CCFA Conference Notes 2014 (part 2)

Posted on March 28, 2014 by gutsandgrowth

Yesterday’s notes highlighted the most useful discussion at this year’s meeting regarding mucosal healing (MH) in inflammatory bowel disease.

Many points were intriguing but often at odds. For example, the speakers noted that symptoms and scoring systems like CDAI are unreliable in establishing remission. It was noted that the FDA is mandating more objective measures (like endoscopic improvement) in future studies. Yet, the studies cited for their arguments often were derived from studies which did not use objective endpoints. Similarly, some of the arguments were based on small studies and yet experts often caution to use evidence-based medicine.

Bo Shen (Cleveland Clinic) “Surgerical Options in IBD”

50-71% of CD patients require some type of surgery within 10 years of diagnosis
End-ileostomy may be a cure for some CD patients, For UC, end-ileostomy 98% are cured. 2% develop enteritis.
Can use infliximab after surgery. Immune system different after surgery and may work even
‘Don’t operate until a CD patient develops a complication. But, don’t wait until further complications develop.’

Different type strictures –web-like strictures are suitable for dilatation, others are more difficult: spindle-like (longer) , ulcerated stricture, and anastomotic.

Classification: Gast Endosc 2013; 78: 8181-35.
Etiology: primary, secondary (anastomotic), benign, malignant
Short-long: Length (<4cm) if dilating
Degree: high-grade, low-grade
Number: single, multiple
Associated conditions: abscess, others

Determining resection margin –does not depends on absence of histologic activity (Ann Surg 1996; 224: 563-71). Try to save as much bowel as possible, often based on how thick bowel is rather than histologic margins.

Save the gut –stricturoplasty. 1^st surgery –usually is a resection rather than stricture plasty. Heineke-Mikulicz (most common) <10 cm for short , Finney for strictures 10-20 cm, Michelassi >20 cm (sid-to-side isoperistaltic). (Dis Colon Rectum 2007) Stricturoplasty –best for mid small bowel, minimum inflammation, no fistula

Fistula –Hollow-organ to hollow-organ fistula –treat surgically. Whereas if fistula is perianal, start with medical treatment. Perianal fistulas often treated with seton; seton often kept in place for a long time (“forever if not bothering patient”).

Abscess—avoid surgical drainage if possible. Delineate anatomy and consider elective surgery later. If less than 3 cm, could aspirate and not leave in drain. If >3 cm, start with interventional radiology

Post-op management –Ruttgerts score. Rescope 6 months post-op to determine if needs more aggressive treatment.

UC Surgery: issues: preoperative biologics, 2- or 3-stage operations, what type of pouch

There may be increased risk with biologics (studies have not shown this consistently) –depends on type of surgery. If very sick, use 3-stage rather than 2-stage operation. Don’t do pouch at time of 1^st operation if very sick DCR 2013; 56: 1243-52).
J-pouch now standard. Kock pouch –catheterize pouch/no ostomy. S-pouch –problemswith mechanical obstruction.
Even with mucosectomy (vs. stapler/no mucosectomy)–can still develop cuffitis and malignancy. Mucosectomy may increase risk of incontinence.

Edward Loftus (Mayo Clinic) “Optimizing Biologic Therapy: Maximizing Benefit and Minimizing Risk”

Is azathioprine an effective drug? Should we be using biologics sooner?

Key points:

ACT1 and ACT2 were pivotal studies for infliximab approval for UC. 1/3rd chance of going into full remission, 1/3rd chance of response, 1/3rd chance of not responding. Infliximab lowers risk of colectomy. Favorable studies of other anti-TNFs as well: adalimumab (Gastroenterol 2012; 142: 257-65) and golimumab (Gastroenterol 2014; 46: 85-95 & 96-109). No head-to-head anti-TNF trials.
Crohn disease: 5-ASA products don’t work for Crohn disease. Reviewed pivotal trials of anti-TNF agents (infliximab, adalimumab, certolizumab)-30% in remission.
Natalizumab (anti-alpha 4 integrin) for refractory disease was discussed (NEJM 2005; 353: 1912-25). Takes longer to work then anti-TNFs but maintenance data look good. PML risk: 395 cases among 118,100 patients treated as of August 2013. Lots of paperwork and physicians have to be certified. If you are JC virus serology is negative, “your risk is about 1 in one million in the next year. If you are positive, about a 1% risk in the following year.”
Azathioprine (AZA) not very effective (Gastroenterol 2013; 145: 766-74 & 758-65). Prospective double-blind Spanish study (n=131) –no statitistical benefit. 2^nd reference is French study. N=132. No significant difference at 36 months in patients with added AZA. In U.S., most “thought leaders” going straight to anti-TNFs.
Combination therapy works best in adults (SONIC study for Crohn disease, UC Success for UC). UC Success only studied 16 weeks, no maintenance therapy trial. However, methotrexate (MTX) with anti-TNFs combination has not been proven to be effective (Gastroenterol 2014; 146: 681-8). Reason this was a negative study, per lead author, may have been related to steroid use.

Other pointers:

Don’t rely on symptoms alone. Symptoms/CDAI do not correlate with CDEIS (endoscopic improvement). FDA mandating all future trials have an endoscopic endpoint and not rely on use of CDAI alone. Other factors cause symptoms including IBS, infections, and bacterial overgrowth. Take-home point: Need to look (endoscopy) if someone is not doing well.
In the SONIC trial –if there was inflammation on endoscopy, there was an impressive 30% delta in response to treatment (with combination therapy compared with AZA monotherapy). Whereas if you have no lesions, combination therapy no more effective than either monotherapy agent. Patients whose complaints are due to irritable bowel rather than inflammation do not respond well to treatment.
OLD paradigm –treat based on symptoms. NEW paradigm–treat based on biologic/radiographic markers or endoscopic findings. “Treat to target” has been approach used by Dr. Sandborn. Target mucosal healing and then assess mucosal healing every 6 months until target achieved, then less frequently. Yet mucosal healing cannot be achieved in many/most patients.
Therapeutic drug monitoring. For example, 6-TGN >235 associated with better response to AZA (OR 5.0)
Pharmacokinetics of anti-TNFs: lower clearance if concomitant use of immunomodulators, increased clearance if high CRP, higher BMI
New drugs: Ustekinumab –three phase 3 trials underway. Should be available in about 2 yrs for Crohn disease. Vedolizumab –under FDA review (NEJM 2013; 369: 699-710). Infusion (similar to remicade frequency). Blocks lymphocyte homing in the gut. UC data much more robust than with CD, but probably will be approved for both. Rate of adverse events were low. Etrolizumab—similar to Vedolizumab, but SC administered. Currently, this drug is in phase 2 studies.

Eva Szigethy (Pittsburgh Pediatrics) “Psychological evaluation and assessment in IBD”

Key points:

Anxiety/depression ~25-40% of pediatric IBD. Occurs in both active and inactive disease.
IBD effects on brain: inflammation, drugs (steroids, biologics)–both have direct effects on brain.
15% of kids and 25% of adults are having thoughts of death on screening tools. Pain is frequent trigger for suicidal thoughts.
Simple depression screen: Mood, Energy, Sleep, Suicide/Self-esteem, Anhedonia (lack of pleaure), Guilt, Eating (change in appetite)
We should not ignore adjustment disorders. We may be able to prevent a full-blown psychiatric disorder. Each time we let problems like anxiety or depression go untreated, this can leave long-term changes in brain.
Anxiety screen: Tense, Tired, Recurrent worries/fear, Restless, Avoidance, Poor sleep/nightmares, Poor concentration
Important to look at patient perspective of their disease: identity (what they see as their symptoms), cause/etiology, timeline (how long the patient believes that the illness will last), consequences, cure/control.
Catastrophizing –more persistent pain and increased visceral hyperalgesia. Abnormal brain activation. Poor coping drives development of depression and anxiety.
With adult IBD, 20% of patients consume up to 80% of medical costs. Chronic pain and depression are key factors (Binion et al 2010).
Management of anxiety/depression: Cognitive Behavioral therapy –changing behaviors and thinking, problem-solving. ACT –activities, calm (relaxation, guided imagery, hypnosis), think positive (cognitive reframing). Antidepressants: TCA, SSRI, SNRI. SSRI/SNRI –few side effects or drug interactions. Overdose risk is highest with TCA (but typically using low doses of these agents). No pediatric studies in IBD and only small studies in adults. If inactive IBD, SSRI often 1^st line. If active IBD, Bupropion often used as 1^st line.
For anxiety, most likely use SSRI if comorbid anxiety
For pain, most likely use SNRI or low dose TCA
Opiates are problematic due to psychological/physical dependence, increased mortality/infection risk, narcotic bowel
Sleep –don’t go to bed if not tired, aim for consistency, if not asleep in 20 minutes, then do something else. 1^st line pharmacology: consider antihistamines or melatonin.

Sachin Kunde (Michigan State University, Helen DeVos Children’s Hospital) “FMT for IBD”

Key points:

Microbial diversity altered in IBD –can we modulate dysbiosis to treat IBD?
Issues with cause and effect. Is dysbiosis due to IBD or causing IBD.
FMT –“the ultimate probiotic.” Application of FMT. For recurrent C difficile, cure rate nearly 90% –?better with lower GI route. For any indication besides C difficile infection (CDI), can only be given through clinical trials (FDA IND). Currently 9 ongoing trials for IBD (1 pediatric, 3 in U.S).

FMT in IBD: Studies:

-Anderson et al. Aliment Phar Ther 2012: 13/18 without CDI had some resolution of IBD symptoms.
-Kunde et al JPGN 2013: n=10. PUCAI decrease by 15 indicated response found in 78% (7/9) at 1 week, and 67% (6/9) at 1 month, 3 (33%) went into remission.
-Kump et al IBD 2013: n=6. FMT for UC was not effective. Transient improvement in 2/6 patients, 1/6 improved on Mayo sub score.

Bottomline for FMT & IBD: More questions than answers: efficacy, route of administration, # of infusions needed, fresh vs. frozen, adverse effects, best donor, etc.

For today’s post today and yesterday’s post, I may have made some transcription errors and these notes were not reviewed with the speakers. Also, due to brevity, some useful information was not included. Thus, the disclaimer with these posts is particularly important.

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.

Related blog posts:

CCFA Conference Notes 2014 (part 1)

Posted on March 27, 2014 by gutsandgrowth

Each year our local CCFA chapter holds a one day seminar with separate lectures for health care providers and families. Overall, it is a good opportunity to hear ‘cutting edge’ material. I did not pick up as much at this year’s seminar as in previous years, but will highlight what I thought was most important.

Key points:

Symptoms are not accurate at determining effectiveness of IBD therapy.
More frequent use of objective markers are needed to optimize treatment. Mucosal healing is starting to be a target in clinical practice, but limited by number of medications available.
Stricture classification and operative techniques were reviewed.
IBD frequently results in psychological problems: anxiety, depression, pain, sleep. 15% of kids and 25% of adults are having thoughts of death on screening tool intake.
Fecal microbiota transplantation (FMT) –not enough data to recommend for IBD. Clinical trials ongoing.

Debate: What should be the End Points in Therapy?

Tanvi Dhere (Emory): Goal: clinical symptoms
Cary Sauer (Emory Pediatrics): Goal: mucosal healing and normal bloodwork

In my opinion, this was the most thought-provoking and best presentation

Mucosal healing (MH) consensus definition –normal mucosa after previously abnormal with complete absence of ulceration, macroscopic and histologic signs of inflammation. In practice MH = absence of ulcerations.

Reasons why mucosal healing as a target is problematic:

Problems with MH –not validated. No long-term data utilizing endoscopic scoring indices of MH.
MH relies on a binomial endpoint –Yes or no, but there may be intermediate endpoints.
How likely is MH (different definitions in these studies)? SONIC –MH in 43.9% of combination Rx (30.1% in those with infliximab monotherapy); EXTEND (Adalimumab) 27% and 24.2% 12/52 weeks; MUSIC (certolizumab at 10/54 weeks) 11.5% and 18.9%.

In practice, Mayo Score 0-1 both considered to have MH.

Images above online at www.nature.com

In small study, MH at 1 year were not associated with improved outcomes at 5 years. Risks of MH: more procedures, more costs of treatment, and potential for more complications.

Dr. Sauer’s reply. Three simple questions –why should I try to target MH, is it possible, what is needed to get this done?

If the goal were only an asymptomatic patient – why do screening colonoscopy in the general population, much less in IBD?
In IBD, long-term evolution of IBD (Cosnes J et al. Inflamm Bowel Dis. 2002 Jul;8(4):244-50) is toward structuring and penetrating disease. CD Evolution This needs to be modified if possible.

Why MH? Improved symptoms, better quality of life, less likely to develop colon cancer, and it is an objective measure of treatment response.

In MH patients, less steroids and fewer flares over 2 year period.
MH healing patients have sustained clinical benefit over 96 months.
With MH, there is a decreased colectomy in UC. In one study, there was a lower colectomy rate at 8 years if colonic CD (62% vs 8%), decreased steroids in CD, decreased hospitalizations, & decreased fistulae.

Is MH possible in clinical practice? The accuracy of CDAI to detect endoscopic healing is low in patients with CD. (Bouguen G et al Clin Gastrohep 2014). More frequent adjustments in medical therapy –could lead to MH in up to 80% over 80 week study period. Same story in UC (Bouguen G et al IBD 2014).

What do I need to do to obtain MH? Endoscopy (or MRE), maximize medications (checking levels), change medications, and most important –set a target. “Adjusting infliximab dose alone could lead to MH in up to 60%.”

When to assess for MH? Consider endoscopy at 6 months into treatment if symptoms and at 12 months if in clinical remission.

Other viewpoints on MH from panel:

Dr. Loftus –“I think of this like oncology.” He agreed with using the best evaluating tool 6 months into treatment. Cross-sectional imaging is often more helpful, but may need more than one tool.

Dr. Long—“Are we going to check every 6 months?” No. She stated that she does not do this and tries to avoid repeated endoscopic procedures if this will not change treatment. Goal is to make sure patient is headed in right direction, often after starting therapy. Dr. Long stated that stool biomarkers most useful for colonic disease.

Dr. Dhere—documenting MH is important for deescalating treatment.

Millie Long “Quality of Care in IBD”

75% of Crohn disease patients will need surgery, 10% in 1^st year
“One way to gauge quality of care is to examine the degree of consistency in care”
High variability in care in IBD (Aliment Pham Ther 2007; 26: 1005-18)
“Over half of institutions with worst quality have mortality in normal range.” Outcomes may not occur until several years after treatment, thus more useful to measure process measures

PQRS IBD Quality Measures in Adults: 10 Measures

#1 Establishing/documenting IBD type, anatomic location, and activity
#2 Preventive care: corticosteroid sparing. Steroids associated with mortality (OR 2.1 in TREAT registry)
#3 Preventive care: Preventing bone loss. Limiting steroid use. Recommend weight-bearing exercise, Quit Smoking, Measure DEXA, added Calicum/Vit D/Bisphosphonates
#4: Vaccination –pneumococcal vaccine. Avoid live virus vaccines
#5 Vaccination –influenza vaccine, zoster vaccine
#6 Testing for latent TB prior to anti-TNF
#7 Testing for hepatitis B virus
#8 Testing for C diff with patients hospitalized with IBD
#9 VTE prophylaxis in adult IBD patients. Risk assessment on admission to hospital is recommended. IBD patients have 1.5-3.5-fold higher risk of VTE àwhich can increase mortality risk
#10 Screening for tobacco. Tobacco use after surgery increases recurrence by 2.5-fold. It also increases risk for reoperation.

Last year’s notes:

How Colonoscopy & Preps are Indicative of Patient Activation and Health Care Decision-Making

Posted on March 26, 2014 by gutsandgrowth

I found two recent studies on bowel preps interesting primarily because of how they help us understand problems with utilization and problems with patient motivation.

The first study (Clin Gastroenterol Hepatol 2014; 12: 443-50) utilized a 5% random national sample of Medicare claims data. The authors determined that among 57,597 Medicare beneficiaries 66 years and older that underwent screening colonoscopy (not therapeutic) 24.8% of these procedures were performed in individuals with a life expectancy <10 years. Given the nature of the study (eg. relying on administrative data), there were several limitations. However, the implication of the study is that there are a lot of unnecessary colonoscopies. That is, screening colonoscopies are intended to interrupt a sequence of adenoma to adenocarcinoma that can take years; even when cancer is present, it can take several years before the onset of clinical symptoms. Currently, the US Preventive Services Task Force (USPSTF) recommends against routine screening in those aged 75-84, precisely because the benefits of screening may be outweighed by the risks of screening.” The authors note that “people with multiple comorbidities (and therefore lower life expectancy) are more likely to visit multiple providers, which increases the chances of receiving testing.”

The second study (Clin Gastroenterol Hepatol 2014; 12: 451-57) showed that patients with lower “patient activation” are much more likely to have a poor colonoscopy preparation. Patient activation is defined as “an individual’s knowledge, skill, and confidence for managing his/her own health and health care.” The author’s note that the “Patient Activation Measure (PAM) is a validated scale developed…to measure this construct.” This cross-sectional study took place in Chicago between 2008-2010 at either an academic practice or a ‘federally qualified health center.’ Key findings:

One-third of patients (n=134/462 adults) had suboptimal quality of bowel preparations. Of these, 15% (n=62) were fair quality and 17% (n=72) were poor quality.
After multivariable analysis and adjustments, patient activation (OR 2.12) and diabetes (OR 2.45) were independent predictors of suboptimal bowel preparation quality.
Health literacy (a measure of cognitive skill) was not correlated with patient activation (a measure of patient engagement).

Also noted in same journal issue: Clin Gastroenterol Hepatol 2014; 12: 470-77. “In a supervised setting, nurse endoscopists perform colonoscopies (after a minimum of 100) according to quality and safety standards that are comparable with those of physician endoscopist and can substantially reduce costs.”

Take-home messages:

Poor bowel preparations are common. In studies of adult patients, split-dose preparations can help. The associated editorial (pg 458-462) recommends delaying case and considering further oral prep or enemas for patients arriving with stool that is not clear or yellow.
Colonoscopies are performed too frequently in some patients and not frequently enough in others. Thus, something as simple as a colonoscopy is not so simple.

Related blog posts:

Colonoscopy, Split-dosing bowel preps, and Ottawa scores … This link provides numerous annotated references, including a link to Dave Barry’s column on bowel preparation.
And the Best Prep is… | gutsandgrowth
Three PEG Pediatric Cleanouts | gutsandgrowth
Data Supporting Miralax | gutsandgrowth

Zip Code or Genetic Code -which is more important for longevity?

Posted on March 25, 2014 by gutsandgrowth

From NY Times: http://t.co/fNm0nFOUdK

An excerpt:

Fairfax County, Va., and McDowell County, W.Va., are separated by 350 miles, about a half-day’s drive. Traveling west from Fairfax County, the gated communities and bland architecture of military contractors give way to exurbs, then to farmland and eventually to McDowell’s coal mines and the forested slopes of the Appalachians. Perhaps the greatest distance between the two counties is this: Fairfax is a place of the haves, and McDowell of the have-nots. Just outside of Washington, fat government contracts and a growing technology sector buoy the median household income in Fairfax County up to $107,000, one of the highest in the nation. McDowell, with the decline of coal, has little in the way of industry. Unemployment is high. Drug abuse is rampant. Median household income is about one-fifth that of Fairfax.

One of the starkest consequences of that divide is seen in the life expectancies of the people there. Residents of Fairfax County are among the longest-lived in the country: Men have an average life expectancy of 82 years and women, 85, about the same as in Sweden. In McDowell, the averages are 64 and 73, about the same as in Iraq….

There have long been stark economic differences between Fairfax County and McDowell. But as their fortunes have diverged even further over the past generation, their life expectancies have diverged, too. In McDowell, women’s life expectancy has actually fallen by two years since 1985; it grew five years in Fairfax.

“Poverty is a thief,” said Michael Reisch, a professor of social justice at the University of Maryland, testifying before a Senate panel on the issue. “Poverty not only diminishes a person’s life chances, it steals years from one’s life.”

That reality is playing out across the country. For the upper half of the income spectrum, men who reach the age of 65 are living about six years longer than they did in the late 1970s. Men in the lower half are living just 1.3 years longer.

This life-expectancy gap has started to surface in discussions among researchers, public health officials and Washington policy makers. The general trend is for Americans to live longer, and as lawmakers contemplate changes to government programs — like nudging up the Social Security retirement age or changing its cost-of-living adjustment — they are confronted with the potential unfairness to those who die considerably earlier.

The link between income and longevity has been clearly established. Poor people are likelier to smoke. They have less access to the health care system. They tend to weigh more. And their bodies suffer the debilitating effects of more intense and more constant stress. Everywhere, and across time, the poor tend to live shorter lives than the rich, whether researchers compare the Bangladeshis with the Dutch or minimum-wage workers with millionaires.

But is widening income inequality behind the divergence in longevity over the last three decades? …

Living in Fairfax is different than living in McDowell.

In Fairfax, there are ample doctors, hospitals, recreation centers, shops, restaurants, grocery stores, nursing homes and day care centers, with public and private entities providing cradle-to-grave services to prosperous communities…

The jobs tend to be good jobs, providing health insurance and pensions, even if there is a growing low-wage work force of health aides, janitors, fast-food workers and the like. “It’s a knowledge-based work force,” Mr. Fuller said. “And we have an economy built on services, technology-intensive services.”

…350 miles away, …

Coal miners still dig into and blast off the tops of steep Appalachian hills. But the industry that once provided thousands of jobs is slowly disappearing, and the region’s entrenched poverty has persisted. The unemployment rate is 8.8 percent, down from more than 13 percent in the worst of the recession. The current number would be even higher if more residents hadn’t simply given up looking for work.

Government assistance accounts for half of the income of county residents. Social workers described shortages of teachers, nurses, doctors, surgeons, mental health professionals and addiction-treatment workers. There is next to no public transportation…

Many people … have multiple woes: “Diabetes. Obesity. Congestive heart failure. Drug use. Kidney problems. Lung conditions from the mines.” Problems often start young and often result in shorter lives, she said. Earlier that day, she handed me a list of recent funerals with about half highlighted in yellow; they signified that the deceased was under 50…

But dollars in a bank account have never added a day to anyone’s life, researchers stress. Instead, those dollars are at work in a thousand daily-life decisions — about jobs, medical care, housing, food and exercise — with a cumulative effect on longevity…

As such, the health statistics for Fairfax and McDowell are as striking as their income data. In Fairfax, the adult obesity rate is about 24 percent and one in eight residents smokes. In McDowell, the adult obesity rate is more than 30 percent and one in three adults smokes. And the disability rate is about five times higher in McDowell.

In both counties, food availability matters. There are only two full-size grocery stores in McDowell; minimarts and fast-food restaurants are major sources of nutrition. “We don’t have gyms or fitness centers,” said Pamela McPeak, who grew up in McDowell getting creek water to flush her family’s toilet. “It’s cheaper to buy Cheetos rather than apples.” She now runs a nonprofit program that provides tutoring and helps high school students get into college.

Education is also correlated with longevity, as it is with income and employment. Educated individuals are much more likely to work, and much more likely to have higher incomes. In McDowell, about one in 18 adults has a college degree; in Fairfax, the share is 60 percent.

Finally, and perhaps most powerfully, researchers say that a life in poverty is a life of stress that accumulates in a person’s very cells. Being poor is hard in a way that can mean worse sleep, more cortisol in the blood, a greater risk of hypertension and, ultimately, a shorter life…

It is hard to prove causality with the available information. County-level data is the most detailed available, but it is not perfect. People move, and that is a confounding factor. McDowell’s population has dropped by more than half since the late 1970s, whereas Fairfax’s has roughly doubled. Perhaps more educated and healthier people have been relocating from places like McDowell to places like Fairfax. In that case, life expectancy would not have changed; how Americans arrange themselves geographically would have…

In particular, changes in smoking and obesity rates may help explain the connection between bigger bank accounts and longer lives. “Richer people and richer communities smoke less, and that gap is growing,” said Dr. Murray at the Institute for Health Metrics and Evaluation…

To some extent, the broad expansion of health insurance to low-income communities, as called for under Obamacare, may help to mitigate this stark divide, experts say. And it is encouraging that both Republicans and Democrats have recently elevated the issues of poverty, economic mobility and inequality, But the contrast between McDowell and Fairfax shows just how deeply entrenched these trends are, with consequences reaching all the way from people’s pocketbooks to their graves.

Related blog posts:

Feeling Guilty about Stopping Breastfeeding? (Part 2)

Posted on March 24, 2014 by gutsandgrowth

Another study (J Pediatr 2014; 164: 487-93, editorial pg 440-42) echoes yesterday’s study.

Design: The authors used a nationally representative sample in a longitudinal survey of 7500 children. In addition to breastfeeding practices, the authors explored parenting behaviors including putting an infant to bed with a bottle and frequency of reading.

Results: “there is a positive relationship between predominant breastfeeding for 3 months or more and child reading skills, but this link is the result of cognitively supportive parenting behaviors and greater levels of education among women who predominantly breastfed. We found little-to-no relationship between infant feeding practices and the cognitive development of children with less-educated mothers. Instead, reading to a child every day and being sensitive to a child’s development were significant predictors of math and reading readiness outcomes.”

Take-home message: the editorial states that parents should not be concerned that being unable to breastfeed will be detrimental to a child’s cognitive function. But, “encouragement of breastfeeding for other reasons, including health benefits to the infant and enhancement of mother-infant attachment”…merit recommendation along with good parenting practices (eg. reading to infants).

Feeling Guilty about Stopping Breastfeeding?

Posted on March 23, 2014 by gutsandgrowth

From NY Times, Link: http://t.co/rBXCORx3mM

Excerpt:

Many women who are unable to breast-feed feel guilty about it and worry they may be depriving their children of a range of benefits. Groups like the American Academy of Pediatrics and the World Health Organization recommend six months of exclusive breast-feeding for all infants, citing studies that show breast milk is easily digestible and has nutrients that are superior to or absent from infant formulas, including immunological substances that reduce rates of infection and fatty acids important in brain development.

But now a new study suggests that many of the long-term benefits attributed to breast-feeding may be an effect not of breast-feeding or breast milk itself but of the general good health and prosperity of women who choose to breast-feed.

Researchers at Ohio State University compared 1,773 sibling pairs, one of whom had been breast-fed and one bottle-fed, on 11 measures of health and intellectual competency. The children ranged in age from 4 to 14 years.

The researchers recorded various health and behavioral outcomes in the sibling pairs, including body mass index, obesity, asthma, hyperactivity, reading comprehension, math ability and memory-based intelligence. The study, published online in Social Science & Medicine, found no statistically significant differences between the breast-fed and bottle-fed siblings on any of these measures.

By studying “discordant” siblings — one of whom had been breast-fed and the other not — the authors sought to minimize the possibility that racial, socioeconomic, educational or other differences between families could affect the results. Many earlier studies on breast-feeding failed to control for such factors, they say.

… researchers have consistently found large socioeconomic and racial disparities in breast-feeding rates. A C.D.C. survey in 2008 found that 75 percent of white infants and 59 percent of black infants were ever breast-fed, and in 2013, the agency reported that 47 percent of white babies but only 30 percent of black babies were still being breast-fed at 6 months. Compared with bottle-fed infants, breast-fed babies are more likely to be born into families with higher incomes, have parents with higher educational attainments, and live in safer neighborhoods with easier access to health care services.

Still, sibling studies such as this latest one do not solve all the problems of bias…

Geoff Der, a statistician at the University of Glasgow who has worked with the same data in previous studies, said that the findings in the present study were robust and the authors’ method for eliminating selection bias was powerful…“In a society with a clean water supply and modern formulas,” he said, “a woman who isn’t able to breast-feed shouldn’t be feeling guilty, and the likelihood that there’s any harm to the baby is pretty slim.”

Related blog posts:

Active Video Games –Part of Weight Loss Program?

Posted on March 22, 2014 by gutsandgrowth

From JAMAPediatrics (full article): http://t.co/CmwQjCyhdJ

An excerpt:

Design, Setting, and Participants Group-randomized clinical trial conducted during a 16-week period in YMCAs and schools .. Seventy-five overweight or obese children (41 girls [55%], 34 whites [45%], 20 Hispanics [27%], and 17 blacks [23%]) enrolled in a community-based pediatric weight management program. Mean (SD) age of the participants was 10.0 (1.7) years; body mass index (BMI) z score, 2.15 (0.40); and percentage overweight from the median BMI for age and sex, 64.3% (19.9%).

Interventions All participants received a comprehensive family-based pediatric weight management program (JOIN for ME). Participants in the program and active gaming group received hardware consisting of a game console and motion capture device and 1 active game at their second treatment session and a second game in week 9 of the program. Participants in the program-only group were given the hardware and 2 games at the completion of the 16-week program…

Results Participants in the program and active gaming group exhibited significant increases in moderate-to-vigorous (mean [SD], 7.4 [2.7] min/d) and vigorous (2.8 [0.9] min/d) physical activity at week 16 (P < .05). In the program-only group, a decline or no change was observed in the moderate-to-vigorous (mean [SD] net difference, 8.0 [3.8] min/d; P = .04) and vigorous (3.1 [1.3] min/d; P = .02) physical activity. Participants in both groups exhibited significant reductions in percentage overweight and BMI z scores at week 16. However, the program and active gaming group exhibited significantly greater reductions in percentage overweight (mean [SD], −10.9% [1.6%] vs −5.5% [1.5%]; P = .02) and BMI z score (−0.25 [0.03] vs −0.11 [0.03]; P < .001).

Conclusions and Relevance Incorporating active video gaming into an evidence-based pediatric weight management program has positive effects on physical activity and relative weight.

Comment: The costs of the games and game consoles were about $350 according to the authors. Since this was a short study (16-weeks), it is not clear that this will be cost-effective. However, any tools that may help kids become more active are certainly welcome.

Related Blog Posts:

Think Like a Doctor –Another Reason for Cyclic Vomiting

Posted on March 21, 2014 by gutsandgrowth

When cyclic vomiting pattern starts in young adults, the differential diagnosis is different than in toddlers. A case in point is a recent think like a doctor column from NY Times.

The initial presentation described a 25-year-old man who gets sweaty and nauseated and starts vomiting uncontrollably every few weeks.

1st the link with the case challenge: challenged Well readers to figure out

A big clue in this case was the fact that hot showers ameliorated his symptoms.

Now the answer, full link: http://nyti.ms/1lcPJKj

“The correct diagnosis is…

Cannabinoid hyperemesis caused by smoking synthetic marijuana.”

Briefly Noted…Scoliosis, Cystic Fibrosis, Specific Carbohydrate Diet, GGT, Surgeon General

Posted on March 20, 2014 by gutsandgrowth

“Net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional status was minimal” according to this prospective study of 31 children: JPGN 2014; 58: 38-45.

Lactobacillus reuteri ATCC55730 was associated with reduced pulmonary exacerbations (but not improved FEV1) in 61 patients with cystic fibrosis who were enrolled in a prospective randomized, double-blind, placebo-controlled study over 6 months between 2007-2009 (JPGN 2014; 58: 81-86).

A retrospective chart review of seven children with Crohn disease who were treated with the specific carbohydrate diet with an average diet duration of 14.6 months showed that all symptoms resolved and laboratory studies improved or normalized. (JPGN 2014; 58: 87-91). More studies on this diet are expected to be published soon.

Data from 200 preterm infants and 383 term infants help provide updated GGT (gamma-glutamyl transferase) reference values. In preterm infants during 1st 7 days: 141 ± 89 U/L, then between days 8-28: 131 ± 85 U/L. In term infants the values were similar 140 ±86 U/L and 145 ± 87 U/L respectively. (JPGN 2014; 58: 99-101).

And from NEJM twitter feed, Congress may allow the NRA veto power in the selection the next surgeon general: http://nej.md/1nECFlM.

Revising the Textbooks on Isoniazid Hepatotoxicity

Posted on March 19, 2014 by gutsandgrowth

Previously, isoniazid (INH) hepatoxicity has generally been described as “idiosyncratic.” New research shows that INH-induced hepatotoxicity is often associated with anti-INH and anti-cytochrome P450 antibodies (Hepatology 2014; 59: 1084-93, editorial 746-48).

Background: INH is a crucial treatment for tuberculosis. About 10% of patients receiving monotherapy may develop mild elevations (<3-fold the upper limit of normal) of alanine aminotransferase. However, 0.5-1% develop overt hepatitis and some develop acute liver failure (ALF). Risk factors for ALF include female gender, age >35 years, cotreatment with other tuberculosis medications, INH dose >50 mg/kg, ethanol use, and slower metabolic pathways (slow acetylator N-acetyltransferase 2 or cytochrome (CYP) P450 2E1 genotype).

The authors utilized two patient groups: 19 from the ALF study group registry who had >50% likelihood of IHN toxicity and 20 control patients who were receiving INH prophylaxis. In this control group, 15 had no liver injury and 5 had mild hepatitis. The authors utilized several immunoassays.

Key findings:

15 of 19 cases of INH-associated ALF had detectable antibodies: 8 anti-INH and 11 had antiCYP2E1 Abs.
None of these antibodies were detected from INH-treated controls

Bottomline: from the authors of the study “Although the presence of these antibodies only in INH-induced liver failure suggests that INH-induced liver injury is immune mediated, there is no evidence that these Abs are actually responsible for the liver injury.”

In this same issue is a lengthy guideline on the “Evaluation for Liver Transplantation in Adults”: http://t.co/AnnJHHVNh0