist, it is clear that more efforts will be needed for the pediatric population.  While the authors note that “financial pressures will intensify over time,” at the current time there is extremely wide variation on the use of common procedures; in fact, physicians are typically incentivized to perform procedures even in the setting of low yield.  So the first steps will be to define a high value pediatric GI practice.

Another reference with regard to value care (J Pediatr 2014; 165: 650-51) discusses how infectious disease consultations improve outcomes, can decrease costs (length of stay, complications) and improve usage of appropriate antimicrobials.  Another helpful point: “Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations.”  This is often due to incomplete or inaccurate data.

Related blog posts:

How to Protect Children From Celiac Disease

Posted on by

While many parents have asked what they can do to protect their children from celiac disease, the new answer will be more limited than in the past.  Two recent studies from NEJM indicate that timing of gluten introduction and breastfeeding do not appear to significantly influence the development of celiac disease.

Here are the links:

1st Study: Introduction of Gluten (6 months vs 12 months)

  • Results: (n=707) At 5 years of age, the between-group differences were no longer significant for autoimmunity (21% in group A and 20% in group B, P=0.59) or overt disease (16% and 16%, P=0.78 by the log-rank test).
  • CONCLUSIONS: Neither the delayed introduction of gluten nor breast-feeding modified the risk of celiac disease among at-risk infants, although the later introduction of gluten was associated with a delayed onset of disease. A high-risk HLA genotype was an important predictor of disease.

2nd Study: Gluten 16-24 weeks or Delayed  n=944

  • CONCLUSIONS As compared with placebo, the introduction of small quantities of gluten at 16 to 24 weeks of age did not reduce the risk of celiac disease by 3 years of age in this group of high-risk children.

Here’s a story from Boston Globe summarizing findings: Tactics to Prevent Celiac

Bottomline: These well-designed studies argue persuasively against the previously held views that breastfeeding and timing of gluten introduction influence the development of celiac disease.

Related blog posts:

NASPGHAN Educational materials for medical professionals –NASPGHAN Celiac Link

Another Look at Gluten-free Diet for Asymptomatic Celiac

Posted on by

Previously, a blog entry (Benefits of Gluten-Free Diet for “Asymptomatic” Celiac …) reviewed the abstract (available early online) from Gastroenterol 2014; 147: 610-17.  With the publication of the printed version, some useful commentary (Gastroenterol 2014; 147: 557-59) provides perspective.

Study limitations: small number (20 assigned to gluten-free diet, 20 regular diet).

Key points from editorialists:

  • “This study provides some of the strongest data yet supporting celiac disease screening of family members of patients with celiac disease.  However, important issues must be addressed before screening is widely adopted.”
  • “This [study] leaves us in the uncomfortable position of offering a diagnosis that may improve gastrointestinal symptoms, but simultaneously worsen socialization, offer limited overall change in health-related quality of life, and for which the long-term risk-to-benefit ratios are unknown.”
  • This “makes the cost of a gluten-free loaf of bread for all with asymptomatic celiac disease too high, unless and until additional more substantial benefits can be demonstrated.”

Related blog posts:

Have You Heard of Harvoni?

Posted on by

The U.S. Food and Drug Administration on 10/10/14 approved Harvoni (ledipasvir and sofosbuvir) to treat chronic hepatitis C virus (HCV) genotype 1 infection.

“Harvoni is the first combination pill approved to treat chronic HCV genotype 1 infection. It is also the first approved regimen that does not require administration with interferon or ribavirin, two FDA-approved drugs also used to treat HCV infection.”

Full FDA press release –includes data supporting approval.

Related blog post: The Future is Now (for Hepatitis C) | gutsandgrowth

Sweet Alternative to Splenda for Budesonide

Posted on by

A recent article (JPGN 2014; 59: 317-20) has shown that Neocate Nutra is a good alternative to splenda as a delivery vehicle for budesonide for children with eosinophilic esophagitis.

This retrospective review of 60 children treated with oral viscous budesonide (OVB) who used either splenda (n=46) or with Neocate Nutra (n=14).  With regard to budesonide, in patients less than 10 years, the dose was 1 mg/day and older children received 2 mg/day.  For splenda patients, 10 packets were used to create a slurry whereas with Neocate Nutra powder the amount was 2.5 cm3 per milligram of budesonide.  Followup endoscopy took place at least 10 weeks after the start of treatment.

Key findings:

  • 13 of 14 Neocate Nutra patients achieved a histologic response (peak eosinophils <15/hpf) compared with 30 of 46 Splenda patients.
  • Mean eosinophil count dropped from 62 to 9 for Neocate Nutra patients and from 59.5 to 25.5 for Splenda patients.

Limitations of study: small number, retrospective study.

Take-home message: Neocate Nutra is at least as effective as Splenda as mixture with budesonide.  In addition, many parents may prefer to avoid Splenda.

Related blog posts:

Four Food Group Diet for Adults with Eosinophilic Esophagitis

Posted on by

A recent study published online (here’s a link: EoE 4-food Group Diet) shows that a four food elimination diet was effective in 54% of the adults in this study.  Here’s the abstract:

Background

Eosinophilic esophagitis (EoE) is an esophageal disorder predominantly triggered by food antigens. A six-food group elimination diet (SFGED) achieves remission in more than 70% of adult patients with EoE. After individual food reintroduction, just 1 or 2 food triggers for EoE can be identified in 65% to 85% of the patients, so some dietary restrictions and endoscopies after food challenge may be unnecessary.

Objective

To evaluate the efficacy of a four-food group elimination diet (FFGED) (dairy products, wheat, egg, and legumes) for adult patients with EoE.

Methods

Prospective multicenter study. All patients were reevaluated after 6 weeks on an FFGED. Response to the FFGED was defined by clinical and histologic (<15 eos/hpf) remission. Responders underwent reintroduction of each individual food over 6 weeks followed by endoscopy and esophageal biopsies. Nonresponders were offered a rescue SFGED.

Results

A total of 52 adult patients were included, of whom 12 patients (23%) had previous failure to topical steroid therapy. Twenty-eight of the 52 patients (54%) achieved clinicopathologic remission on the FFGED and 6 of the 19 (31%) nonresponders to the FFGED were successfully rescued with the SFGED. Twenty-two of 28 responders to the FFGED (78%) finished the individual food reintroduction challenge. Milk was identified as an EoE trigger in 11 patients (50%), egg in 8 (36%), wheat in 7 (31%), and legumes in 4 (18%). All patients had just 1 or 2 food triggers, with milk being the only causative food in 27% of the patients.

Conclusions

An FFGED achieved clinicopathologic remission in 54% of adult patients with EoE. An SFGED was effective in almost a third of FFGED nonresponders, resulting in a combined efficacy of 72% of both strategies.

Related blog post:

What is the Role for Allergy Testing in Eosinophilic Esophagitis?

Posted on by

A recent review article (Clin Gastroenterol Hepatol 2014; 12: 1216-23) summarizes the potential role of allergy testing for eosinophilic esophagitis (EoE).

The article summarizes the potential ways to use various allergy testing and reviews the literature on its effectiveness.  The article notes a couple of key points:

  • Overall, using skin prick testing (SPT) and atopy patch testing (APT), allergy testing has not proved more reliable then empirically administering a 6-food elimination diet.  Thus, “the issue remains whether food allergy testing provides a useful tool in EoE.” However, targeted testing-based diets (especially in children) may require elimination of fewer foods.
  • “Serum IgE food-specific IgE panels should not be used for EoE.”  “Testing for foods, especially IgE testing, leads to recognition of food sensitizations that may not be clinically relevant and that on elimination, could result in the loss of tolerance to the food.”
  • Testing for milk allergy is noted have a high false negative rate.
  • IgG based testing is not recommended.  In fact, IgG immunoglobulins are “associated with tolerance rather than allergy.”
  • “Only 8% of children will become tolerant to all foods that cause their EoE.”

Bottomline: While foods commonly triggers EoE, the tests to identify these foods are far from perfect. I find that families are quite uninformed about the frequent lack of correlation between allergy testing and true EoE triggers.

Related blog posts:

Summary of article: GI & Hepatology News August 2014 Role of Allergy Testing in EoE