CCFA: Updates in IBD Conference (part 2)

My notes from Georgia Chapter of CCFA’s conference. There could be errors of omission, transcription and/or errors in context based on my understanding.

Sandy Kim, MD –Children’s Hospital of Pittsburgh

Diet in Inflammatory Bowel Disease: Food for Thought

This was a terrific lecture –though much of the topic has been reviewed recently in this blog: Dietary Therapy for Inflammatory Bowel Disease.

Key points:

  • Changes in diet can change microbiome quickly, within 24 hrs
  • Some diets (eg. more fruit/vegetables/fish) may help lower risk of developing IBD
  • Dietary therapy, especially exclusive enteral nutrition (EEN), is effective therapy for Crohn’s disease
  • Why does EEN work?  It is not clear.  There are some changes in microbiome but decrease or little change overall in microbial diversity
  • Reviewed newer dietary approaches: SCD (www.nimbal.org), CD-TREAT, Crohn’s Disease Exclusion Diet

Related blog posts:

Frank Farraye, MD –Mayo Clinic

Health Maintenance in the Adult Patient with IBD

  • Good Practice: Update Vaccinations in IBD population
  • Recent concerns include measles outbreak, and frequent occurrence of Herpes zoster
  • No evidence that vaccination exacerbates IBD
  • New Hepatitis B Recombination Vaccine (Heplisa-B) -2 doses given over one month (for patients older than 18 years. Seroprotective anti-HBs after two doses: 95.4%
  • Shingrix -new recombinant Zoster vaccine.  Overall efficacy 97.2%.  Frequent adverse reactions
  • Women with IBD should undergo annual cervical cancer screening
  • IBD patients should be seen by dermatology
  • Consider depression screening in IBD patients
  • Counsel patients to quit smoking
  • Consider bone density screening in at risk patients

One audience member (Jeff Lewis, MD) pointed out that more attention needs to be paid to depression and anxiety which are much more common and more frequently health-threatening than issues like vaccination.

Related blog posts:

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.

 

Expert Advice for Diagnosis and Treatment of Rumination Syndrome

Full text: M Halland et al Clinical Gastroenterol Hepatol 2018; 16: 1549-1555 provide an excellent review and practical recommendations for rumination syndrome.

The article describes the high prevalence which is ~0.8-0.9% of adults and ~5% of children.  Some populations like patients with eating disorders and fibromyalgia have even higher rates.

Other key points:

  • Long delay in diagnosis: patients “visit an average of 5 physicians over 2.7 to 4.9 years before being diagnosed correctly”
  • The diagnosis is a clinical based on Rome IV criteria, though most patients undergo an esophagogastroduodenoscopy or barium study to rule out other disorders
  • Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting.
  • Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely.
  • Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up.
  • Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome.
  • Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique.
  • This article gives instructions on this technique: “Diaphragmatic breathing can be learned easily by putting a hand on the chest and on the abdomen during respiration, and only allowing the hand on the abdomen to move out with inspiration while the chest remains in position (Figure 3). We instruct patients to take breaths by protruding the abdomen while keeping the chest as stationary as possible. Each inhalation or exhalation should be slow and complete, aiming for 6 to 8 respirations per minute. We recommend diaphragmatic breathing for 15 minutes after each meal, or longer if the sensation of impending rumination remains. The technique also should be practiced in the absence of meals to become expert at the technique. Uncontrolled studies and case series have reported resolution or improvement in rumination symptoms after diaphragmatic breathing in 20%–66% of patients. Figure 3: The patient slowly inhales through the nose while protruding the abdomen and keeping the chest stationary. (B) The patient slowly exhales via the mouth and allows the abdomen to retract.”
  • Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations.
  • Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory [adult] patients.

My take: This is a useful review article.  Rumination needs to be considered particularly in patients with regurgitation, often labelled vomiting by families, that happens quickly after meals.

Related posts:

In the news…from Washington Post:

Vaccination and Inflammatory Bowel Disease -Resources Targeted for Adult Patients

From a recent Gastroenterology & Hepatology –Full Link:

Gastroenterology & Hepatology  July 2017 – Volume 13, Issue 7; Vaccination of Patients With Inflammatory Bowel Disease.  Francis A. Farraye, MD, MSc

Thanks to John Pohl’s twitter feed for this link that provides recommendations for Adults with IBD.

An excerpt:

G&H  What specific resources for vaccinations are available to help gastroenterologists?

FF  It is helpful for providers to keep a copy of the Crohn’s and Colitis Foundation’s health maintenance recommendations posted in their office. This 1-page checklist (available at http://www.crohnscolitisfoundation.org/science-and-professionals/programs-materials/ccfa-health-maintenance.pdf) includes all recommended vaccines and also comments on other important health maintenance items, such as screening for cervical and skin cancer, depression, and osteoporosis. In addition, Cornerstones Health has a vaccination checklist (available at http://www.cornerstoneshealth.org/wp-content/uploads/2017/06/Monitoring-and-Prevention-3.10.2017.pdf) that can be downloaded, printed, and placed in each examination room to reinforce the importance of vaccination. Primary care providers as well as gastroenterologists can use these checklists as reminders in their busy practices.

Related blog post:

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.

Vaccination Can Lower the Risk of a Childhood Cancer

From NY Times: How a Childhood Vaccine Reduces the Risk of a Cancer

An excerpt:

Young children are routinely vaccinated against Haemophilus influenza type B, or HiB, a bacterium that can cause meningitis and other serious problems. But the HiB vaccine has an added benefit: It reduces the risk for acute lymphoblastic leukemia, or ALL, the most common childhood cancer, and now scientists know why.

Dr. Markus Müschen, the senior author of a new study published in Nature Immunology,… using a mouse model … found that in some cases, the HiB virus triggers a vigorous immune reaction that activates two enzymes. These enzymes can cause mutations in certain types of blood cells, driving them into malignancy. When this happens, children are more likely to develop leukemia when they are 5 to 7 years old.

Dr. Müschen, a professor of medicine at the University of California, San Francisco, said that the effect of the vaccine was a 20 percent reduction in risk for leukemia. “This seems small,” he said. “But it’s highly significant in large populations. Whatever activates the immune system early in life reduces the risk for ALL.”

Turner Field,  June 6th

Turner Field, June 6th

1400 Different Immunization Schedules -What Could Go Wrong?

A recent study (J Pediatr 2015; 166: 151-6) has examined the frequency of “alternative” (non-standard) vaccination schedules among 222,628 children in New York (2009-2011), using a statewide mandatory immunization information system.

Key findings:

  • 25% of children followed an non-standard immunization schedule.
  • At 9 months of age, children on an non-standard schedule were less likely to be up-to-date (15% compared with 90%, P<0.05).

The authors note that in a separate study that there were “1400 individualized vaccination patterns.”  These patterns break down into three: delays of vaccine, selective refusal of specific vaccines, and reduction in the number of vaccines.

In a brief summary, Sarah Long notes that for parents/doctors –“Although their intent is heightened protection of their children/patients from harm, the result is the opposite.  Alternative “schedules” are completely untested for immunogenicity or safety.”

One limitation of this study is that it was conducted in New York.  There is wide variability in the resistance to vaccination among states.

Bottomline: Their has been an increase in the use of non-standard vaccine schedules.  This is contributing to community vulnerability to vaccine preventable diseases.

A related story: “Disneyland” Measles Outbreak (from USA Today) and from NY Times (1/21/15): Measle cases linked to Disneyland (& unvaccinated students).  1/28/15 Measles in Arizona reaches ‘critical point’

Related blog posts:

Measles, Seizures and Sometimes Death due to Vaccine Delays and Avoidance

Three recent news items provide more up-to-date reasons for childhood vaccines.

1. Delaying vaccines may increase seizures –here’s the link and an excerpt (from NY Times):

Some parents postpone their children’s vaccinations because they believe the delay decreases the risk. But a new study finds the opposite may be true.

The analysis, published online in Pediatrics, involved 5,496 children born from 2004 to 2008 who had seizures in the first two years of life.

For children who received any of their shots as recommended before age 1, there was no difference in the incidence of seizure in the 10 days after vaccination compared with the period before vaccination. But compared with giving it in the first year, giving the measles-mumps-rubella vaccine at 16 months doubled the incidence of seizure, and giving the measles-mumps-rubella-varicella vaccine at that age increased it almost six times.”

 

2. Rate of measles infections at 20 year high –here’s the link and an excerpt: (from USA Today)

The USA has the most measles cases in 20 years…The confirmed case count for 2014, as of May 23, was 288 and growing, the CDC says. That number includes 138 cases from Ohio, where the biggest outbreak is ongoing – and where the actual count is 166 as of Thursday, according to the state Health Department.

The nationwide total is the highest for late May since 1994, when 764 cases were reported, the CDC says. It surpasses the 220 cases reported in all of 2011, which was the most in the post-2000 era.

“This is not the kind of record we want to break, but should be a wake-up call for travelers and for parents to make sure vaccination records are up to date,” said Anne Schuchat, director of the CDC’s National Center for Immunizations and Respiratory Diseases. Schuchat…Before the measles vaccine became available in 1963, the virus infected about 500,000 Americans a year, causing 500 deaths and 48,000 hospitalizations.

Cases this year have been reported in 18 states and New York City. Ninety percent have been among people who have not been vaccinated or have unknown vaccination status, according to the CDC. Most of the patients report religious, philosophical or personal reasons for avoiding vaccines.”

 

3. When parents withhold vaccines, vulnerable children get sick and sometimes die  –here’s the link (reference noted from Eric Benchimol’s twitter feed) and an excerpt:

Jason Lawson recalled a terrifying 10 days in B.C. Children’s Hospital when his son Beckett was six, after Beckett became severely ill from chicken pox.

At the time, Beckett was still receiving a maintenance dose of chemotherapy to kill potential cancer cells. That treatment also suppressed Beckett’s immune system.

When an unvaccinated child at the school passed on chicken pox, the consequences were dire — at one point the virus got into Beckett’s liver and started to do damage, which in some cases can be irreversible….

Lawson said he’s speaking out to remind families that protecting their friends and neighbours is another good reason to make the effort.

Take home message:  With every medical intervention, there are risks and benefits.  Those who forego vaccines increase the risk for themselves, their families and friends.

Related blog posts: