This article is from 2018 and still relevant:
Full Text Link: NEJM 2018; 379: 1193-6: How to Stop Mass Shootings
Figure shows Age-Adjusted Rates of Death (per 100,000) from Firearms in 2016 (All Intents). Data are from the Centers for Disease Control and Prevention.
A recent study (EB Tapper et al. Hepatology 2020; 71: 225-34, editorial 11-13) shows that advanced practice providers (APPs) provide care that translates into better outcomes for adults with cirrhosis. APPs include physician assistants and nurse practitioners.
In a retrospective analysis (2001-15) of the Optum Clinformatics database (private insurance) with 389,257 adult patients, the authors show that patients who had an APP involved in their care had better outcomes.
Key findings among patients with APP care (with and without specialist involvement):
My take: Based on my experience, this study likely could be replicated in most medical fields. APPS improve patient outcomes.
Island Ford National Recreational Area, Sandy Springs
A recent study (D Ohnemus et al. Liver Transplantation 2020; 26: 45-56, editorial 9-11) examined health-related quality of life (HRQOL) and cognitive functioning approximately 15 years after liver transplantation (LT).
Study details:
Median age 16 years. Original group was a SPLIT research cohort recruited from 20 centers and then tested at multiple time points; for this study, 8 sites of the original 20 were included. It is noted that patients with serious neurologic injury were excluded. Among an initial group of 108, there were 79 available for potential enrollment. In this group, 65 parent surveys were completed and 61 child surveys.
Key findings:
The editorial notes that the PedsQL Cognitive Functioning Scale scores used by the investigators were considered subjective. “The more objective PedsPCF scores fell within the normal range.”
My take: This report indicates that a majority of children are likely to have some cognitive deficits and many are likely to have reduced HRQOL following liver transplantation; in addition, if these problems are detected at a younger age, they are likely to persist.
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Mural on Atlanta’s Beltway
A recent retrospective study (SH Baek et al. JPGN 2020; 70: 171-77) provide useful information on cholangitis following a Kasai portoenterostomy in patients (n=160) with biliary atresia (BA).
Key points:
It is worth noting that Up-to-Date has several recommended regimens for acute cholangitis (in adults). For lower-risk infections, the authors recommend either a single agent like piperacillin-tazobactam or dual therapy with specific cephalosporins (eg. cefotaxime, ceftriaxone) and metronidazole. For higher-risk infections, the Up-to-Date recommendations include meropenem or piperacillin-tazobactam as single agents or one of two cephalosporins (cefepime or ceftazidime) along with metronidazole.
My take: Cholangitis is common after biliary atresia. Familiarity with changing susceptibility, particularly local patterns, will help optimize outcomes.
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Piedmont Park
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A recent study has shown how pervasive surprise billing has become. This is another area in medicine in which deceptive billing practices undermine the relationship between families and health care providers.
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The “weekend effect” is a term used to indicate that outcomes for many medical conditions are worse when patients are admitted to the hospital on the weekend.
A recent study (MD Egberg et al. Inflamm Bowel Dis 2020; 26: 254-60; editorial by C Ballengee Menchini 261-2) documents the degree of this effect on the risk of complications for pediatric patients with inflammatory bowel disease (IBD).
This study used a cross-sectional analysis with the Kids’ Inpatient Database (KID), a nationally representative database. The study included 3255 urgent surgical hospitalizations and included patients 18 years old and younger.
Key findings:
Possible Reasons for Weekend Effect:
Limitations include reliance on administrative data and potential for misclassification and unidentified confounding variables.
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From Weekend Hike on Mount Yonah:
Climate change:
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Sugary beverage Law:
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Cost of IBD Care is Increasing. From Healio Gastro: Chronic inflammatory disease expenditures nearly double over last 2 decades Reference: Click B, et al. Poster 22. Presented at: Crohn’s and Colitis Congress; Jan. 23-25, 2020; Austin, Texas
An excerpt from Healio Gastro summary: [Using] the Medical Expenditure Panel Survey (MEPS), a nationally representative database of health care use and expenditure data collected since 1998…The researchers assessed total annual, outpatient, inpatient, emergency and pharmacy expenditures in both patients with IBD (n = 641) and RA (n = 641). They used three separate time periods – 1998-2001, 2006-2009 and 2012-2015 –to compare expenditures over time…
Median per-patient annual health care expenditure in patients with IBD was $6,570 compared with $4,010 in patients with RA across all years of the study. Total annual spending increased approximately 2.2 times (95% CI, 1.6-3; P < .01) over the study period and was 36% higher in IBD than RA (P = 0.01).
Pharmaceutical spending increased more than fourfold (95% CI, 3.2-6.1; P < .01) and became the largest cost category (44% total). However, inpatient expenses in IBD decreased 40% over the study period.
My take: While the cost has increased, these new treatments are improving outcomes. With the emergence of biosimilars, there may be improvement in pharmaceutical spending.
More on Proactive Therapeutic Drug Monitoring (pTDM) Being Helpful: SR Fernandes et al. Inflamm Bowel Dis 2020; 26: 263-70, editorial 271-2. In this study, a prospective group of patients (n=56) undergoing pTDM were compared with a historical control group (n=149). pTDM had less frequent surgery (9% vs. 21%) and higher rates of mucosal healing (73% vs. 39%). Treatment escalation was 3 times more common with pTDM than in the control group.
Increased risk of VTE in IBD patients: JD McCurdy et al. Inflamm Bowel Dis 2020; https://doi.org/10.1093/ibd/izaa002
Abstract Link: Risk of Venous Thromboembolism After Hospital Discharge in Patients With Inflammatory Bowel Disease: A Population-based Study
In a population-based study from Ontario, the authors analyzed a total of 81,900 IBD discharges (62,848 nonsurgical and 19,052 surgical) which were matched to non-IBD controls… The cumulative incidence of VTE at 12 months after discharge was 2.3% for nonsurgical IBD patients and 1.6% for surgical IBD patients…Nonsurgical IBD patients and surgical patients with ulcerative colitis are 1.7-fold more likely to develop postdischarge VTE than non-IBD patients.
One of the most difficult clinical situations I helped manage involved a newborn who had a devastating intracranial hemorrhage after the parents had refused the routine administration of vitamin K. At that time, I did not ask the parents what they were thinking. I presumed that they were well-intentioned. Nevertheless, they allowed their child to suffer permanent neurologic injury.
A recent editorial highlights this growing problem: NY Times: Vitamin K for Newborns is a No-Brainer Here’s an except:
Parents are increasingly questioning, and declining, vitamin K, which protects newborns from serious bleeding…
Accounts of healthy babies developing serious, even fatal bleeding in the days and weeks following birth can be found going back centuries…
Since the early 1960s, it has been standard-of-care for newborns to receive an intramuscular injection of vitamin K shortly after delivery. Nearly six decades’ worth of data demonstrate that this intervention virtually eliminates vitamin K deficiency bleeding and carries no compelling risk of serious side effects…
Many of the reasons my patients’ parents decline vitamin K are similar to the reasons they decline vaccines: They worry about interventions they perceive as “unnatural” or unnecessary, about whether the doses and ingredients are “toxic” and whether there may be serious complications that doctors are not aware of or that are even being purposefully obscured by doctors, public health officials and pharmaceutical companies…
Parents continue to ask me whether vitamin K might cause childhood cancer, though this suggested association has been debunked….Others simply prefer to spare their newborn the pain of an injection…
Each year in the United States, if no vitamin K were administered, more than 70,000 infants would most likely be affected…
The seeds of mistrust — along with skepticism of science and intellectualism, the allure of the “natural” and the development of social-media-fueled communities founded on these values — run deep, and they’re threatening the health of our youngest and most vulnerable.
My take: Just like seat belts, the approach to this problem should be policy-based. In my view, if an infant suffers from vitamin K-refusal bleeding, reports should be made public health departments.
Related blog post: Educated or Misinformed –Leading to Hemorrhagic Disease of the Newborn
Caution with hemoglobin A1c interpretation: MM Kelsey et al. J Pediatr 2020; 216: 232-5. In the HEALTHY Study (n=8814), the authors note that a hemoglobin A1c was ≥5.7% in 2% of normal weight youth. “This suggests need for cautious interpretation of prediabetes hemoglobin A1cs in youth”
Daily aspirin for NAFLD: TG Simon et al. Clin Gastroenterol Hepatol 2019; 17: 2776-84. In this prospective cohort of 361 adults with biopsy-proven NAFLD, the use of daily aspirin (in 151) was associated with lower odds of NASH (aOR.68) and reduced risk of fibrosis (aOR 0.54). “The greatest benefit found with at least 4 years or more of aspirin use” (aHR =0.50). The associated editorial (pages 2651-3) recommends controlled studies to determine if potential benefits outweigh the known risks (eg. bleeding).
Glecaprevir/pibrentasvir for HCV Treatment Failure: AS Lok et al. Gastroenterol 2019; 157: 1506-17. This randomized study with 177 patients showed that 16 weeks of glecaprevir and pibrentasvir was effective in retreatment of patients with genotype 1 hepatitis C viral infection (after prior failure with sofosbuvir plus an NS5A inhibitor). The sustained virologic response 12 weeks after treatment was >90%.
Liver transplantation for Niemann-Pick Disease, type B: YLY Luo et al. Liver Transplantation 2019; 25: 1233-40. This report analyzed 7 children receiving liver transplantation for Niemann-Pick disease, type B. The authors report survival in the entire cohort and with normalized liver function within 3 weeks. In addition, they noted improvement in psychomotor ability ( 10 months after transplantation) and resolution of insterstitial lung disease. They state that developmental delay still existed in 4 patients during follow-up. The editorial (1140-1) notes that these findings need to be confirmed but open a new window in improving the phenotype. “A similar experience occurred with LT in maple syrup urine disease (MSUD), in which the liver is considered to host only 12-15% of the defective enzyme responsible for the disease…in MSUD, liver replacement is able to counteract 85% of extrahepatic expression of the disease and to completely correct the phenotype.”
Increased Abdominal-Surgery Risk in Patients with Idiopathic Noncirrhotic Portal Hypertension: L Elkrief et al. Hepatology 2019; 70: 911-24. Among 44 patients (median age 44 years) with noncirrhoitic portal hypertension, 16 (33%) had one or more portal hypertension-related complication within 3 months after surgery. 4 (9%) died within 6 months. “An unfavorable outcome (i.e. either liver or surgical complication or death) occurred in 22 (50%) patients” and was more likely in those with ascites, creatinine >100 micromol/L, or other extrahepatic complications related to portal hypertension.
One of my blog readers shared this image of “Liver Shorts” that can be purchased online
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