Recommended Read (February 2014)

Recommended Read (February 2014)

The Education committee is happy to present another edition of ‘recommended read’ to our members.

  I would like to start this edition with a thought provoking review on the topic of obesity published in Gut 2014;63:687-695 doi:10.1136/gutjnl-2013-306235. Recent advances in clinical practice, challenges and opportunities in the management of obesity. Michael Camilleri et al describes the pathogenic mechanisms in the development of obesity including adiposity, food intake, GI and adipocyte related hormones, inflammatory mediators, the GI- brain axis and the role of hypothalamus. The authors discuss about the guidelines (based on Category A evidence) published by the National Heart, Lung and Blood Institute in 1998, which suggest that a 10 percent reduction in body weight reduces disease risk factors. Weight should be lost at a rate of 1 to 2 pounds per week based on a calorie deficit of 500–1000 kcal/day. These guidelines also recommend increased physical activity and pharmacological approach to augment weight loss. This approach has been efficacious in multiple large-scale clinical trials. The authors discuss the new pharmacological approaches, recently approved by the FDA, to decrease appetite and result in weight loss: Lorcaserin (Belviq) is a serotonin 2c (5-HT2C) receptor agonist that activates pro-opiomelanocortin (POMC) neurons of the hypothalamic arcuate nucleus, decreasing appetite and resulting in an average 5.8% weight loss when compared with 2.1% in the placebo group.  A second, approved drug is the combination phentermine-topiramate extended release (ER) (Qsymia) that produces mean 8–10% weight loss in different trials when compared with 1.6% weight loss in the placebo group. The authors state that bariatric surgery is the most effective treatment option for obese patients. Available procedures include laparoscopic and open Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, adjustable gastric band, vertical banded gastroplasty, duodenal switch and bilio-pancreatic diversion. RYGB is currently the bariatric surgical procedure of choice. They go on to say that despite proven efficacy and the fact that mortality from bariatric surgery is comparable to that of cholecystectomy or appendectomy in bariatric centres with high surgical volumes, only less than 1% of obese subjects who qualify for bariatric surgery will undergo such intervention because of high costs and the frequency of early and late complications of surgery. The authors balance the argument by concluding that further insights on vagal, hypothalamic and GI hormonal control are key to the development of interventions that can be applied in the large number of eligible patients with obesity and metabolic syndrome. They also state that future interventions targeting the microbiome or intraluminal mechanisms such as interference with intraluminal digestion or bile acid-related augmentation of incretin responses may be feasible peripherally-directed therapies.

  Proton pump inhibitors like Omeprazole and Lansoprazole have revolutionised the way we manage acid peptic disorders to an extent that nobody need to undergo procedures like Billroth 1  surgery for peptic ulcer. However the use of PPI has been attributed to increased incidence of pneumonia and enteric infections by some authors. However data from Swansea University suggests that individuals prescribed a PPI probably have a pre-existent increased risk of GI infection prior to PPI prescription.  Brophy S, Jones KH, Rahman MA, et al Am J Gastroenterol  doi:10.1038/ajg.2013.30 Does the use of proton pump inhibitor increase the risk of enteric pathogenic infection? Using Campylobacter and Salmonella as examples of significant GI infection, the authors analysed data on nearly 2 million patients registered with NHS general practitioners in Wales and compared the incidences of these infections between PPI prescribed and non-PPI prescribed individuals. Furthermore, for individuals prescribed PPI they also analysed rates of infection in the 12-month period prior to index PPI prescription, thus controlling for individual confounding factors by using the same patients as their own controls. Between 1990 and 2010,    358,938 (18.7%) patients were prescribed a PPI. Patients prescribed a PPI were older with a greater frequency of females compared with controls. The PPI patients were more likely to have other factors associated with GI symptoms such as antibiotic use, oral steroid use, NSAID prescription, immunosuppressant medication, bowel surgery, or a diagnosis of arthritis. Rates of Campylobacter and Salmonella infection were higher after a prescription for PPI compared with rates in the same individual for the period before prescription. However, this increased rate was also observed in the non-PPI group. Patients prescribed a PPI already had a 6.9-fold greater risk for Campylobacter infection and a 3.1-fold greater risk for Salmonella infection in the 12 months prior to prescription than patients not prescribed a PPI. The authors conclude “there is an association between taking a PPI and GI infection with Salmonella or Campylobacter. However, this risk is largely owing to differences between those who are prescribed PPIs and those who are not, rather the PPI prescription.” It may be that BSPGHAN could organise a similar study in paediatric practice?

  If any trainee wants to impress his or her consultant with knowledge in IBD trivia, here is a little help from education committee.  The highest IBD incidence in the world is found on the Faroe Islands. However that is not the only take home message from the paper published by J Burisch, N Pedersen1, S Čuković-Čavka et al in Gut 2014;63:588-597 doi:10.1136 titled East–West gradient in the incidence of inflammatory bowel disease in Europe: the ECCO-EpiCom inception cohort. The authors have created a prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people. 1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The median crude annual incidence rates per 100,000 in 2010 for CD were 6.5 (range 0–10.7) in Western European centres and 3.1 (range 0.4–11.5) in Eastern European centres, for UC 10.8 (range 2.9–31.5) and 4.1 (range 2.4–10.3), respectively, and for IBDU 1.9 (range 0–39.4) and 0 (range 0–1.2), respectively.  You are in for disappointment if you are expecting to see all the Western European centres are doing better in following the national and international guidelines.  In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively in Eastern Europe. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy. The patient populations in Eastern and Western Europe are identical in terms patient characteristics, disease extent and phenotype, smoking habits and diagnostic delay.  The authors believe that this web based epidemiological methodology is feasible and affordable and needs to be further developed to look at the disease outcomes following treatment.

  There are many factors to consider when choosing a feed for a neuro-disabled patient who is not very mobile and we are very fortunate to have the expertise of our dietetic colleagues. However, tube feedings may be complicated by vomiting and with aspiration resulting in aspiration-induced pneumonia.  The prevalence of aspiration pneumonia in such patients is reported to be in the range of 10–22% and is often caused by aspiration of refluxed stomach contents. Reducing the time the meal is in the stomach might also reduce aspiration risk. Factors that affect gastric emptying include the content and energy density of the meal. Akira Horiuchi, Yoshiko Nakayama, Ryosei Sakai  et al in their paper in American Journal of Gastroenterology doi:10.1038/ajg.2013.10 Elemental Diets May Reduce the Risk of Aspiration Pneumonia in Bedridden Gastrostomy-Fed Patients had shown that elemental diets were associated with more rapid gastric emptying and fewer episodes of aspiration than standard liquid diets in bedridden PEG patients. To look at the risk of aspiration they have enrolled 127 patients, 60 with elemental and 67 with standard liquid diets. The diet was aspirated from the trachea in none (0%) with the elemental diet vs. 8 (11.9%) with standard liquid diets (P=0.0057); aspiration pneumonia developed none with the elemental diet vs. 5 (7.5%) with standard liquid diets (P=0.031) (number needed to treat 14, 95% confidence interval 7–85). To look at the rate of gastric emptying the authors conducted  a randomized, crossover trial using elemental or standard liquid diets containing 13C sodium acetate as a tracer given to bedridden PEG patients who had experienced aspiration pneumonia. 13C breath tests were performed to estimate gastric emptying. 19 patients were enrolled in this study and the elemental diet was associated with a significant increase in the 10, 30 or 50% emptying (excretion) time (P<0.001). Any young investigators looking for a research project in the field of nutrition in children may want to explore this hypothesis.

  Trainees always wonder when their call goes to their consultant’s voice mail, whether their call was ignored by the consultants because they were in the middle of executing a tricky golf shot or simply the consultant had not heard the ring tone. If you are one of those trainees, you might be reassured to hear that the medical membership in golf clubs is in decline and also it is very unlikely to have a hearing deficit due to golf playing. I had the privilege to be trained under a past president of our society who is a keen golf player. Even after spending 12 months with him, I could not get my enthusiasm up for a hitting a small white ball and then strolling to the place where it has landed, never mind the risk of hidden rabbit holes and also being struck by the ball of another golfer. Any society member who would like to take up this sport instead of attending long meetings in your hospital in the afternoons should be reassured by the findings of this study published in BMJ Open (2014;4:e003517,doi:10.1136/bmjopen-2013-003517). The authors state that the immediate danger of noise induced hearing loss for an amateur golfer is quite unlikely. However it may be dangerous to hearing if the noise level generated by the golf clubs exceeded 116dBA. In my case all the telephone calls were answered very promptly by the consultant without any suggestion of any hearing loss.

  Most of these articles could be accessed by your Athens account. Please do send your feedbacks to education@bspghan.org.uk . Please also use twitter account of BSPGHAN to share your views.

Rafeeq
Chair of Education committee
February 2014