Category Archives: General Health

Glaring Omission in Pediatric Healthcare

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This weekend The Atlanta Journal-Constitution (AJC.com) ran a front page, top-of-the-fold, story of how Georgia’s mental health system is failing kids. This story highlighted how Children Healthcare of Atlanta is building a $1.5 billion 14-story state-of-the-art hospital that will not have a single psychiatry bed. Coincidentally, the NY Times 18-page opinion section also focused on America’s mental health crisis.

Related article from AJC (Dec 2021): Children’s Healthcare of Atlanta amasses immense wealth as some Georgia families struggle to access quality pediatric care

My take: Mental health issues are clearly NOT prioritized in many health care systems/providers nor by payers.

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Repetition of Misleading Information: “Illusory Truth” Effect

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A Hassan, SJ Barber. Cogn Res Princ Implic. 2021 Dec; 6: 38. Open Access! The effects of repetition frequency on the illusory truth effect. doi: 10.1186/s41235-021-00301-5

“Repeated information is often perceived as more truthful than new information. This finding is known as the illusory truth effect, and it is typically thought to occur because repetition increases processing fluency…In Experiment 1, we showed participants trivia statements up to 9 times and in Experiment 2 statements were shown up to 27 times…In both experiments, we found that perceived truthfulness increased as the number of repetitions increased. However, these truth rating increases were logarithmic in shape. The largest increase in perceived truth came from encountering a statement for the second time, and beyond this were incrementally smaller increases in perceived truth for each additional repetition.”

My take (from authors): “Although believing repeated information to be true is evolutionarily efficient in a context where most of the information encountered is correct, it can be detrimental to believe information that is incorrect.”

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Eklutna Lake, AK

It’s Still Not Needed: Pre-op COVID Testing Prior to Endoscopy

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Last year, the AGA stated that pre-endoscopy COVID testing is not needed:

This has turned out to be good advice:

A Hann et al. Gut 2022; http://dx.doi.org/10.1136/gutjnl-2022-327053. Open Access! Impact of pre-procedural testing on SARS-CoV-2 transmission to endoscopy staff

In this retrospective study, “during a 20-month period until December 2021 using PPE and three different test approaches: no testing (n=4543), rapid antigen (RA) testing (n=682) and RT-PCR testing (n=10 465). In addition, 60 endoscopies were performed in patients with proven COVID-19. Not a single staff member became infected with SARS-CoV-2 during the 20 months analysed; vaccination rate of the team was 97%.”

The authors note that routine testing of clinical team was not performed; thus, they cannot exclude the possibility of asymptomatic infections.

My take (borrowed in part from authors): “PPE is highly effective for avoidance of SARS-CoV-2 transmission during upper or lower GI endoscopies.” Pre-op testing for COVID has many downsides: increased costs, delays in care, potential exacerbation of health disparities, and detrimental effects to endoscopy efficiency (especially with inconclusive results)

Knik River Glacier, AK

More Guns in Georgia, More Bad Outcomes

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Firearm-related deaths are now the leading cause of death in U.S. children. The push to make guns more available is resulting in more tragic outcomes. In the U.S., putting too much mayonnaise on a sandwich can be a death sentence:

In Georgia, the law, signed by current governor Brian Kemp, allows Georgians to carry concealed handguns without first getting a license from the state. This law along with a previous “Guns Everywhere Law” has been associated with increased gun sales and increased gun violence and deaths.

After Uvalde, Amanda Gorman published the following poem

NY Times (5/27/22): Hymn For The Hurting

Everything hurts,
Our hearts shadowed and strange,
Minds made muddied and mute.
We carry tragedy, terrifying and true.
And yet none of it is new;
We knew it as home,
As horror,
As heritage.
Even our children
Cannot be children,
Cannot be.

Everything hurts.
It’s a hard time to be alive,
And even harder to stay that way.
We’re burdened to live out these days,
While at the same time, blessed to outlive them.

This alarm is how we know
We must be altered —
That we must differ or die,
That we must triumph or try.
Thus while hate cannot be terminated,
It can be transformed
Into a love that lets us live.

May we not just grieve, but give:
May we not just ache, but act;
May our signed right to bear arms
Never blind our sight from shared harm;
May we choose our children over chaos.
May another innocent never be lost.

Maybe everything hurts,
Our hearts shadowed & strange.
But only when everything hurts
May everything change.

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Imminent COVID-19 BA.5 Variant Booster

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From Eric Topol: The imminent BA.5 vaccine booster

Key points:

  • “There are no data for a BA.5 booster in people…Each year the flu vaccine quadrivalent program is updated using mice data, so there’s certainly a precedent for using such data.”
  • “It’s actually striking that in 2 months from the June 28th FDA meeting, there is a BA.5 vaccine booster made at scale. That is finally in keeping with all the excitement about the plasticity of the mRNA vaccine platform, that it could be ideal for rapid updating.”

Safe Sleep Recommendations

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This blog has discussed safe sleep many times. Sleep-related infant deaths exact an enormous toll. All pediatric physicians should take the opportunity to counsel parents to reduce this risk.

Recently, the AAP updated their recommendations, open access: RY Moon et al. Pediatrics (2022) 150 (1): e2022057990. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Some of the recommendations:

  • Sleep surfaces: Use a flat, noninclined sleep surface. A crib, bassinet, portable crib or play yard should conform to the safety standards of the Consumer Product Safety Commission (CPSC). Recent biomechanical analyses have demonstrated that sleep surfaces that are inclined more than 10 degrees from horizontal are unsafe for infant sleep.
  • Sleep location Infants should sleep in the parents’ room, close to the parents’ bed but on a separate surface designed for infants, ideally for at least the first six months.
  • Bedding Do not place any soft objects, including pillows, blankets or bumper pads, in the infant’s sleep environment.
  • Pacifiers Pacifier use is associated with a reduced risk of SIDS. For infants who are not directly breastfed, pacifiers can be introduced at any time. For breastfed infants, the pacifier can be started once breastfeeding is firmly established 

Bed-sharing “Although the AAP cannot recommend bed-sharing based on the evidence, it also respects that many parents choose to bed-share routinely for a variety of reasons. It is important for clinicians and parents to have frank and nonjudgmental discussions about the family’s bed-sharing circumstances. The policy provides a risk-stratification analysis to guide these discussions…The safest place for a baby to sleep is on a separate sleep surface designed for infants close to the parents’ bed.

These situations “increase the risk of SIDS or unintentional injury or death while bed sharing, and these should be avoided at all times:

  • Bed sharing with a term normal weight infant aged <4 mo and infants born preterm and/or with low birth weight…even for breastfed infants…
  • Bed sharing with a current smoker (even if he or she does not smoke in bed) or if the mother smoked during pregnancy
  • Bed sharing with someone who is impaired in his or her alertness or ability to arouse because of fatigue or use of sedating medication
  • Bed sharing on a soft surface, such as a waterbed, old mattress, sofa, couch, or armchair
  • Bed sharing with soft bedding accessories, such as pillows or blankets

Summary of new guidelines from AAP News: New safe sleep recommendations can help pediatricians guide families

My take: It is a good idea to incorporate safe sleep messages when infants are seen for a variety of disorders including reflux and colic.

Related blog posts:

  • Safe Sleep A terrific website that focuses on this crucial issue: Charlieskids.org; it has videos, do’s and don’ts as well as a link to Cribs for Kids (discounted safe crib website). In addition,this website has a book called “Sleep Baby Safe and Snug” which incorporates updated recommendations on safe sleep practices.
  • The High Toll of Sudden Infant Death From 2013-2015, there was an average of 3523 US infants each year who died from SUID (sudden unexpected infant death), peaking at 1-2 months of life.  More black infants died of SUID in the first year than black children who died from firearm homicides in all of childhood through age 19 years. SUID deaths from 2013-2015 (10,568) was similar to the total number of motor vehicle-traffic deaths in all of childhood (10,714) and greater than the total number of any of the other causes.
  • Are We Making Progress on Infant Sleep-Related Deaths? (not anymore) 
  • Safe Sleep (AAP 2017) 
Momma deer in our backyard
Chattahoochee National Recreational Area (Sandy Springs)

More Data: COVID-19 Vaccine Effective in Patients with IBD & Maternal COVID-19 Vaccination Protects Infants

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A Jena et al. Clin Gastroenterol Hepatol 2022; 20: 1456-1479. Open access: Effectiveness and Durability of COVID-19 Vaccination in 9447 Patients With IBD: A Systematic Review and Meta-Analysis

This was a systematic review and meta-analysis that included 46 studies.

  • Key findings:
    In 9,447 subjects who were completely vaccinated, the pooled seroconversion relative risk was 0.96 (95%CI, 0.94-0.97), and was higher for mRNA vaccines (0.97, 95%CI 0.96-0.98) than for adeno-associated vaccines (0.87, 95%CI: 0.78-0.93)
  • The pooled seroconversion rates were similar regardless of IBD therapy, and ranged from 0.93 to 0.99.
  • The pooled relative risk of breakthrough COVID-19 infections in vaccinated patients with IBD was not significantly different from that of vaccinated controls. However, a decay in antibody titers after 4 weeks from vaccination appeared to be accelerated in those on anti-TNF agents, immunomodulators or their combination.

My take: IBD patients benefit from complete COVID-19 vaccination similar to healthy controls.

Related blog post: COVID Booster Advice for IBD from Dr. David Rubin (@IBDMD)

NB Halasa et al. NEJM 2022; 387: 109-119. Open access: Maternal Vaccination and Risk of Hospitalization for Covid-19 among Infants

Using a case-control design, the authors found that complete (2 dose) vaccination during pregnancy —Key findings:

  • The effectiveness of maternal vaccination against hospitalization for Covid-19 among infants < 6 months was 52% overall, 80% during the delta period, and 38% during the omicron period.

My take: Vaccination protects mother and infant. “Maternal vaccination with two doses of mRNA vaccine was associated with a reduced risk of hospitalization for Covid-19, including for critical illness, among infants younger than 6 months of age.”

Covid Updates

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Vaccines have been estimated to have saved more than 20 million deaths. The Lancet Infectious Diseases new release: COVID-19 vaccines are estimated to have prevented 20 million deaths worldwide in the first year of the vaccine program, modelling study find

Omicron has been associated with lower rates of MIS-C in children compared to other surges –95% less than alpha. WSJ: Covid-19 Complication Among Children Fades in Latest Wave of Virus.

Getting boosted is important for those >50 years. There was a 29-fold reduction when comparing 2 boosters vs unvaccinated and a 4-fold reduction when comparing 2nd booster vs 1 booster. CDC: Rates of COVID-19 Cases and Deaths by Vaccination Status

Misinformation in Medicine

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RJ Baron, YD Ejnes. NEJM 2022; 387:1-3. Physicians Spreading Misinformation on Social Media — Do Right and Wrong Answers Still Exist in Medicine?

The authors, representing the American Board of Internal Medicine (ABIM), assert that “there aren’t always right answers, but some answers are clearly wrong.” In their commentary, they note that there is “growing allegiance to crowd-endorsed ‘facts.'” Yet, they expect physicians to adhere to higher standards; however, they note the inherent conflict between speech that can be prohibited by licensing boards and speech protected by the First Amendment.

My take: While the authors state that physicians risk disciplinary action for spreading misinformation, I remain skeptical that licensing boards have the appetite to do this, particularly when it comes to disciplining high-profile offenders like Mehmet Oz or Joseph Ladapo (Florida Surgeon General) (Business Insider: Dr. Oz is running for US Senate in Pennsylvania. Here are 8 times he’s made false or baseless medical claims; Insider: Florida’s surgeon general breaks with CDC advice, says the state will be the first to ‘officially recommend against the COVID-19 vaccine for healthy children‘).

PA Cohen et al. NEJM 2022; 387: 3-5. Institutionalizing Misinformation — The Dietary Supplement Listing Act of 2022

Dietary supplements are another part of medicine with rampant misinformation. In fact, there is nearly ubiquitous misinformation through advertisements across all media segments. Americans spent ~$55 billion on dietary supplements in 2020. This commentary discusses a Senate bill, the Dietary Supplement Listing Act of 2022, which ostensibly would improve this situation.

However, this is NOT the case. This bill requires manufacturers to provide the FDA with a product’s name, ingredients and health claims. It mandates the FDA create a searchable database. What the legislation doesn’t do:

  • Provide the the FDA with a mechanism to confirm a product’s ingredients
  • Enable regulation of misleading health claims
  • Stop the promotion and sale of supplements with dangerous ingredients
  • Allow the FDA to remove products from its registry determined to have unlawful ingredients and remove products deemed hazardous

My take: This legislation needs to be strengthened to limit deception. In its current form, this registry would appear to confer FDA oversight to dietary supplements (which is minimal) and paradoxically legitimize dietary supplements .

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Hilton Head at Sunrise