G Parthasarathy et al. Gastroenterol 2016; 150: 367-79. Mucosal and fecal microbiota samples were collected from 25 healthy women and 25 women with chronic constipation. Key finding: The mucosal, but not fecal, microbiota profile were 94% predictive of constipation. The associated editorial (pg 300) provides a framework for understanding these findings and show the complexity of trying understand the interations between diet, motility and microbes.
S Fukudo et al. Gastroenterol 2016; 150: 358-66. This prospective study of Ramosetron for 576 women with IBS-D. Key finding: 50.7% of treatment patients reported global improvement compared with 32.0% of control patients. Patients had less abdominal pain, less discomfort, and better stool consistency. Ramosetron, a 5-HT3 antagonist, has not been reported to cause ischemic colitis (in contrast to alosetron).
In followup to a post earlier in the week, another worrisome study on the Zika virus in pregnancy from NEJM. Here’s an excerpt:
Fetal abnormalities were detected by Doppler ultrasonography in 12 of the 42 ZIKV-positive women (29%) and in none of the 16 ZIKV-negative women. Adverse findings included fetal deaths at 36 and 38 weeks of gestation (2 fetuses), in utero growth restriction with or without microcephaly (5 fetuses), ventricular calcifications or other central nervous system (CNS) lesions (7 fetuses), and abnormal amniotic fluid volume or cerebral or umbilical artery flow (7 fetuses).
Farjado, Puerto Rico
While Zika virus infections may not be seen frequently by pediatric gastroenterologists, this infection will be a common concern for the families we treat and we may end up taking care of children with feeding problems/neurologic impairment due to congenital infection.
I attended a recent Georgia American Academy of Pediatrics board meeting. One of the topics discussed was the Zika virus. An update was given by Dr. Harry Keyserling, chair of the infectious disease committee (who has given permission for me to share some of his slides). Some of the important points from his talk:
- The Zika virus shares some similarities with the Dengue virus. The Zika virus is a single-stranded RNA flavivirus. Incubation period is 3 days to a few weeks. It can be acquired from mosquito bites, spread sexually, transplacentally or intrapartum. It may be transmissible via blood, organ donation or possibly breastmilk.
History of Zika Virus
Most are asymptomatic. The clinical spectrum in those with symptoms are noted above.
- 80% of infected individuals are asymptomatic.
Approximate distribution of mosquito vector
- Due to the geographic distribution of the vector, it is likely that there will be many more cases in Georgia.
- The most alarming association has been with microcephaly. In some locations, there have been recommendations to avoid pregnancy until 2018. After natural infection has spread, it is likely to lead to immunity and then should be safe to become pregnant.
- Zika can be acquired through sexual-transmission which indicates that pregnant women in endemic areas could need to avoid sex.
My take: Because the Zika virus is going to continue to spread and the methods for prevention are not entirely effective, the next few years are going to present a lot of challenges. This will continue until some population immunity develops (following infection or perhaps after development of an effective vaccine).
An interesting commentary (P Hartzband, J Groopman. NEJM 2016; 374: 106-8) explains the history of trying to achieve better efficiencies in medicine and some of the problems with this.
Frederick Taylor has been described as the “father of scientific management” and the original “efficiency expert.” He supported the notion that there is one best way to do every task. This was initially applied to car production but there have been attempts to adopt this idea into medicine. The authors make several key points:
- “The standardization integral to Taylorism and the Toyota manufacturing process cannot be applied to many vital aspects of medicine”
- “There is a certain hypocrisy among some of the most impassioned advocates for efficiency and standardization…they all want a different kind of health care for themselves and their families than they profess for everyone else. What they want is what every patient wants: unpressured time from their doctor or nurse and individualized care rather than generic protocols for testing and treating.”
- “Medical Taylorism began with good intentions — to improve patient safety and care. But it has gone too far…we must reject its blanket application…Good medical care takes time, and there is no one best way to treat many disorders.”
Zika NEJM Link (full text): Zika Virus in the Americas Anthony Fauci/David Morens
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Isla Verde, San Juan