• U.S. Surgery Rates for Benign Colon Polyps Are Going the Wrong Way
• Thyroid Autoimmunity and Assisted Pregnancy: Levothyroxine May Not Be the Solution
• Encouraging Adolescents to Diet May Have Long-Term Negative Consequences
• The ACA, Prenatal Care, and Preterm Birth
• Disparities in Pediatric Cardiac Surgery Outcomes by Neighborhood Income
• A Potential Screening Tool for Pre-Mild Cognitive Impairment
• Why Do Alcohol Use Disorders Run in Marriages?
• Amantadine Extended Release for Walking Impairment in Multiple Sclerosis?
• The Impact of Cerebrospinal Fluid Testing on Multiple Sclerosis Diagnosis
• Comorbidities Are Associated with Treatment Intolerance in Multiple Sclerosis
• Do Antibiotics Reduce Efficacy of Hormonal Contraception?
• Embracing Minimally Invasive Surgical Treatment for Endometrial Cancer
• The Vaginal Microbiome Is Associated with Susceptibility to HIV Infection
• Expert Guidance on Evaluating Possible Extraesophageal Complications of GERD
Gastroenterology 2018 Jan 6
U.S. Surgery Rates for Benign Colon Polyps Are Going the Wrong Way
Despite endoscopic resection being safer and more cost-effective, surgery was increasingly used to remove benign polyps between 2000 and 2014.
Consistent evidence now establishes that endoscopic resection is safer and costs less than surgical resection for large benign colorectal polyps.
A large all-payer, inpatient U.S. healthcare database was used to examine incidence rates of surgery for cancer and benign colorectal polyps for the period 2000 to 2014.
During the study interval, rates of surgery for colorectal cancer went down, consistent with declining incidence rates. However, rates of surgery for nonmalignant colorectal polyps increased from 5.9 to 9.4 per 100,000 U.S. adults during the same period. Rates of surgery for benign polyps went up in adults aged 50 to 79 years but went down during the latter part of the period for those aged 80 and older. Rates increased in all racial groups and in all areas of the country, though the greatest increases were in the South and the Midwest.
By hospital type, the greatest increases were in urban teaching hospitals. The increased rates of surgery were not attributable to increases in colonoscopy volumes, which remained stable over the study interval.
COMMENT: The inability of the authors to identify an explanation for this trend is alarming, as it suggests that referral patterns are based on factors other than evidence-based medicine, guidelines, and the best interest of patients. Greater use of regional centers for endoscopic resection of large sessile and flat polyps should be an important goal.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S): Peery AF et al. Increasing rates of surgery for patients with non-malignant colorectal polyps in the United States. Gastroenterology 2018 Jan 6; [e-pub].
(http://dx.doi.org/10.1053/j.gastro.2018.01.003)
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JAMA 2017 Dec 12; 318:2190
Thyroid Autoimmunity and Assisted Pregnancy: Levothyroxine
May Not Be the Solution
In a Chinese trial, levothyroxine had no effect on miscarriage rates after IVF in women with antithyroperoxidase antibodies and normal thyroid function.
Thyroid autoimmunity is the most common cause of hypothyroidism in women of childbearing age; moreover, this immune condition is associated with excess risks for infertility, miscarriage, and preterm labor. To explore the pregnancy-associated outcomes of giving levothyroxine during a single cycle of in vitro fertilization (IVF) to women with antithyroperoxidase antibodies and normal thyroid function, investigators in China conducted an open-label trial involving 600 women (mean age, 32) who were randomized to levothyroxine or no treatment within 2 to 4 weeks before beginning an IVF cycle. Levothyroxine dosages were sufficient to maintain thyroid-stimulating hormone (TSH) levels within the normal range for pregnancy but without rendering TSH unmeasurable.
Throughout the 4.5-year study, miscarriage rates (defined as pregnancy ending before 28 weeks' gestation) were 10.3% (11 of 107) in the levothyroxine group and 10.6% (12 of 113) in the control group. Almost all miscarriages occurred during the first 12 weeks of gestation. Rates of clinical pregnancy, live birth, and preterm delivery did not differ between groups.
COMMENT: Management of thyroid abnormalities during pregnancy remains challenging and controversial, but these findings add to our knowledge: If thyroid function is normal, levothyroxine administration to women with antithyroperoxidase antibodies does not improve either pregnancy rates (during IVF) or pregnancy outcomes. As other studies indicate, even treatment of women in general with subclinical hypothyroidism (elevated TSH with normal T4) must be considered carefully because of the potential risks inherent in the therapy itself (NEJM JW Womens Health Mar 2017 and BMJ 2017; 356:i6865).
CITATION(S): Wang H et al. Effect of levothyroxine on miscarriage among women with normal thyroid function and thyroid autoimmunity undergoing in vitro fertilization and embryo transfer: A randomized clinical trial. JAMA 2017 Dec 12; 318:2190.
(http://dx.doi.org/10.1001/jama.2017.18249)
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Pediatrics 2018 Mar 6; 141:e20180233
Encouraging Adolescents to Diet May Have Long-Term Negative Consequences
When these adolescents become adults, they are more likely to have unhealthy weight control behaviors and to encourage their own children to diet.
Investigators examined whether adolescents who are advised to diet by parents are at increased risk for encouraging their own children to diet (intergenerational transmission) and to have unhealthy weight outcomes as adults. Using survey data from a longitudinal, population-based study of a socioeconomically and racially/ethnically diverse sample, the investigators identified 550 participants (mean age, 31; 65% women) who were parents and who had completed surveys when they were adolescents (mean age, 15). Analyses were controlled for age, race/ethnicity, sex, and family socioeconomic status.
- Overall, 29% of men and 42% of women reported being encouraged to diet by their parents during adolescence. These participants, compared with those who were not encouraged to diet were:
- Approximately 50% more likely to talk about diet and weight with their own children.
- 25%–35% more likely to be overweight/obese, 20% more likely to diet, and 72% more likely to binge eat.
- Significantly more likely to report unhealthy weight control practices and lower levels of body dissatisfaction.
COMMENT: Encouraging children to diet is counterproductive and sets up a negative trajectory of weight discussions that persist into the next generation. Editorialists emphasize how difficult it may be for parents to break free of this cycle and encourage us to be empathetic when counseling parents who encourage their children to diet. Asking these parents to reflect on whether they heard the same message when they were children and how that felt at the time may help them avoid diet- and weight-related talk and focus instead on creating a healthy household environment consisting of eating nutritious meals together (and avoiding sugar-sweetened beverages), family fitness and exercise, and limiting adolescents' screen time.
CITATION(S): Berge JM et al. Intergenerational transmission of parent encouragement to diet from adolescence into adulthood. Pediatrics 2018 Mar 6; 141:e20172955.
(https://doi.org/10.1542/peds.2017-2955)
Bauer KW et al. Parenting in an obesogenic environment: Ghosts at the dinner table. Pediatrics 2018 Mar 6; 141:e20180233.
(https://doi.org/10.1542/peds.2018-0233)
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JAMA 2018 Feb 13; 319:579
The ACA, Prenatal Care, and Preterm Birth
Use of prenatal care rose and incidence of preterm birth fell with Affordable Care Act implementation.
The Affordable Care Act (ACA) allowed individuals to stay on their parents' insurance plans until age 26. To evaluate the effects of this policy on young women's receipt of prenatal care and birth outcomes, researchers conducted a retrospective cohort study using U.S. birth certificate data. They assessed birth outcomes before (i.e., 2009) and after (2011–2013) enactment of the ACA's dependent coverage provision among 1.4 million U.S. women aged 24 to 25 (who were potentially affected by this policy change) compared with women aged 27 to 28 (who were not affected by this policy change).
The ACA appears to have increased the proportion of privately insured births among unmarried women younger than 26, increased receipt of adequate prenatal care, and decreased rates of preterm birth. Incidence of low birth weight, neonatal intensive care unit admission, and cesarean delivery remained unchanged.
COMMENT: This study adds important evidence that the ACA has improved the health of our nation. Now just imagine if all Americans had timely, equitable, affordable access to healthcare whenever they needed it!
CITATION(S): Daw JR and Sommers BD. Association of the Affordable Care Act dependent coverage provision with prenatal care use and birth outcomes.
JAMA 2018 Feb 13; 319:579.
(https://doi.org/10.1001/jama.2018.0030)
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Pediatrics 2018 Mar; 141:e20172183
Disparities in Pediatric Cardiac Surgery Outcomes by Neighborhood Income
Children from the lowest-income (vs. the highest-income) neighborhoods were more likely to die following cardiac surgery and required more intensive post-op care.
Disparities in health outcomes based on neighborhood have been documented for obesity and asthma, among other conditions. To evaluate whether this disparity exists in pediatric cardiac surgery outcomes, researchers examined administrative data from over 100,000 children aged <19 years who underwent surgery for a congenital heart defect at 1 of 46 pediatric tertiary care hospitals. These data were linked with U.S. Census data on household income by zip code. Cardiac transplantation and ligation for patent ductus arteriosus cases were excluded.
Children from the lowest-income neighborhoods had a significantly higher mortality rate (3.5% vs. 2.2%), longer length of stay (9 vs. 7 days), and higher median standardized inpatient hospital cost (US$58,000 vs. US$49,000) compared with children from the highest-income neighborhoods. Adjusting for race, payer, and hospital had only minimal effects on the disparities in outcomes.
COMMENT: Creating a system of healthcare that ensures predictable health outcomes for children regardless of neighborhood and geography is a challenge. In this study, access to prenatal diagnosis of heart defects and timing in subspecialty referral may account for some of the disparities seen. Improving access to timely, efficient, and high-quality care for all children is the goal to which we aspire.
CITATION(S): Anderson BR et al. Disparities in outcomes and resource use after hospitalization for cardiac surgery by neighborhood income. Pediatrics 2018 Mar; 141:e20172183.
(https://doi.org/10.1542/peds.2017-2432)
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J Psychiatr Res 2018 Jan; 96:33
A Potential Screening Tool for Pre-Mild Cognitive Impairment
Performance on a new cognitive test may mark individuals who have a heightened risk for mild cognitive impairment.
Mild cognitive impairment (MCI) can predict progression to dementia owing to Alzheimer disease (AD) and is diagnosed by clinical history and impairment in at least one cognitive domain on neuropsychological testing. Another clinical category, dubbed PreMCI, has been proposed to classify individuals with features of MCI on clinical history from patient and collateral informants but without neuropsychological deficits. PreMCI is associated with neuropathologic and imaging features consistent with AD and accelerated rates of progression to MCI and AD, but a slower rate of progression to AD than MCI. To date, no easily administered screening tool exists for PreMCI.
The current researchers assessed a somewhat novel cognitive test (LASSI-L) in 49 older adults with PreMCI and 117 normal controls (mean age, 72). PreMCI was determined by memory deficits (both subjective and from an extensive clinical interview) and normal performance on several neuropsychological tests, including the Mini-Mental Status Exam. LASSI-L measures vulnerability to proactive semantic interference or difficulty in replacing an older list of words with a new list in memory.
Four LASSI-L metrics — most strongly, failure to recover from proactive semantic interference effects (frPSI) and delayed recall — distinguished individuals with PreMCI from controls. Although no group differences in brain imaging were seen, frPSI was related to AD-associated brain changes, including greater inferior lateral ventricle dilatation and lower hippocampal and parietal volumes.
COMMENT: This short test would be easy to administer in a clinical setting. The unique metric frPSI may have high potential for distinguishing between normal individuals and those with PreMCI. If findings are replicated and show that frPSI has reasonable sensitivity and specificity for predicting trajectories of development of PreMCI into MCI or AD, the measure could become a useful screening tool.
CITATION(S): Crocco EA et al. A novel cognitive assessment paradigm to detect pre-mild cognitive impairment (PreMCI) and the relationship to biological markers of Alzheimer's disease. J Psychiatr Res 2018 Jan; 96:33.
(https://doi.org/10.1016/j.jpsychires.2017.08.015)
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JAMA Psychiatry 2018 Feb 7
Why Do Alcohol Use Disorders Run in Marriages?
Spousal interaction appears to play a bigger role than assortative mating.
Being married to someone with an alcohol use disorder (AUD) raises risk for AUD in the unaffected spouse (NEJM JW Psychiatry Jul 2016 and Am J Psychiatry 2016; 173:911) — but is this because people with similar traits are attracted to each other (assortative mating), or because they influence each other? In a Swedish registry study, researchers examined data on 8562 marital pairs in which neither spouse had a previous AUD history, but one spouse later developed an AUD. A second, within-person, analysis involved 4891 repeatedly married people whose first spouse did not have an AUD and whose second spouse did, or vice versa.
In the first analysis, just after registration of an AUD in a husband or wife, risk for an AUD in the wife or husband increased 14- or 9-fold, respectively, compared with controls having no spousal AUD; 2 to 3 years later, excess risk fell to within 4-fold. In the multiple marriage analysis, shifting from a spouse with an AUD to one without an AUD reduced risk for developing an AUD by about half. In contrast, transitioning from a spouse without an AUD to one with an AUD increased risk for developing an AUD by sevenfold in husbands and ninefold in wives.
COMMENT: The swift increase in risk for an AUD in the spouse of someone who has also developed an AUD suggests that marital interaction is largely responsible. The within-person study strengthens this impression and adds that marrying someone who has not developed an AUD is protective against experiencing a similar problem. Clinicians should involve spouses of those who develop AUDs in treatment right away, not only to reduce the risk to the unaffected spouse, but also to invoke protective factors associated with having a nonalcoholic spouse.
CITATION(S): Kendler KS et al. The origin of spousal resemblance for alcohol use disorder. JAMA Psychiatry 2018 Feb 7; [e-pub].
(http://dx.doi.org/10.1001/jamapsychiatry.2017.4457)
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Mult Scler 2018 Jan 1
Amantadine Extended Release for Walking Impairment in Multiple Sclerosis?
A greater proportion of amantadine recipients than placebo recipients had a clinically meaningful improvement in walking with treatment at 4 weeks in a phase-2 study.
Better treatments are needed for gait disorders in patients with multiple sclerosis (MS). Amantadine extended-release was studied in a randomized, double-blind, phase 2, multicenter, manufacturer-sponsored trial for those diagnosed with MS who were ambulatory. After a 1-week titration, 59 patients took the full 274 mg daily dose or placebo during weeks 2 through 4.
Improvements over baseline walking speed by the timed 25-foot walk (T25W) were 17% at week 2 and 25% at week 4 in the amantadine group, versus 8% at both weeks 2 and 4 in the placebo group. The proportion of responders (those with ≥20% improvement on the T25W, averaged over weeks 2 and 4) was 30% with amantadine and 17% with placebo. Five amantadine recipients discontinued due to adverse events and one for noncompliance. The most common side effects were dry mouth, constipation, and insomnia.
COMMENT: Amantadine immediate-release is used off-label to improve fatigue in multiple sclerosis. This study of an extended-release formulation suggests improvement in walking speed. Additional studies are needed for confirmation. Walking and fatigue are two of the more common and challenging MS symptoms to address. A phase 3 trial is planned (ClinicalTrials.gov, NCT03436199).
CITATION(S): Cohen JA et al. Safety and efficacy of ADS-5102 (amantadine) extended release capsules to improve walking in multiple sclerosis: A randomized, placebo-controlled, phase 2 trial. Mult Scler 2018 Jan 1; [e-pub].
(https://doi.org/10.1177/1352458518754716)
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Brain 2018 Feb 16
The Impact of Cerebrospinal Fluid Testing on Multiple Sclerosis Diagnosis
The presence of oligoclonal bands increased the likelihood of eventual multiple sclerosis diagnosis and decreased the time to confirmed diagnosis.
Cerebrospinal fluid (CSF) gained more prominence in the 2017 McDonald multiple sclerosis (MS) criteria for fulfilling dissemination in time (DIT) and avoiding misdiagnoses
(NEJM JW Neurol Mar 2018)
and Lancet Neurol2018; 17:162). Researcher have now published an assessment of the value of oligoclonal bands (OCBs) in CSF that was (while in press) instrumental in the 2017 recommendations and changes in the criteria. The investigators measured OCBs in CSF and serum within 3 months of a clinically isolated syndrome presentation by agarose isoelectric focusing combined with immunoblotting. This cohort included 398 with OCB determination, of whom 314 had at least 3 years' follow-up.
Compared with patients who had a clinically isolated syndrome but no brain lesions and no OCBs, patients with an abnormal MRI that met criteria for DIS (≥2 MRI lesions in ≥2 typical locations) with negative OCBs had a hazard ratio of 10.4 for developing MS; those with both DIS and OCBs had a hazard ratio of 15.3. Of 137 patients who fulfilled requirements for DIS, 111 met 2010 McDonald MS criteria at 3 years. OCBs were present in about 74% of those who developed MS. Specificity for MS increased from 81% among all participants with DIS regardless of OCB status to 88% in those with DIS+OCBs.
COMMENT: Patients who present with a first demyelinating event consistent with MS, and who have DIS plus OCBs, can now be diagnosed with MS instead of CIS. Presence of OCBs increases the specificity of the MS diagnosis, although around 25% may not have OCBs at this early stage of their disease. For patients with classic presentations and demographics for MS, along with numerous lesions in the brain and spinal cord, CSF testing may be optional. When the diagnosis is unclear, CSF should be pursued.
CITATION(S): Arrambide G et al. The value of oligoclonal bands in the multiple sclerosis diagnostic criteria. Brain 2018 Feb 16; [e-pub].
(https://doi.org/10.1093/brain/awy006)
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Neurology 2017 Nov 28; 89:2222
Comorbidities Are Associated with Treatment Intolerance in Multiple Sclerosis
Almost one quarter of MS patients have a comorbidity at diagnosis and may have greater disability accumulation and intolerance to disease-modifying drugs.
Despite the increasing number of disease-modifying drugs (DMDs) available for multiple sclerosis (MS), little is known about the prevalence of comorbidities among MS patients and whether these comorbidities are related to disease course and DMD choice, efficacy, and tolerance. To examine these questions, investigators performed a retrospective analysis of prospectively acquired clinical data on patients newly diagnosed with MS since 2010 and their comorbidities at the time of diagnosis. The sample included 1877 patients, which represented about 10% of Italian MS patients diagnosed during this period.
Overall, nearly one quarter of patients had ≥1 comorbidity at diagnosis. Other autoimmune diseases — especially autoimmune thyroid disease, type 1 diabetes, and celiac disease — were most common. Comorbidities were particularly common among older patients. There was no association between comorbidities and DMD choice, and comorbidities were not associated with DMD switch due to inefficacy. However, patients with comorbidities were more likely to change from their current DMD (from interferon-beta in particular) due to intolerance, but no specific comorbidity was associated with DMD intolerance. After adjusting for multiple demographic and disease factors, patients with comorbidities experienced a larger change in their Expanded Disability Status Scale score than those without comorbidities, although this difference (0.28 vs. 0.10) was small.
COMMENT: Clinical trial data from highly selected populations are difficult to generalize to heterogenous patient populations. Comorbidities and prior treatments can substantially affect treatment outcomes in real-life patients. This study highlights that comorbidities are common among MS patients and may affect disability accumulation and tolerance of particular DMDs, especially interferon-beta. The major limitation of this study is the small number of patients included who were treated with oral and intravenous DMDs. Further studies are needed to address how DMD selection should be adjusted based on patient comorbidities, especially in regard to oral and intravenous DMDs.
Dr. Saylor is Assistant Professor of Neurology and Director, Hopkins Global Neurology Program, Johns Hopkins University School of Medicine, Baltimore.
CITATION(S): Laroni A et al. Assessing association of comorbidities with treatment choice and persistence in MS: A real-life multicenter study. Neurology 2017 Nov 28; 89:2222.
(http://dx.doi.org/10.1212/WNL.0000000000004686)
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Am J Obstet Gynecol 2018 Jan; 218:88
Do Antibiotics Reduce Efficacy of Hormonal Contraception?
Systematic review provides reassurance that nonrifamycin antibiotics do not impair HC's efficacy.
Many clinicians and pharmacists advise that women using hormonal contraception (HC) employ backup contraception during treatment with antibiotics. Although rifampin and other rifamycin antibiotics induce hepatic enzymes that metabolize HC steroids, other antibiotics do not have such pharmacokinetic effects. Investigators performed a systematic review of 29 studies addressing pregnancy rates, serum progesterone levels, sonographic evidence of ovulation, changes in bleeding patterns, and pharmacokinetics in women using nonrifamycin antibiotics concurrently with HC.
Concomitant antibiotic use (including penicillins, cephalosporins, quinolones, tetracyclines, macrolides, trimethoprim sulfamethoxazole, metronidazole, dapsone, and isoniazid/streptomycin) was not associated with changes in pregnancy rates or ovulation, unscheduled uterine bleeding, or significant declines in serum progestin levels in women using estrogen-progestin pills, vaginal rings, or oral emergency contraception.
COMMENT; Appropriate contraceptives for women using rifamycin antibiotics include injectable depot medroxyprogesterone acetate (a high-dose progestin-only contraceptive) and intrauterine devices (which act locally). Women using nonrifamycin antibiotics (which are more common) can be reassured that these will not reduce efficacy of HC.
CITATION(S): Simmons KB et al. Drug interactions between non-rifamycin antibiotics and hormonal contraception: A systematic review. Am J Obstet Gynecol 2018 Jan; 218:88.
(https://doi.org/10.1016/j.ajog.2017.07.003)
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Obstet Gynecol 2018 Jan 9; 131:304
Embracing Minimally Invasive Surgical Treatment for Endometrial Cancer
Large U.S. analysis indicates adoption of laparoscopic techniques has improved postoperative outcomes.
Although minimally invasive (laparoscopic, including robotic) approaches have been shown to improve perioperative outcomes for benign and malignant gynecologic conditions, the move away from open surgical approaches (laparotomy) was jump-started by the FDA's approval of robotic hysterectomy in 2005. To assess trends in surgical route and perioperative outcomes of treatment for endometrial cancer from 2008 through 2014, investigators queried a large database encompassing 750 U.S. hospitals (>12,000 women; mean age, 62; mean body-mass index [BMI], 35 m/k2; proportion with BMI ≥40, 27%).
During the study period, use of minimally invasive surgery rose from 24% to 71% of procedures (P<0.001), and the proportion of women with any complication fell from 13% to 7% (P<0.05). Although open surgery tended to require less time than minimally invasive surgery (likelihood of operative time <2 hours, 38% vs. 27%), incidence of major complications within the first 30 postoperative days (9% vs. 3%), median length of hospital stay (3 days vs. 1 day), and rates of transfusion (14% vs. 2%), readmission (9% vs. 3%), and death (0.8% vs. 0.2%) were all higher with open surgery (P<0.001 for all comparisons).
COMMENT: This report clarifies that embracing minimally invasive surgery has made the management of endometrial cancer substantially safer. Nonetheless, more than one quarter of hysterectomies in this setting are still performed via laparotomy (with notable disparities along racial/ethnic and socioeconomic lines). Accordingly, understanding the remaining barriers to minimally invasive surgery in this patient population is a priority. As prevention is the best medicine, weight loss, progestin-containing contraceptives, and breast-feeding must also be considered in the fight against endometrial cancer.
CITATION(S): Casarin J et al. Adoption of minimally invasive surgery and decrease in surgical morbidity for endometrial cancer treatment in the United States. Obstet Gynecol 2018 Jan 9; 131:304.
(https://doi.org/10.1097/AOG.0000000000002428)
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Lancet Infect Dis 2018 Jan 25; S1473-3099(18)30058-6
The Vaginal Microbiome Is Associated with Susceptibility to HIV Infection
Increased risk for HIV acquisition was associated with bacterial vaginosis, greater microbial diversity, and higher concentrations of certain vaginal bacteria.
To explore the potential role of the vaginal microbiome in HIV acquisition, researchers conducted a nested case-control study in 55 HIV-positive women and 55 matched HIV-negative (control) women within a cohort of 349 women from 6 sub-Saharan African countries. Following broad-range polymerase chain reaction (PCR) analysis in vaginal samples from the entire cohort, the 20 most common bacterial species were selected for taxon-directed real-time PCR.
In the case-control comparison, lower relative abundance of Lactobacillus iners was associated with significantly higher probability of HIV acquisition. Real-time PCR in the full cohort showed that higher concentrations of Parvimonas species type 1 and type 2, Gemella asaccharolytica, Mycoplasma hominis, Leptotrichia/Sneathia, Eggerthella species type 1, and Megasphaera were significantly associated with increased risk for HIV acquisition. Greater diversity of vaginal bacteria was associated with HIV acquisition; moreover, in a subset of 316 women with available Gram stains, bacterial vaginosis (Nugent score range, 7–10) was associated with about twice the risk for acquiring HIV.
COMMENT: This study in an emerging investigational area highlights the relation between bacterial diversity in the vaginal microbiome and HIV acquisition, while identifying specific bacteria that may be involved. Previous studies have elucidated the roles of certain vaginal bacteria in causing genital tract inflammation as a mechanism for increased HIV susceptibility in African women. The importance of lactobacilli in influencing HIV risk, confirmed here, now forms the basis for probiotic interventions to alter the vaginal microbiome for HIV prevention.
CITATION(S): McClelland RS et al. Evaluation of the association between the concentrations of key vaginal bacteria and the increased risk of HIV acquisition in African women from five cohorts: A nested case-control study.
Lancet Infect Dis 2018 Jan 25; S1473-3099(18)30058-6; [e-pub].
(https://doi.org/10.1016/S1473-3099(18)30058-6)
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Clin Gastroenterol Hepatol 2018 Feb 7
Expert Guidance on Evaluating Possible Extraesophageal Complications of GERD
An AGA committee offers current best practices for this common referral to gastroenterologists.
Sponsoring Organization: American Gastroenterological Association (AGA)
Target Audience: Gastroenterologists, primary care providers, pulmonologists, allergists, otolaryngologists
Background and Objective: Over the last two decades, in the heat of discussions about gastroesophageal reflux disease (GERD), there was a common philosophy that the classic features of heartburn and regurgitation were just the “tip of the iceberg,” below which were the majority of patients whose undiagnosed GERD manifested via wide-ranging extraesophageal complications. This hypothesis has led to extended controversy about whether these alleged GERD complications are actually related to GERD and amenable to acid reduction therapies directed at treatment of GERD.
Now, the Clinical Practice Updates Committee of the AGA has issued an expert consensus opinion to provide guidance on management of patients with possible extraesophageal manifestations of GERD.
Key Points
- As the cause of extraesophageal symptoms is typically multifactorial or originating outside of the esophagus, nongastrointestinal evaluations should be done initially by nongastrointestinal specialists (e.g., otolaryngologists [ENTs], pulmonologists, allergists).
- No single test can definitively identify reflux as causal.
- Depending on high or low probability, respectively, of baseline GERD, pH testing on or off proton-pump inhibitors (PPIs) can be performed.
- Empiric therapy with PPIs for 6 to 8 weeks can help solidify the causal role of GERD in these complications. Lack of response reduces the likelihood of a relationship.
- Surgical fundoplication should be discouraged if symptoms are nonresponsive to PPIs. An exception is in patients with significant mechanical defect (large hiatal hernia) and continued reflux on PPI therapy.
COMMENT: Gastroenterologists are plagued by referrals for extraesophageal complications of suspected GERD, in particular by ENTs for the laryngeal findings of “classic laryngopharyngeal reflux.” Controlled trials for these extraesophageal symptoms have demonstrated that “silent GERD” — i.e., without the classic features of heartburn and/or regurgitation — is rarely related, nor do aggressive acid reductive therapies show significant benefit.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S): Vaezi MF et al. Extraesophageal symptoms and diseases attributed to GERD: Where is the pendulum swinging now? Clin Gastroenterol Hepatol 2018 Feb 7; [e-pub]. (https://doi.org/10.1016/j.cgh.2018.02.001)
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