“If You Never Give Up, You Cannot Possibly Lose”

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Recently I was reviewing the “Black Knight scene” from Monty Python’s Holy Grail.  This scene in which the Black Knight continues to insist on fighting King Arthur even after losing all of his limbs came to mind as I was reading a recent study (JPGN 2014; 58: 226-36).  The blog title comes from an explanation of the scene from John Cleese who intended the scene to mock this philosophy. (Wikipedia link: Black Knight (Monty Python) – Wikipedia, the free encyclopedia)

The study is another trial of a proton pump inhibitor (rabeprazole) for 1- to 11-month old infants with symptomatic GERD.  In the discussion the authors note that this is the “fourth DB randomized placebo-controlled study published in the last 4 years that fails to show the efficacy of PPIs to treat symptomatic GERD in infants younger than 1 year.”

If anything, the design of this study should have allowed a therapeutic effect to be witnessed if present.  Infants selected for participation (n=268 in the double-blind phase) had been responsive to a 10 mg open-label usage of rabeprazole before randomization.  Yet, those infants who continued to receive 5 mg or 10 mg daily fared no better than placebo-treated patients.

The good news: no new safety signals in those who were treated compared to placebo.

The findings of this study are in marked distinction to clinical practice which has embraced PPIs in all age groups. In the same issue of JPGN, using a national database, De Bruyne et al (JPGN 2014; 58: 220-25) show a huge increase in PPI usage over the past decade in the Netherlands, especially in children ages 2 years and younger.  From 2004 to 2008, use of PPIs nearly doubled in this population.

The rabeprazole study manuscript which had nearly as many pediatric GI investigators as enrolled patients discusses the potential drawbacks of PPI therapy in infants including enteric infections like Clostridium difficile, lower respiratory infections (e.g.. pneumonia), and “perhaps even an increased incidence of necrotizing enterocolitis in premature infants.”  Unlike the Black Knight, after four blows to the PPI cause, the authors recommend yielding on PPIs except under much more stringent criteria (1 of 3):

  • Nonimproving symptoms at 1 year of age & resistant to conservative measures
  • Presence of underlying conditions that predispose to a natural history of severe chronic unremitting reflux
  • Erosive reflux esophagitis proven on endoscopy

Take-home message: PPIs have not been shown to be effective in infants…again!

Related blog posts:

Alan Alda (aka Hawkeye Pierce) on Communicating Science

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Link from Dr. Chris Simpson: http://t.co/f4etUVUiQr

Here’s an excerpt:

While Alda is best known for his role on  M.A.S.H  , the 78-year-old is also a science enthusiast who has spent more screentime hosting a PBS show called Scientific American Frontiers  than portraying Hawkeye Pierce. On that fateful day ten years ago, he was at a mountain observatory in Chile for Scientific American Frontiers, preparing to interview some astronomers, when he felt a sudden pain in his gut….

Alda recounted this [near-death] story…in Chicago, where hundreds of scientists from around the world crowded into a packed conference hall to hear him talk about science communication. Alda was one of       four plenary speakers     at the       2014 AAAS meeting     , the world’s largest annual general science conference.

His plenary speech was about communicating science, a subject Alda has become intensely passionate about over the years. He has described his stint at Scientific American Frontiers as “the best thing I ever did in front of a camera” — but it also showed him that many scientists have incredible stories but lack the tools to describe their work in a way that most people can understand.

This is a very real problem, one that journalists often struggle with when interviewing scientists. But for scientists, learning how to describe their work is not only a necessity, it is also a responsibility.

“Communication is essential to science,” Alda said. “It’s essential to the funding of science and even in the doing of it.”

So nowadays, Alda devotes himself to helping scientists discover their inner storytellers. He is a visiting professor at the Alan Alda Center for Communicating Science at Stony Brook University and has also created an improv class for scientists. A few years ago, he also started an annual competition challenging scientists to explain a scientific concept — for example, “what is a flame?” — in terms that would make sense to 11-year-olds, who actually judge the entries. This year’s challenge: “What is colour?”

(Last year’s winner, by the way, was a       PhD student from the University of Ottawa     who made this       video     to entertainingly answer the question “what is time?”).

On Saturday, Alda said he is often asked for tips on how to communicate science better. But there are no shortcuts, he said— becoming a storyteller is something that takes training, practice and commitment to improve.

But his speech left the audience with one general rule of thumb: storytelling is a powerful tool for helping people understand science.

“If you don’t begin with a story, or some kind of introduction to the hard words, we’re suffering from something awful that a couple of people have called the curse of knowledge,” Alda said. “It’s a curse when you know something in such depth, and with such a level of complexity, that you forget what it’s like not to know it at that depth. That’s a curse.”

Related blog post:

Why I have always liked Arthur Caplan… | gutsandgrowth

Even the Experts Agree: pH-MII is a “Flawed Test”

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A recent study (JPGN 2014; 58: 22-26) reports on the combination of a new technique of intraesophageal pressure recording (IEPR) along with multichannel intraluminal impedance with pH (pH-MII).  While this prospective study is small with only 20 children who had a history of chronic intractable cough, some of its observations are important, especially for those who have embraced pH-MII.

In determining whether the pH-MII studies were abnormal the authors relied on symptom index (SI) defined as the number of symptoms associated with reflux/total number of symptoms.  SI is considered positive if >50%.  In addition, the authors calculated the symptoms sensitivity index (SSI) which is defined as the total number of reflux episodes associated with symptoms/total number of reflux episodes; it is considered positive if it is >10%.  The authors note SAP and SI have a comparable positive predictive value and “our experience suggests that SAP calculation using software is unreliable.”

Key Results/Discussion:

  • IEPR changed the diagnosis in 15-20% of patients depending of scoring index used.  That is, IEPR assisted the detection of reflux-associated cough.
  • IEPR detected 106% more coughs than patient report alone.  Thus, this study, if accurate, indicates that “symptom reporting during pH or pH-MII testing is significantly flawed and, if possible, should not be used alone for clinical decision making.”
  • “We did not find a significant association between cough production and the height of the refluxate.”
  • The authors argue that since nonacid reflux can be associated with cough and is not always detected with pH-MII, that this could “explain why studies that have tried to use pH criteria to predict clinical outcome after acid suppression therapy have been negative.”  The two studies cited at that point by the authors were landmark studies (referenced below) showing that proton pump inhibitors are not effective in children or adults in improving asthma.  I think the authors’ comment misses the importance of these studies entirely.  There are no proven effective GERD (acid or nonacid) therapies that alter the course of asthma.

Take-home message from authors: “Studies are now needed to determine whether this increased detection improves therapeutic outcomes, but clearly, relying on symptom reporting by patients is flawed and clinical decision making based on patient report alone should be done with caution.”

Referenced studies:

  • JAMA 2012; 307: 373-81
  • NEJM 2009; 360: 1487-99

Related blog posts:

Calprotectin: Part of diagnostic algorithm for IBD?

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Full text available at this link from Jeremy Adler: cghjournal.org/article/S1542-3565(13)01044-6/abstract#.Ut5vnV5z8Cw.twitter …

This article describes the use of fecal calprotectin (FC) levels as a screen for inflammatory bowel disease.  The false-negative rate for this assay is related to pre-test probability of having IBD.  Thus, in patients with a low probability of IBD, a normal calprotectin may allow avoidance of endoscopic evaluation and may be “particularly cost-effective when baseline clinical suspicion for IBD is low to moderate…the low FC cutoff value of 50 μg/g would substantially reduce the likelihood of false-negative FC, minimizing delayed diagnosis of true IBD.” In those with persistent symptoms, the article’s algorithm recommends proceeding with endoscopic evaluation.

Excerpt from abstract:

Conclusions

Screening adults and children to measure fecal levels of calprotectin is effective and cost-effective in identifying those with IBD on a per-case basis when the pre-test probability is ≤75% for adults and ≤65% for children. The utility of the test is greater for adults than children. Increasing the FC cutoff level to ≥50 μg/g increases diagnostic accuracy without substantially increasing total cost.

Related blog posts:

7 Ways Parents Can Influence Risk of Obesity

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Here’s a link with some good advice for parents about developing healthy eating habits http://t.co/ChlRj2hEWV from Huffington Post and an excerpt (from Kristin Kirkpatrick, M.S., R.D., L.D):

I was recently called out for not being a “fun” mom because I wouldn’t buy artificially colored “fun” junk food for my son. …

We strive to teach manners, independence and kindness to our children but we often times fail to teach something just as important — the value of exercise and healthy eating. The majority of your child’s attitudes about food and nutrition, they’re desire to be physically active and even their weight will come directly from their parent’s.

Here are eight things about you that will most likely be passed down to your children. 

1. You’ve got a weight problem While part of your child’s risk for obesity, and even how picky they might be about trying certain foods may be caused by genetic factors, the bulk of your child’s predisposition to be overweight may actually be determined by your weight.  That’s right, if you’re overweight or obese, your child’s chances of following the same fate are between 25 to 50 percent. What about your child’s other parent? If he or she is also overweight, the chances just shot up to 75 percent.

A 2012 study found that a simple formula could predict a baby’s propensity to become obese and noted in the study that based on longitudinal cohort data, that 20 percent of children predicted to have the highest risk at birth make up 80 percent of obese children. The calculation is based on five factors including birth weight, the body mass index of the parents, the number of people in the household, the mother’s professional status and whether she smoked during pregnancy…

2. You use food to reward or withhold on a regular basis …

3. In your home, junk food is its own food group A 2014 study  suggested that it wasn’t actually the vast presence of fast food establishments that was to blame for the pediatric obesity epidemic but rather overall bad habits that originated in the home. Homes that followed a “Western diet” defined in the study as having a prevalence of sugared sweetened beverages, salty snacks, high-fat sandwiches, candy and desserts were more likely to have obese or overweight kids with poor dietary habits.

The desire for junk food may actually be affected before birth as well. A 2013 animal study found that pregnant mothers who consumed junk foods, particularly fast food, actually altered the opiate signaling pathways in the brains of their offspring, making their baby’s more likely to crave foods high in fat and sugar.

4. You’re a couch potato A 2013 study found that kids whose moms encouraged them to exercise and eat well (and modeled these behaviors in themselves) were more likely to engage in physical activity and adhere to healthy eating habits. That means more movement, mom and dad, and less couch time! In addition to keeping kids sedentary, spending too much time on the couch as a family exposes your little one to more commercials that promote unhealthy foods, a risk factor for childhood obesity…

Limiting overall “screen time” in young children is also critical and has been shown  to reduce the risk for obesity and chronic conditions. Finally, if you’re thinking about letting your little one have a TV in his or her bedroom, think again! A 2012 study found that children having a TV in their room were more likely to have a higher waist circumference.

5. You’re labeling your child as “picky” Have you ever told another parent that your child is a picky eater? Simply labeling your child as picky could cause them to turn away from fruits and vegetables according to one study. The study showed that moms who labeled their child as “picky” had children who were less likely to try various types of produce and were actually less likely to eat fruits and vegetables themselves.

6. You think breakfast is for sissies Habitual breakfast in children is associated with  higher academic performance, a reduced risk for obesity and an increased intake of vitamins and minerals.

7. There’s no mealtime routine in your family … Eating as a family unit has been linked  with increased fruit and vegetable consumption and lower intakes of soft drink consumption. Further, adolescents who experience family meals often have a better diet as they head into adulthood.

Parents, it’s your job to help shape the taste buds, views about food and weight for life. That doesn’t mean your kid should never have a cookie. It just means that these foods shouldn’t be the norm. Teach your kids about which foods make them strong and which foods make them weak by using words and phrases they’ll understand such as “This salad will help you grow tall,” or “This apple makes mommy’s brain super strong.”

Most importantly, if your child already has a weight problem or less-than-perfect eating habits, it’s not too late to help him or her change. The step is recognizing the problem (few parents  actually do) and working together with your child to change behavior. I’m happy to keep my “non-fun” mom status if that means that I can help my son be a healthy eater and maintain a normal weight throughout his life. One day …perhaps he’ll realize just how “fun” being healthy, staying fit and avoiding sickness can really be.

 

How often do you wipe down your stethoscope?

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From NY Times, http://t.co/RoyhpjtPTQ; an except:

Doctors’ stethoscopes are contaminated with bacteria that can easily be transferred from one patient to another, a new study has found.

Researchers cultured bacteria from the fingertips, palms and stethoscopes of three doctors who had done standard physical examinations on 83 patients at a Swiss hospital. They tested for the presence of viable bacterial cells, looking specifically for the potentially deadly methicillin-resistant Staphylococcus aureus, or MRSA. The study appears in the March issue of the Mayo Clinic Proceedings.

Fingertips on the doctors’ dominant hands were the most contaminated, but the part of the stethoscope that touches the patients’ skin held more than twice as much bacteria as the physicians’ palms…

The authors acknowledge that the study was small and may not be applicable to other health care sites. Except for MRSA, they did not distinguish harmful from harmless bacteria.

That bacteria are found on stethoscopes is “not a surprise,” said the senior author, Dr. Didier Pittet, a professor of medicine at the University of Geneva Hospitals. He cleans his own stethoscope with alcohol swabs after each examination, but “most physicians do not.”

 

 

“More to It Than Meets the BMI”

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This blog post title is quoted from a clever editorial which reviews the use of BMI and the effect of obesity with outcomes after liver transplantation (Liver Transpl 2014; 20: 253-54, related article pages 281-90.)

Key points from editorial and study:

  • Study enrolled 202 consecutive adult (mean 51 years) patients (200-2010) as part of cohort study.  Data was obtained at time of transplantation and reviewed with retrospective analysis. NAFLD was transplant indication in 7%.
  • “Use of BMI as a marker of obesity is flawed.” Authors showed only 86% agreement between calculated BMI and percent body fat as measured with DXA.
  • Patients with high BMI due to greater lean muscle mass may have improved outcomes.  Sarcopenia (loss of muscle mass) likely has greater effect on outcomes.
  • The study shows that the combination of diabetes and obesity increases the risk of complications and prolongs hospital stays (5.81 days, P<0.01).
  • Metabolic risk factors had no effect on 30-day, 1-year, or 5-year patient survival.

Another article in same issue: Liver Transpl 2014; 20: 311-22. This study retrospectively examined 148 normal-weight, 148 overweight, and 74 obese patients who underwent living donor liver transplantation. Key finding: “there were no differences in graft survival [hazard ratio (HR) =0.955] or recipient survival [HR = 0.90]” between these groups.  Obese patients do require larger grafts which can delay identifying suitable donor.

Bottomline from editorial: “this study shows us that the combination of diabetes and obesity dramatically increases the risk of complications” but not survival.  “If there comes a day when the cost of a human life is less than the cost of a 6- to 7-day hospital stay, that is the day to reckon. None of us may survive.”

Related blog post:

Sarcopenia, fatigue, and nutrition in chronic liver … – gutsandgrowth

Missing ingredients in TPN -Case Report

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Recently one of my radiology colleagues, Dr. Laura Hayes, put together (lead author) a presentation (poster) for an upcoming meeting.  The main focus of the presentation is a TPN-dependent toddler who presented with refusal to walk due to copper deficiency.

Attached is a link to the presentation: TPN Copper.  This link is a power point presentation with numerous radiographs and even bone scan images.

Key points:

  • All TPN components except dextrose have been in periods of shortage over the last few years.
  • TPN-dependent patients may not be receiving all the needed components and their physicians may not have been notified of the specific shortage(s).
  • Copper deficiency leads to reduced activity of numerous enzymes important for function of bone, blood, skin, nervous system and hair.
  • Subperiosteal hemorrhage leads to the periosteal thickening seen in this case and is associated with the bone pain our patient experienced.
  • Increased losses of bilious fluid can increase the risk of copper deficiency due to the excretion of copper in bile.
  • Other TPN-related deficiencies reviewed include thiamine deficiency (Wernicke’s encephalopathy), Vitamin D deficiency (Rickets), and Vitamin C deficiency (Scurvy).

Another recent case report:

Oestreich AE, Cole CR. Vigorous periosteal reaction secondary to copper deficiency in an infant on total parenteral nutrition. (2013) Pediatr Radiol 43:1411-1413.

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PCORI: Spending Money to Save Money

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I hadn’t heard much about PCORI (Patient-Centered Outcomes Research Institute) until I learned about two large awards given to ImproveCareNow (ImproveCareNow | LOOP).  (This blog has previously discussed ImproveCareNow -see links below.)

Now a perspective article provides a lot more detail regarding PCORI (NEJM 2014; 370: 592-94) including the fact that it will commit as much as $1.5 billion over the next 3 years to research projects.  While this is impressive, on a side note, PCORI could benefit from a better name.  In England, a similar organization is called NICE (National Institute for Health and Care Excellence).  Of course, NICE may be more about promoting evidence-based medicine than funding clinical effectiveness research (CER) like PCORI.

A full list of funded projects is available at http://www.pcori.org/pfaawards/?viewby=priority.  From this website: “The Patient-Centered Outcomes Research Institute (PCORI) was created to fund research that will provide patients and those who care for them with the evidence-based information needed to make better-informed health and healthcare decisions. We do this by supporting studies that seek to answer questions important to patients and meaningfully involve patients and others across the healthcare community at all stages of the research process.”

According to the perspective article, PCORI has funded 162 CER studies, “37 (23%) focus on cancer detection, treatment or surveillance; 30 (19%) on mental health; 26 (16%) on cardiovascular diseases; and 18 (11%) on endocrine disorders, including diabetes mellitus.”

Bottomline: Though I would appreciate a better name, PCORI clinical effectiveness research projects are going to shape many important healthcare decisions.

Related blog entries: