Category Archives: General Health

Modern Malady: Text Neck

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In every age, our bodies need to adapt to new challenges.  Apparently, in this age, we need to solve another problem induced by texting, “Text Neck.”

NY Times: Keep Your Head Up: How Smartphone Addiction Kills Manners and Moods

Here’s an excerpt:

The average human head weighs between 10 and 12 pounds, and when we bend our neck to text or check Facebook, the gravitational pull on our head and the stress on our neck increases to as much as 60 pounds of pressure. That common position, pervasive among everyone from paupers to presidents, leads to incremental loss of the curve of the cervical spine. “Text neck” is becoming a medical issue that countless people suffer from, and the way we hang our heads has other health risks, too, according to a report published last year in The Spine Journal.

Posture has been proven to affect mood, behavior and memory, and frequent slouching can make us depressed…

And the remedy can be ridiculously simple: Just sit up.

My take: Smartphone use increases the risk of many health problems besides “Text Neck” including car accidents.  Their use also contributes to missing social cues, including placing those in front of you behind those who interrupt conversations with texts and phone calls.

American Academy of Pediatrics: Georgia Chapter Governing Board Meeting

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As usual, I learned a great deal from our recent governing board meeting of the Georgia Chapter of the American Academy of Pediatrics ((AAP).   Here are some notes, including nutrition committee notes at the bottom of this post. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Influenza This Year –Harry Keyserling:

  • 85% of pediatric deaths have occurred in those without influenza vaccine. The vaccine, even when not stopping the influenza (lower efficacy this year), lowers the risk of death.  Probably 50-60% of all Georgia kids are immunized against the flu and  there is a higher rate of immunization (~75%) in younger age (~75%)
  • ‘We are not seeing Tamiflu resistance with this year’s strain’
  • 53 pediatric deaths this year at this point (2/3/18)
  • Children attending public schools have higher rates of vaccination than children attending private schools

Amy Jacobs, Commissioner of Ga Dept of Early Care & Learning (DECAL)

  • decal.ga.gov Website is resource for child care and sponsored meals
  • Georgia Pre-K now in 25th
  • QualityRated.org Useful website for identifying high quality child care
  • ~50,000 children supported with scholarships for childhood care caps.decal.ga.gov 833-442-2277
  • Text “FOODGA” to 877-877 Summer Meal Programs or Call toll free 855-550-7377

Project S.A.V.E.  –Robert Campbell, Richard Lamphier

  • Started in 2004 with the mission of promoting and improving prevention of sudden cardiac arrest (SCA) in children, adolescents and others in Georgia communities..  Website: Project S.A.V.E.
  • Primary prevention: pediatric office, preparticipation physical exams
  • Secondary prevention: after cardiac arrest –emergency action plan
    • Where’s the nearest AED? (Mr. Lamphier’s car).  At our office, GI Care For Kids’ AED –>Formula closet/Stan’s dictation area
    • Is there a plan if an emergency occurs? Name of building, address. Any barriers?
    • Almost always someone is willing to donate AED (~$700) -not a lot of money, this is a process issue much more than a financial one
    • If you wait for an ambulance (~10 minutes) with SCA, you probably won’t need an ambulance –the patient will not survive
  • There are fire drills –last death from fire in Georgia School in 1950s. Schools need emergency action plans in place.  For AEDs to be useful, there is a need for them to be accessible; thus, schools may need to have them in multiple locations.  About 15 pediatric cardiac arrests (data not formally collected) per year in Georgia.

Nutrition Committee Notes:

Probiotics for Colic –2018 Update

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There is some debate about whether colic is truly a GI disorder.  A recent commentary (V Sung, MD Cabana. J Pediatr 2017; 191: 6-8) provides some insight.

Key points:

  • “‘Colic’ is a term coined by the ancient Greeks…derived from ‘kolikos,’ meaning crampy pain, sharing its root with the the word colon.”
  • “Since 1994, there have been at least a dozen case-control studies that have indicated differences in the gut microbiota between infants with and without colic.”
  • Studies have had conflicting results with whether calprotectin levels are increased in infants with colic compared with controls.
  • Among probiotics, L reuteri DSM17938 “is the best studied strain.” Despite several studies suggesting efficacy, “the largest and only double-blind randomized trial that included both breastfed and formula-fed infants with colic (n=167) in Australia was ineffective.
  • The commentary reviews a recent study (Fatheree NY et al. J Pediatr 2017; 191: 170-8) “although very small in comparison, adds to this literature, being the second double-blind randomized, placebo-controlled trial of L reuteri DSM17938 shown to be ineffective in breastfed infants with colic.” Sample size =20. “It is the first to document increased fecal calprotectin levels that decrease with reduced crying” …though this “may be reflections of normal levels in healthy young infants, which change over time.”  In addition, this study did not find evidence of systemic inflammation.  The authors speculate that the frequent use of antireflux medications could dampen the effects of probiotics.

My take: We still do not know whether efforts at changing an infant’s microbiome improve clinical outcomes in colic.

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NYT: Do You Trust the Medical Profession?

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An interesting commentary from NY Times: Do You Trust the Medical Profession?

This article explains how lack of trust in medical leaders can effect response to epidemics (eg. ebola), participation in clinical trials, and influence acceptance of vaccines. In addition, on a personal level, individuals who trust their physician are more likely to continue treatment important for their health.

An excerpt:

Trust, in each other and in American institutions, is vital for our social and economic well-being: It allows us to work, buy, sell and vote with some reasonable expectation that our behavior will be met with fairness and good will.

But trust has been declining for decades, and the most tangible and immediate damage may be to public health and safety. Mistrust in the medical profession — particularly during emergencies like epidemics — can have deadly consequences…

Trust is the cornerstone of the doctor-patient relationship, and patients who trust their doctors are more likely to follow treatment plans…

Another study found that trust is one of the best predictors of whether patients follow a doctor’s advice about things like exercise, smoking cessation and condom use. Mistrust can lead people to skip the flu shot or forgo the measles vaccine for their children — with potentially serious consequences for individual patients and the broader population…

A degree of skepticism is inevitable and important. But when doubt becomes pervasive, it can erode the glue that binds society together, and the medicine that keeps us healthy.

Related blog posts:

 

Legalized Cannabis Associated with Increased Vomiting and Dependency But What About Alcohol?

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In politics, one hears a lot of “What about?”  If a problem is identified, many times a politician will try to divert the focus and/or justify a contentious issue to a related issue with a “what about” question. In medicine, when we see problems with marijuana, one could ask, ‘What about alcohol?’

A recent retrospective study (M Al-Shammari et al. Clin Gastroenterol Hepatol 2017; 15: 1876-81) found an increase in cannabis dependency unspecified (CDU) (ICD code) coinciding with the legalization of marijuana. Thanks to Seth Marcus for pointing out this study.

Key finding:

  • “We observed an increasing trend of CDU or an aggregate of CDU and persistent vomiting…the legalization of marijuana significantly increased the incidence rate during the legalization period (by 17.9%)…compared to the prelegalization period.

Related article: Aaron Carroll Alcohol or Marijuana? A Pediatrician Faces the Question

An excerpt:

The immediate answer, of course, is “neither.” …

The easy answer is to demonize marijuana. It’s illegal, after all. Moreover, its potential downsides are well known. Scans show that marijuana use is associated with potential changes in the brain. It’s associated with increases in the risk of psychosis. It may be associated with changes in lung function or long-term cancer risk, even though a growing body of evidence says that seems unlikely. It can harm memory, it’s associated with lower academic achievement, and its use is linked to less success later in life.

But these are all associations, not known causal pathways…

When I’m debating my answer, I think about health as well…Binge drinking accounted for about half of the more than 80,000 alcohol-related deaths in the United States in 2010, according to a 2012 report by the Centers for Disease Control and Prevention. The economic costs associated with excessive alcohol consumption in the United States were estimated to be about $225 billion. Binge drinking, defined as four or more drinks for women and five or more drinks for men on a single occasion, isn’t rare either. More than 17 percent of all people in the United States are binge drinkers, and more than 28 percent of people age 18 to 24…

Marijuana, on the other hand, kills almost no one…

I think about which is more dangerous when driving. A 2013 case-control study found that marijuana use increased the odds of being in a fatal crash by 83 percent. But adding alcohol to drug use increased the odds of a fatal crash by more than 2,200 percent. A more recent study found that, after controlling for various factors, a detectable amount of THC, the active ingredient in pot, in the blood did not increase the risk of accidents at all. Having a blood alcohol level of at least 0.05 percent, though, increased the odds of being in a crash by 575 percent…

 In 1995 alone, college students reported more than 460,000 alcohol-related incidents of violence in the United States… On the other hand, a 2014 study looking at marijuana use and intimate partner violence in the first nine years of marriage found that those who used marijuana had lower rates of such violence…

[Thus]  if I’m forced to make a choice, the answer is “marijuana.”

My take: While the cited study shows a correlation between cannaboid legalization with both CDU and increased vomiting, the commentary by Dr. Carroll helps provide context to the risks of marijuana use.  From a safety standpoint, the risks posed by alcohol appear much greater.

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Medication Manager Apps

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From Cincinnati Children’s Staff Bulletin: A review of medication manager apps

My take: I have not tried the apps below.  I do think ‘old school’ products like weekly pill boxes can be very useful.

An excerpt:

For some families, medication apps can help them establish a routine of taking medication at the same time each day. For others, the app acts as a reminder every once in a while when the family has a really busy day and may have forgotten otherwise.

Possible Features
 MyMedScheduleMobile Mango Health Medication Manager
 MedCoach Medication Reminder MediSafe Meds & Pill Reminder
Alerts you to take meds  X X X
Prescription refill reminders  X
Connect with pharmacy to refill prescriptions  X  X
Track progress  X  X
Create medication schedules  X  X
Create list of medications for doctor  X  X
Synchronizes with other family members  X
Drug interaction warnings  X
Gives points and rewards  X
FREE  X  X  X  X

 

Looking at the ‘Less is More’ Narrative

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There is a widespread claim that up to 30% of health care dollars are wasted.  This claim is similar to other claims of fraud and abuse often extolled in political campaigns.  The questions, at least in medicine, is whether this claim is accurate and even if it is, is there a way to improve health care spending.

A recent commentary (L Rosenbaum. NEJM 2017; 377: 2392-7) tackles the “Less-Is-More-Crusade” in medicine.  Some of the key points:

  • The 30% waste figure is often attributed to Dartmouth investigators ((http://www.dartmouth.atlas.org/keyissues/issue.asp?con=1338)
  • This figure has many limitations including inadequate control for severity of illness, regional price differences, and the possibility that variation is due to underuse as well as overuse.
  • Confounders: difficulty controlling for sicker patients
  • “Other research suggests that higher spending is actually associated with better outcomes.”

Dr. Rosenbaum describes how MIT economists identified what worked out to be a randomization experiment of health care.  These economists examined hospital performance among patients transported by ambulance.  Since the ambulance companies had hospital preferences, the “patients [were] essentially randomly assigned to hospitals.”  Key finding: “hospitals that spend more during hospitalizations for various acute conditions have lower mortality rates at 1 year post-hospitalization than lower-spending-hospitals, a relationship driven largely by inpatient treatment intensity” (J Pol Econ 2015; 123: 170-214).

Another recent analysis found that Medicare beneficiaries discharged from EDs in “hospitals with the lowest admission rates were 3.4 times as likely to die within a week” as their counterparts at hospitals with the highest admission rates.  In addition, “low-admitting EDs tended to serve generally healthier populations.”

Dr. Rosenbaum points out that while many attribute physician greed as a driver of excess testing/overdiagnosis in a fee-for-service model, there are many other explanations.  Physician expertise and desire for more certainty are relevant factors.

My take: This commentary provides a lot of nuance.  Yes, there is certainly waste but there is a lot of underuse in medicine. Like in areas outside of medicine, “eliminating fraud and abuse” is an oversimplification and will be difficult to achieve.

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Reminders and Hard Stops -One Way to Improve Care Using an Electronic Medical Record

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A recent study (MA Konerman et al. Hepatology 2017; 66: 1805-13) provides a tangible example of how an electronic medical record (EMR) could be helpful in improving care.

Implementation of EMRs has been a source of consternation for many physicians.  Some of the concerns include spending inordinate amounts of time completing documentation and how they can make the patient encounter less personal.

Nevertheless, with a good EMR, there is the potential for better care.  One way to implement a specific improvement is to place a “hard stop” or a reminder.  A hard stop can prevent completing documentation until an issue is addressed.  A reminder can pop up for appropriate patients to query whether a specific problem is being addressed.  In theory, both could be helpful; though, too many reminders can trigger alarm fatigue and too many hard stops can be quite annoying and further slow delivery of patient care.

In the above-mentioned study, the authors placed a reminder (“best practice advisory”) that encouraged screening for hepatitis C virus (HCV) among patients born between 1945-65 who lacked a prior HCV diagnosis and lacked prior testing.  This resulted in an increase in HCV screening in a primary care setting from 7.6% to 72% (one year after implementing).  Of the 53 newly diagnosed patients, all were referred for specialty care.  11 had advanced fibrosis or cirrhosis.

My take: Using EMR tools, specific screening goals can be achieved.  Before placing hard stops and/or reminders, we need to make sure that these goals are carefully selected to generate a net benefit.

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Deprescribing Initiative

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A recent article (Gastroenterol & Endoscopy News, October 2017; 64-66) described an effort to reduce the problem of “polypharmacy.”  While this is clearly a problem for adult medicine, increasingly, this is an issue with pediatrics as well.

Key points:

  • In 2015, 35.8% of adults were taking at least 5 medications (JAMA 2016; 176: 473-82)
  • More medications increase the risk of adverse events, drug interactions, and costs
  • The deprescribing initiative (http://deprescribing.org/) encourages active review of medications and removing those with questionable risk-benefit trade-off
  • If stopping medicines, generally remove one at a time