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Pilot program study finds that pediatric obesity patients like telehealth services    

For youth dealing with obesity who need extra help losing weight, experts suggest a multidisciplinary approach in which care is provided by several health specialists. However, the logistics of traveling to multiple appointments, even if just across town, can be a barrier to receiving care, especially for low-income families.    

UCLA researchers who work with this patient population set up a pilot program using telehealth technology - a secure system that allowed patients to see and speak with their health care providers at UCLA over a computer from their local health clinic - to evaluate if such a system could be an effective strategy to help overcome these issues.  

Their study of the program found that the great majority of pediatric patients - approximately 80 percent - were satisfied with their telehealth appointment, saying it was just as good as talking to the doctor in person, that it was easier to go to the local clinic than to the UCLA campus in Westwood, that they felt comfortable and that their privacy was protected.    

In addition, 80 percent said they would participate in a telehealth appointment again. Responses from the health care providers were similarly positive.    

The results of the project were presented at the Southern California Public Health Association Conference on Dec. 9.  

"One surprise was how natural it was to talk with each other through the telehelath system, even though we never met the patients in person," said lead author Dr. Wendy Slusser, medical director of the Fit for Healthy Weight program at Mattel Children's Hospital UCLA and director of pediatric wellness programs at the Venice Family Clinic. "The interaction was very much like being in the same room together. Some kids even thought it was fun to see themselves on the screen."

To conduct the study, researchers with the Fit for Healthy Weight program worked with UCLA colleagues, the Venice Family Clinic and the Los Angeles Unified School District to implement a telehealth system that met a high standard of encryption and was compliant with national regulations to ensure patient privacy.    

Forty-five patients, whose average age was 10, visited their regular local clinic, either the Venice Family Clinic's Simms/Mann Health and Wellness Center in Santa Monica or the LAUSD's San Miguel Healthy Start Clinic in South Gate. There, they and their parents checked in with an on-site medical assistant and a primary care physician who took their vital signs, including height, weight and blood pressure and performed lab work.  

The patient and a parent then sat in front of a telehealth computer and talked "face-to-face" with specialists from the UCLA Fit for Healthy Weight clinic located at the 200 UCLA Medical Plaza building in Westwood, including a pediatrician, a psychologist and/or a dietitian    

During the telehealth appointment, the UCLA providers reviewed the patients' vitals and blood test results, asked questions about the patient's health and lifestyle, and worked with the family to set healthy lifestyle goals and addressed the patient's health issues.  

To study the effectiveness of this care, satisfaction questionnaires were provided to both the young patients - or to the parent if a child was too young - and the primary care providers at the local clinic after the telehealth appointment. Researchers also reviewed patients' charts to see how their body mass index evolved, tracking their BMI before, during and a few months after their appointment.  

Of the patients, 52 percent were male, and the average baseline BMI was in the 98th percentile. Over time, 86 percent of the 25 patients who were followed after their telehealth appointments either stabilized or decreased their BMI scores, and three of the four patients with high blood pressure normalized their blood pressure.  

The other positive outcome was the relative ease with which the Fit for Healthy Weight program was able to implment and adapt the technology.    

"Although there were a few technological challenges in the beginning, we learned some valuable lessons in implementing a telehealth program," said Margaret Whitley, project manager of the Fit for Healthy Weight program.  

The next phase of this project is a pilot home telehealth so that patients can talk to their doctor from home. This will eliminate the need for patients to travel to a local clinic, which can be especially beneficial for patients with mobility limitations. In addition, researchers are also helping the LAUSD develop a "teledietitian" project.

"Pediatric obesity is a serious epidemic that can lead to long-lasting health problems as children grow into adulthood," Slusser said. "We urgently need to find new ways to overcome barriers, and telehealth is a promising tool."  

The program's research efforts are part of the Mattel Children's Hospital's UCLA Children's Discovery and Innovation Institute 

This project was funded by UniHealth Foundation. Funds from California Proposition 1D were used to provide telehealth equipment.  

In addition to Slusser and Whitley, UCLA co-authors included Nilufar Izadpanah, Dr. Alma Guerro, Dr. Debra Lotstein, Dr. Daniel DeUgarte, Don Ponturo and Justin Stephens. 

The authors have no financial ties to disclose. 

The mission of the Fit for Healthy Weight Program at Mattel Children's Hospital UCLA is to provide comprehensive promotion of healthy eating, physical activity, psychosocial well-being (psychological, social, familial and educational) and overall wellness for children and adolescents and their families. For more information, please visit www.fitprogram.ucla.edu. 

 

Six months of fish oil reverses liver disease in children with intestinal failure, study shows

 

Amy Albin, aalbin@mednet.ucla.edu

Children who suffer from intestinal failure, most often caused by a shortened or dysfunctional bowel, are unable to consume food orally. Instead, a nutritional cocktail of sugar, protein and fat made from soybean oil is injected through a small tube in their vein.

For these children, the intravenous nutrition serves as a bridge to bowel adaptation, a process by which the intestine recovers and improves its capacity to absorb nutrition. But the soybean oil, which provides essential fatty acids and calories, has been associated with a potentially lethal complication known as intestinal failure-associated liver disease, which may require a liver and/or intestinal transplant. Such a transplant can prevent death, but the five-year post-transplant survival rate is only 50-70 percent.

Previous studies have shown that replacing soybean oil with fish oil in intravenous nutrition can reverse intestinal failure-associated liver disease. However, the necessary duration of fish oil treatment had not been established in medical studies.

Now, a clinical trial conducted at the Children's Discovery and Innovation Institute at Mattel Children's Hospital UCLA has found that, compared with soybean oil, a limited duration (24 weeks) of fish oil is safe and effective in reversing liver disease in children with intestinal failure who require intravenous nutrition. The researchers believe that fish oil may also decrease the need for liver and/or intestinal transplants - and mortality - associated with this disease.

The researchers' study, "Six Months of Intravenous Fish Oil Reverses Pediatric Intestinal Failure Associated Liver Disease," is published online in the Journal of Parenteral and Enteral Nutrition.

"With this particular study, we set out to determine if a finite period of six months of intravenous fish oil could safely reverse liver damage in these children, and we have had some promising results," said lead author Dr. Kara Calkins, an assistant professor in the department of pediatrics in the division of neonatology and developmental biology at UCLA. "But because intravenous fish oil is not yet approved by the Food and Drug Administration and is much more costly than soybean oil, it is typically not covered by insurance. As a result, this oil is considered experimental and is currently available only under special protocols. If it proves safe and effective for patients, we hope it would eventually be available for wider use."

For the study, intravenous soybean oil was replaced with intravenous fish oil in 10 patients between the ages of 2 weeks and 18 years who had advanced intestinal failure-associated liver disease and who were at high risk for death and/or transplant. The researchers compared these subjects with 20 historical controls who had received soybean oil.

Results showed that the children receiving fish oil had a much higher rate of reversal of liver disease than those who received the standard soybean oil. In fact, after 17 weeks of fish oil, nearly 80 percent of patients experienced a reversal of their liver disease, while only 5 percent of the soybean patients saw a reversal.

The next phase of research will involve following children for up to five years after they stop fish oil to determine if their liver disease returns and if transplant rates are truly decreased, the study authors said.

"We are also trying to better understand how fish oil reverses this disease by investigating changes in proteins and genes in the blood and liver," Calkins said. "These studies will provide the scientific and medical community with a better understanding of this disease and how intravenous fish oil works."

For Isabella Piscione, who was one of the first patients at UCLA to receive the fish oil treatment under compassionate use, her outcome with the treatment paved the way for researchers to establish the six-month protocol. Because of multiple surgeries due to an obstruction in her intestines, Isabella was left with only 10 centimeters of intestine. She depended on intravenous nutrition for survival, which unfortunately resulted in liver damage.

When Isabella started the fish oil treatment, she was just over 6 months old and was listed for a liver and bowel transplant. Within a month of starting the treatment, her condition started to improve. By six months, her liver had healed, and she no longer needed a transplant.

"We cried tears of joy each week that we saw her getting better and better," said her father, Laureano Piscione. "She is a success story."

Study co-authors from UCLA included Dr. James Dunn; Dr. Stephen Shew; Laurie Reyen, R.N.; Dr. Douglas Farmer; Dr. Sherin Devaskar; and Dr. Robert Venick.

The study was funded by a grant from a National Institutes of Health (NIH/NCRR M01-RR00865). Calkins has received funding from NIH K12HD00140 and T32G075776. Calkins and Venick have received funding from the Today's and Tomorrow's Children Fund.