Category Archives: General Health

Pediatric Gastroenterology Hospitalists –Job Wanted?

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A recent article (M Latorre et al. Clin Gastroenterol Hepatol 2021; 19: 871-875) describes “A Practical Guide to Establishing a Gastroenterology Hospitalist Program (in adult GI)”

Our group had flirted with the idea of a GI Hospitalist (GIH) many years ago when one of the partners expressed some interest. To establish this type of job takes a lot of planning.

Some of the key points:

  • “Proactively incorporating scheduling measures to provide the GIH with coverage and backup is important; otherwise the job can become easily overwhelming.” Outpatient faculty have to provide coverage to assure the individual is protected and covered for emergencies, weekends, and holidays. “Creating dedicated shifts with daily start and stop times allow for more control over the GIH’s hours.”
  • The authors note that when they began their GIH, the outpatient faculty rotated and assisted with afternoon consults/procedures to protect GIH from long days and burnout.
  • In adult medicine, a GIH can help improve GI practice profitability by allowing outpatient doctors to increase office revenue and endoscopic procedures. In pediatrics, it is possible that a GIH would generate more billings than outpatient counterparts due to increased procedural demands for inpatients.
  • GIH can improve patient care (timely endoscopy, focus on inpatient problems), improve continuity, and reduce costs similar to other hospitalists.

My take: If there is adequate help, especially to prevent long days and increased night call, this model could work in pediatric GI as well.

Related blog posts:

This story below was NOT from ‘The Onion.’ NPR 6/10/21:

How Insurance Companies Can Help Stop the Pandemic in the U.S.

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From AJC, Hashem Dezhbakhsh: An incentive to encourage vaccination

This is a good read. An excerpt:

Vaccine hesitancy, which can prolong the pandemic, is a textbook example of a negative consumption externality, where an individual’s choice can harm or impose costs on others. Indoor smoking, drunk driving, or littering are other examples…

One policy option is to use the insurance mechanism, with risk assessment and risk pricing as its enforcing arms….

For example, a risky driver has a higher auto insurance premium than a safe driver, a smoker has a higher health insurance premium than a non-smoker,…Similarly, health insurance premiums, deductibles, and co-pays can be set higher for those who are unvaccinated...

Using risk pricing to set insurance premiums and co-pays for these individuals makes good sense and is fair policy. It incentivizes individuals to vaccinate, while also providing a fairer insurance pricing system by charging those with self-selected higher risk a higher price, instead of shifting their medical costs to others through uniform insurance pricing.

Hydrangeas

This and That: Ear Tubes and Addiction Medicine

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Interesting articles from recent NEJM:

A Hoberman et al. NEJM 2021; 384: 1789-99. Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media

A quick read of this article suggested very bad news for our ENT colleagues. In this prospective, randomized trial (n=250), the authors did not find a significant advantage of tympanostomy tubes over medical management of acute otitis media (OM) among 6-35 month olds with recurrent OM in an intention-to-treat analysis, the rate (±SE) of episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P=0.66).

In an associated editorial (pg 1859-60), (Ellen Wald notes that only 55% of children in the medical management group were actually treated medically throughout the trial making the sample size too small. Her advice: “In a child older than 2 years of age, we can forecast that infections will be fewer in the coming year and that medical treatment should be continued. In the younger child, there is a nearly 50% likelihood that the frequency of infections will continue; the child is likely to have fewer and less severe episodes of acute otitis media with less exposure to antibiotics if tympanostomy-tube placement is undertaken.”

Time to first recurrent episode of acute otitis media (Figure 2). Cumulative percentage of children with recurrent OM with one minus Kaplan-Meier survival estimates according to trial group.

E Poorman. NEJM 2021; 384: 1783-1784. The Number Needed to Prescribe — What Would It Take to Expand Access to Buprenorphine?

This article describes how many physicians are reluctant to treat opioid use disorder. The author notes that “prescribing buprenorphine is one of the most effective ways to save a life. In one study, buprenorphine treatment was associated with a 37% reduction in all-cause mortality during the year after a nonfatal overdose. This reduction is larger than the reduction in mortality associated with any blood-pressure medication, diabetic agent, or statin….But much…will depend on physicians believing that people with a substance use disorder aren’t just “addicts” but are people with a chronic medical disease that we can and should treat.”

Are We On the Verge of Pharmacologic Management of Obesity (Again)?

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In the 1990s, the combination of fenfluramine/phentermine was popularized as a treatment for obesity. Fenfluarmine, though, was shown to cause potentially fatal pulmonary hypertension and heart valve problems, which eventually led to its withdrawal and legal damages of over $13 billion (per Wikipedia: fenfluramine/phentermine).

Now, glucagon-like peptide-1 (GLP-1) receptor agonists, like liraglutide, are showing promise as agents to promote weight loss, primarily by inhibiting appetite. JR Lundrgen et al (NEJM 2021; 384: 1719-1730. Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined) show that liraglutide can promote weight loss, especially if combined with exercise.

Methods: After an 8-week low-calorie diet, participants were randomly assigned for 1 year to one of four strategies: a moderate-to-vigorous–intensity exercise program plus placebo (exercise group); treatment with liraglutide (3.0 mg per day-SC injection) plus usual activity (liraglutide group); exercise program plus liraglutide therapy (combination group); or placebo plus usual activity (placebo group)

Key findings:

  • After the 8-week low-calorie diet, 195 participants had a mean decrease in body weight of 13.1 kg.
  • At 1 year, all the active-treatment strategies led to greater weight loss than placebo: difference in the exercise group, −4.1 kg (95% confidence interval [CI], −7.8 to −0.4; P=0.03); in the liraglutide group, −6.8 kg (95% CI, −10.4 to −3.1; P<0.001); and in the combination group, −9.5 kg (95% CI, −13.1 to −5.9; P<0.001). The combination strategy led to greater weight loss than exercise (difference, −5.4 kg; 95% CI, −9.0 to −1.7; P=0.004) but not significantly more than monotherapy with liraglutide (−2.7 kg; 95% CI, −6.3 to 0.8; P=0.13)
  • The side effects of decreased appetite, dizziness, increased heart rate and palpitations were more common in those receiving liraglutide; palpitations were evident in 12% of the liraglutide monotherapy group and 4% of the combination (with exercise) group.

The details of the exercise program are detailed in the methods section; all participants were assigned an instructor and expected to do a minimum of 150 minutes per week of moderate-intensity aerobic physical activity or 75 minutes per week of vigorous-intensity aerobic physical activity.

These results are similar to the 15% weight loss noted at 68 weeks with the GLP-1 receptor agonist semaglutide.

My take: GLP-1 receptor agonists help individuals lose weight. However, we’ve seen the promise of medical therapy before so we will have to see how the story ends.

Related blog post: Semaglutide: Potential or Problematic New Treatment for Fatty Liver Disease/NASH

Briefly noted: YY Gibbens et al. American Journal of Gastroenterology 2021 April 22. Effects of Central Obesity on Esophageal Epithelial Barrier Function. Key finding:  Obesity+/GER- group demonstrated increased intercellular space, reduced desmosome density, and increased fluorescein leak compared with control subjects. Thus, obesity may worsen esophageal disease by  impairing the structural and functional integrity of the esophageal barrier independent of GER. (Thanks to Mike Hart for this reference)

Can We Learn to Live With Germs Again?

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Correction made on blog post on 5/12/21 Humira Dosing Guidelines. For Crohn’s induction >/= 40kg, there is not an 80mg dose on day 8, just 160mg day 1 and 80mg day 15. Blog post: Ustekinumab for Refractory Pediatric Ulcerative Colitis and Updated Adalimumab Dosing

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NY Times: Can We Learn to Live With Germs Again? (4/23/21)

An excerpt:

Almost everything we know about the microbiome is uncertain, including how our activities and environments influence its makeup...

Despite the now consensus recognition that air transmission, …we continue to annihilate every microbe in our midst, even though most are harmless…

Excessive hygiene practices, inappropriate antibiotic use and lifestyle changes such as distancing may weaken those [microbial] communities going forward in ways that promote sickness and imperil our immune systems. By sterilizing our bodies and spaces, they argue, we may be doing more harm than good…

Dr. Graham Rook, an emeritus professor of medical microbiology at University College London, likens the immune system to a computer. He says that the microbes we encounter in daily life — on other people and in our spaces — are the data that the immune system relies on to program and regulate its operations.

Deprived of these exposures, especially at the start of life, the immune system is prone to malfunction. The result can be allergies, asthma, autoimmune disorders, obesity, Type 2 diabetes and other chronic medical conditions...

 “Even before the pandemic, we know that half of antibiotic use was inappropriate.”…

For those who aren’t yet able to mix and mingle — and right now, that’s most of us — there are other ways to support microbial health. “If you want to do something proactive right now, I would put eating a healthy diet high on your list,” says Dr. Emeran Mayer… plant foods (legumes, greens, whole fruits, a variety of vegetables), as well as fermented foods, support the richness and diversity of the gut microbiome. So, too, does limiting one’s intake of processed and fast foods, especially those that contain added sugar…

Before the pandemic, only one of the top 10 causes of death in America — influenza — was attributable to an infectious disease that someone could “catch.” Nearly all the rest, such as heart disease and stroke, cancer, brain disease and diabetes, are associated with poor microbiome health or dysfunction.

Related blog posts:

World Obesity Day was March 4, 2021

It’s About Time: No Surprises Act

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Pleasant surprises often don’t work out. Case in point: a colleague sent me an email to our joint email account letting me know that he would not be able to come to my wife’s surprise party (she probably knew anyway).

When it comes to medical billing, surprises are never intended to be pleasant. “As many as one in five patients visiting an emergency department or undergoing elective surgery receives an out-of-network bill from a clinician whom they had no ability to choose.”

It appears that improvement in this area is on the horizon. KR Chhabra et al. NEJM 2021; 384:1381-1383. No More Surprises — New Legislation on Out-of-Network Billing

Key points:

  • “Effective January 1, 2022, patients receiving an out-of-network emergency services, air-ambulance transportation, or out-of-network nonemergency services at in-network facilities may be billed only the amount they would owe for an in-network provider.”
  • “Out-of-network providers and insurers will have 30 days to agree on payment and then may invoke a binding arbitration process.”
  • “Three days before scheduled procedures, clinicians and insurers must inform patients of their expected out-of-pocket costs and clinicians’ network status and consenting to out-of-network bills can patients be balance-billed.
  • “This notice-and-consent doesn’t apply to emergency services [and] situations in which there are no in-network alternatives…patients cannot be balance billed in these cases…, even if they provide consent.”
  • “The Congressional Budget Office estimates that the law will reduce payments for some clinicians, reduce insurance premiums by up to 1%, and save the federal government nearly $17 billion over 10 years.”
  • “The law’s transparency provisions–particularly the requirements to provide advance price and network-participation information –may have a larger effect on day-to-day practice than its balance-billing provisions.”
  • Omission in law: ground-ambulance surprise bills
  • Potential effect: insurers may leverage the law to drop high-priced providers and potentially the law may lead to low-price providers to drop out of network

My take: This is a huge advance for patients/families; it is likely to reduce financial harm to patients and improve trust in the health care system.

Related blog posts:

Targeting on Social Media

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A recent survey (n=464) study (TR Pendergrast et al. JAMA Intern Med 2021; 181: 550-552. Prevalence of Personal Attacks and Sexual Harassment of Physicians on Social Media) describes personal attacks that physicians experience due to social media presence.

Key findings:

  • 108 (23%) physicians reported being personally attacked on social media with no significant differences between males and females
  • Women were significantly more likely than men to report online sexual harassment: 44 (16%) vs. 3 (1.5%)
  • Attacks were common within some topics like vaccines and gun control

The authors note that their study is limited by potential sampling error and may not be representative of the physician workforce.

My take: Online harassment is common, particularly with controversial topics. The effects of these attacks is to create distress and reluctance to engage in social media.

Related blog posts: