Not Happy With Functional GI Diseases

Posted on January 21, 2015 by gutsandgrowth

A recent study (J Pediatr 2015; 166: 85-90, editorial 11-14) finds that children with functional gastrointestinal diseases (FGID) had more impaired “quality of life” than children with organic gastrointestinal diseases. For those of us taking care of these children, this finding does not come as a surprise, but there is a lot to learn from this study nonetheless.

Using the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, the authors completed a 9-site study with 689 families for patients with physician-diagnosed GI disorders including functional problems like irritable bowel syndrome and dyspepsia as well as organic diseases like Crohn’s disease and ulcerative colitis. These patients were compared with a healthy control sample of 1114 families.

In addition to obtaining health-related quality of life (HRQOL) data, the authors reported information on school days missed, days in bed, parent missed workdays, and healthcare utilization.

Key findings:

FGID and organic GI diseases demonstrated lower HRQOL than healthy controls across all measures (emotional, physical, social, and school; P<0.001 for all) with larger effect sizes for FGID.
FGID and organic GI diseases also had more school days missed, days in bed, parent missed workdays, and healthcare utilization, again with larger effect sizes for FGID.

The associated editorial tries to work through the reasons why the impact of FGID is greater than an organic disease.

The authors hypothesize that two factors play a big role:

1. Issue of control:

FGID -the cause is less evident
FGID -very few effective treatments
These factors may contribute to families feeling helpless and ‘out of control’

2. Issue of response shift:

The authors explain that response shift indicates a circumstance in which a “patient is compelled to adjust to this new reality.”
Response shift often involves a change in expectations
Response shift often involves a change in prioritization
Thus, response shift could explain why patients with organic GI disease have higher quality of life scores.

In addition, the authors note that with many FGID, that physicians often “suspect constipation is the cause…when laxative therapy is not helpful, this leads to more frustration.” They advocate shifting the focus for these families from “finding a cure to managing day-to-day symptoms.”

In my view, there are a lot of other factors at play that may help explain why HRQOL is lower in patients with FGIDs. This can include a high incidence of emotional disturbances (eg. anxiety, depression) and poor coping skills (eg. catastrophizing). This study also is another example showing that the physical severity of the medical disease does not correlate with the severity of the impact.

Related blog posts:

Will I Have This Stomach Pain Forever? (Part 2)

Posted on January 20, 2015 by gutsandgrowth

The article reviewed earlier today on this blog (Clinical Gastroenterology and Hepatology 2014; 12: 2026-32) has been reviewed on the AGA blog as well (some of this information is redundant from earlier post):

Here’s a link to a summary of the article: AGA blog on RAP and here’s an excerpt: Sara Horst et al investigated whether pediatric functional abdominal pain leads to functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS) in adulthood. They performed a longitudinal analysis of 392 children (8−16 years old) initially seen at a subspecialty clinic for recurrent abdominal pain. Horst et al assessed the contribution of gastrointestinal symptoms, extra-intestinal somatic symptoms, and depressive symptoms to FGIDs 5−15 years later. They found that on average 9 years later, 41% met symptom criteria for FGID—mostly irritable bowel syndrome and functional dyspepsia. Levels of depressive symptoms in childhood correlated a greater likelihood of FGID later in life (see figure).

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

Posted on January 20, 2015 by gutsandgrowth

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.

Related blog posts:

Liver Update -January 2015

Posted on January 19, 2015 by gutsandgrowth

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?

Water -Often Missing from Diet

Posted on January 18, 2015 by gutsandgrowth

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.”

Related blog posts:

Resistance to Maintenance of Certification

Posted on January 17, 2015 by gutsandgrowth

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”

Posted on January 16, 2015 by gutsandgrowth

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.”

Related blog posts:

Positive Results for Probiotics in Latest Study of Colicy Infants

Posted on January 15, 2015 by gutsandgrowth

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.

Related blog posts:

Neonatal Nutrition Lecture -What We Know Right Now

Posted on January 14, 2015 by gutsandgrowth

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

Posted on January 13, 2015 by gutsandgrowth

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.