Taking One ‘Bite’ At A Time -For Celiac Diagnosis

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A small study (reference from KT Park’s Twitter feed –Gastrointestinal Endoscopy DOI: http://dx.doi.org/10.1016/j.gie.2014.10.024) suggests that taking a single biopsy per pass rather than two biopsies per pass results in better quality specimens:

Link: Endoscopic Biopsy Technique in the Diagnosis of Celiac Disease

Here are the results and conclusion of the abstract:

Results

Patients (N = 86) were enrolled, 47% with known celiac disease, 36% with suspected celiac disease, and 17% with an unknown celiac disease status. Well-oriented biopsy specimens were noted in 66% of patients with the single-biopsy technique and 42% of patients with the double-biopsy technique (P < .01). Analysis of matched pairs showed improved orientation with the single-biopsy technique (odds ratio 3.1; 95% confidence interval, 1.5-7.1; P < .01). This persisted in subgroup analysis of patients with known celiac disease (P = .02), villous atrophy (P = .02), and a final diagnosis of celiac disease (P < .01).

Conclusion

The single-biopsy technique improves the yield of well-oriented duodenal biopsy specimens. Endoscopists should consider taking only 1 biopsy specimen per pass of the forceps in patients undergoing biopsies of the duodenal mucosa.

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I'm the one on the right

I’m the one on the right

Lost Decade from Smoking

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A recent study (NEJM 2015; 372; 631-40) showed that smoking is more deadly than previously estimated.  Key points:

  • Deaths per year due to smoking: a new analysis suggests the true figure may be closer to 575,000.  That equates to 1 death in every 5 in the United States.
  • Smoking is thought to shorten life expectancy by more than one decade!
  • The 21 causes of death that have been officially blamed on smoking accounted for only 83% of the actual deaths among smokers

Here’s a link to a summary of the article:  Cigarette Smoking is Even More Deadly Than You Thought (from LA Times)

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From NPR: Enormous Ice Formations at Niagara Falls:

From NPR

From NPR

Accelerated Infliximab Dosing in Acute Severe Ulcerative Colitis -plus one link

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A small retrospective study (n=50) suggests that more rapid induction with infliximab may improve response and lower colectomy rate in acute severe ulcerative colitis (UC).

Link: Accelerated Infliximab in Acute UC

Here’s the abstract:

Background & Aims

Administration of infliximab to patients with acute severe ulcerative colitis (ASUC) (rescue therapy) can reduce the rate of early colectomy (within 12 months), but long-term rates of colectomy are the same as those of the pre-biologic era for these patients. The half-life of infliximab is shorter in patients with ASUC than in patients with non-severe UC, so more frequent dosing might be required to produce a therapeutic effect.

Methods

We performed a retrospective analysis of 50 hospitalized patients who received infliximab for steroid-refractory ASUC at a single academic center from September 2005 through 2013. In 2011 an accelerated dosing strategy for infliximab was introduced; we compared outcomes of standard and accelerated dosing regimens. One group of patients (n = 35) were placed on a standard dosing regimen for infliximab and then given the drug at 0, 2, and 6 weeks and then every 8 weeks thereafter. A second group (n = 15) were placed on an accelerated regimen and received 3 induction doses of infliximab within a median period of 24 days. Rates of colectomy were compared between the groups during induction and follow-up periods.

Results

There were no differences between groups in median baseline levels of C-reactive protein, albumin, or hemoglobin. The rate of colectomy during induction therapy was significantly lower with the accelerated regimen (6.7%, 1 of 15) than with the standard regimen (40%, 14 of 35) (Fisher exact test, P = .039). The standard regimen was associated with shorter time to colectomy (log-rank test, P = .042). Among patients who completed induction therapy, subsequent need for colectomy was similar between the groups during the follow-up period. Multivariate analysis showed that factors independently associated with successful induction therapy were level of albumin (g/L) when the treatment began (P = .003) and the accelerated dosing regimen (P = .03).

Conclusions

In patients with ASUC, an accelerated infliximab induction strategy reduces the need for early colectomy. An intensified infliximab dosing strategy in response to clinical or laboratory signs of breakthrough inflammation merits consideration in prospective studies.

One other link: IBD and College: Do the two play nicely (from Jeremy Adler and UofM) -describes college transition issues for our IBD patients.  Probably the most important piece of advice: “Take your medicine.”  Many really good kids decide to see what happens off therapy, often to their detriment.

How Effective are the Treatments for Functional Abdominal Pain?

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According to a recent systematic review (Korterink JJ et al. J Pediatr 2015; 166: 424-31), “there is no evidence to support routine use of any pharmacologic therapy” for pediatric functional abdominal pain (FAP).  How many pediatric gastroenterologists want to discuss this conclusion with their patients?

How did the authors reach their conclusion?

Design: The authors screened 557 articles and ultimately identified only four articles with a total of 6 studies met inclusion criteria which included the following:

  • systemic review or randomized control trial
  • children 4-18 years
  • diagnosis of FAP established with well-defined criteria
  • intervention was compared to placebo or alternative treatment

Results: All of the studies were reviewed –each received an overall quality rating by the authors as “very low.” The particular treatments included amitriptyline, peppermint oil, famotidine, miralax, tegaserod, and cyprohepatadine.  The study with the most patients had only 90 patients and the longest treatment period was 4 weeks.

In the discussion, the authors make several key points:

  • there is a lack of adequately powered, high-quality, placebo-controlled drug trials in children with FAP
  • weak evidence was found in support of peppermint oil, cyproheptadine, and laxatives at reducing pain; amitriptyline and famotidine had weak evidence supporting some improvement in global symptoms or quality of life.
  • problems with the studies: small sample sizes, poorly reported side effects, lack of follow-up, risk of bias
  • “several nonpharmacologic therapies (e.g.. hypnotherapy and cognitive behavioral therapy) have shown their efficacy in treating children with” FAP…with success rates up to 85%.  Moreover, these therapies are not hampered by severe side effects.”

Bottomline: Our office-based psychologist may be more helpful for our patients than all the medications combined.

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How to Reduce Suffering

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A recent NY Times article (yesterday) discussed ways to reduce patient suffering and improve physician/hospital evaluations: Doctors Strive to Do Less Harm

  • Minimize waking patients up at night.  Eliminate waking patients up for vital signs and blood draws.
  • Reduce waiting times.
  • Spend more time listening.

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Increased Narcotic Usage in Pediatric Patients with IBD

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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

Cover of Clinical Gastroenterology & Hepatology –The pills look cool but wrong age depicted

Will Fitness Devices (like your phone) Help?

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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

Changing Story Regarding Dietary Cholesterol

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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.”

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Good News for Starbucks & Coffee Vendors

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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

  • During an 18-year follow-up period, there were 451 incident cases of hepatocellular carcinoma and 654 deaths from chronic liver disease.
  • Compared with non-coffee drinkers, the researchers noted that those who drank 2–3 cups per day had a 38% reduction in risk for hepatocellular carcinoma.
  • Those who drank ≥4 cups per day had a 41% reduction in hepatocellular carcinoma risk.
  • Compared with non-coffee drinkers, participants who consumed 2–3 cups coffee per day had a 46% reduction in risk of death from chronic liver disease, and those who drank ≥4 cups per day had a 71% reduction.
  • The inverse associations were similar regardless of the participants’ ethnicity, sex, body mass index, smoking status, alcohol intake, or diabetes status.

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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 Parking Garage?

Does Anyone Know Why This Toilet is in our Office Parking Garage?