Category Archives: General Health

Truly Penicillin Allergic?

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Here’s a link to the video story regarding misdiagnosis of penicillin allergy: Your Allergy to Penicillin May Be Non-Existent

Link to print version: Allergy to Penicillin?

An excerpt: Dr. Thanai Pongdee, an allergist at the Mayo Clinic in Jacksonville, Florida and colleagues tested 384 people who said they were allergic to penicillin. Tests showed 94 percent of them were in fact, not allergic.

pcn-allergy

Public Shaming is Not an Effective Drug Pricing Policy

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From NBC News: Congress Doesn’t Scare Drug Execs Into Lowering Prices

Excerpt:

Congress’s routine of publicly shaming drug company executives over high prices works no better than a placebo: It may make some people feel better, but it doesn’t treat the problem…

But a review by The Associated Press of the list prices of nearly 30 brand-name medications and generic versions targeted by congressional investigators shows most haven’t budged since coming under federal scrutiny, according to figures from Truven Health Analytics.

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Update on Chronic Cough

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It is not uncommon for a pediatric gastroenterologist to see a patient with a chronic cough due to concerns about potential gastroesophageal reflux disease (GERD).  As such, a recent clinical practice article (JA Smith, A Woodcock. NEJM 2016; 375: 1544-51) by lung specialists was of interest, even though this article was not targeted to the pediatric population.

Key points:

  • The authors define a chronic cough as lasting more than 8 weeks and note that it common with respiratory conditions (eg. chronic obstructive pulmonary disease, asthma, and bronchiectasis) and some non-respiratory conditions (eg. gastroesophageal reflux and rhinosinusitis).  Medications, particularly ACE inhibitors, can trigger a chronic cough as well.
  • Steps in evaluation: 1. H&P, CXR, spirometry. 2. Consider metacholine challenge, ENT evaluation, consider empiric treatment (eg. inhaled glucocorticoids, PPI), and consider GERD evaluation. 3. High-resolution CT and bronchoscopy.
  • For many patients, there is likely to be an abnormality in neuronal pathways controlling cough and the term “cough hypersensitivity syndrome” has been coined.  Figure 2 (below) illustrates the neuronal pathways.
  • For refractory patients, potential therapies would include low-dose morphine, gabapentin or pregabalin, and speech language therapy.

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GERD:

  • Guidelines “suggest a trial of treatment with acid-suppression therapy” (eg. twice-daily PPIs for up to 3 months).
  • “Most randomized, controlled trials of reflux treatment for cough have not shown a significant improvement in association with this type of treatment.”
  • Subgroups of patients with heartburn, regurgitation, or excessive acid reflux on esophageal pH monitoring “appeared marginally more likely to have a response to PPI treatment.”  pH or impedance tests “are poorly predictive of a response of cough to acid suppression.”

My take: In the absence of clinical reflux, reflux therapy is unlikely to help with chronic cough.  However, in patients with an adequate workup, an empiric course of a PPI is likely more preferable than empiric morphine or gabapentin.

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Academic Performance After Anesthesia

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A new study provides some reassurance that anesthesia at a young age is unlikely to cause harm (little to no effect) in most children.

Full text: P Glatz et al. JAMA Pediatrics, Published online November 7, 2016. doi:10.1001/jamapediatrics.2016.3470: Association of Anesthesia and Surgery During Childhood with Long-Term Academic Performance

Findings  In this cohort study among 33 514 exposed children, exposure to surgery with anesthesia before age 4 years was associated with 0.41% lower school grades and 0.97% lower IQ test scores, with no difference in school grades with regard to age. The overall difference was markedly less than the differences associated with sex, maternal educational level, or month of birth during the same year.

Comment: Despite efforts to control for indications which of themselves could impact the results, it is quite possible that the small changes detected in this study are a result of confounding factors rather than due to the anesthetic itself.

My take (from the authors): “Exposure to anesthesia and surgery before age 4 years is associated with a small difference in academic performance or cognitive performance in adolescence on a population level. The magnitude of this association should be interpreted in light of potential adverse effects of postponing surgery.”

Related blog post: More evidence of anesthetic neurotoxicity

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World Toilet Day and Poo-ems

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Thanks to my favorite blog reader for pointing me towards this NPR piece:

World Toilet Day: Read Winning Poo Haikus About Diarrheal Disease

An excerpt:

That’s the idea behind Poo Haiku, a competition created by Defeat DD, a campaigndedicated to the eradication of diarrheal disease.

Although everybody’s had the runs, it’s not something most folks talk about, says Hope Randall, digital communications officer for PATH’s Center for Vaccine Innovation and Access, which created DefeatDD to bring together resources on vaccines, nutrition, oral rehydration therapy, sanitation and more…

this winning entry from Kat Kelley of the Global Health Technologies Coalition, which references a recent study published in The Lancet:

Just six pathogens
But eighty percent of kids’
Diarrheal deaths….

Check out all of the poo-ems, including some videos, by searching for the hashtag #poohaiku on Twitter.

My take: Today is World Toilet Day -a great day to write your own poo-em. 2.4 billion people do not have access to a toilet.

World Toilet Day this year is November 19th (today).

Sandy Springs

Sandy Springs

 

iPatient and Physician Work Circa 2016

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An interesting commentary (DI Rosenthal, A Verghese. NEJM 2016; 375: 1813-5) provides a closer glimpse into the meaning and nature of physicians’ work at this time.

Key points:

  • Medical students and residents spend 40-50% of their day in front of a computer & much of the rest of their day on the phone (coordinating care).
  • Time spent with patients “has remained stable over the past six decades.”
  • Flipping through the electronic record before seeing patients is commonplace but can lead to a ‘framing bias.’
  • “Our attention is so frequently diverted from the lives, bodies, and souls of the people entrusted to our care”…”despite all the rhetoric about ‘patient-centered care,’ the patient is not at the center of things.”
  • The authors equate the digital representation of the patient as an ‘iPatient.’
  • Physicians are “resentful of the time required to transcribe and translate information.”
  • Higher satisfaction is associated with perceptions of higher quality of care.
  • The authors advocate working on “rebuilding our practices and physical spaces to promote human connections that can sustain us — between physicians and patients, physicians and physicians, and physicians and nurses.”

My take: The authors provide a closer glimpse of the problem showing how our digital health has hindered meaningful interactions that go to the heart of medicine –to provide comfort and care.

Related blog posts:

Neighborhood tree a few weeks ago

Neighborhood tree a few weeks ago

Compared with Zika, CMV is a Greater Threat and Less Discussed

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A recent article in NY Times provides another example of how a common infectious problem has been overshadowed by a more recent epidemic.  CMV is A Greater Threat to Infants Than Zika

Two years ago, it was well-recognized that the flu virus is vastly more dangerous for U.S. than Ebola (Related post:Scarier than Ebola -the Flu | gutsandgrowth). This year, CMV should get more attention.

Here’s an excerpt:

Every year, 20,000 to 40,000 infants are born with CMV. At least 20 percent — up to 8,000 — have or develop permanent disabilities, such as hearing loss, microcephaly, intellectual deficits and vision abnormalities. There is no vaccine or standard treatment…

CMV is the most common congenital viral infection and the leading nongenetic cause of deafness in children. Roughly 400 children die from it annually. By contrast, roughly 900 pregnant women in the continental United States have contracted the Zika virus…

CMV is the most common congenital viral infection and the leading nongenetic cause of deafness in children. Roughly 400 children die from it annually. By contrast, roughly 900 pregnant women in the continental United States have contracted the Zika virus.

The American College of Obstetricians and Gynecologists used to encourage counseling for pregnant women on how to avoid CMV. But last year, the college reversed course, saying, “Patient instruction remains unproven as a method to reduce the risk of congenital CMV infection.”

My take: Perinatal CMV infection merits more discussion.

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Trail to Iceberg Lake, Glacier Nat'l Park

Trail to Iceberg Lake, Glacier Nat’l Park

Big Progress with Smoking

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A remarkable public health advance is happening and has not received much attention.  A recent commentary (MC Fiore. NEJM 2016; 375: 1410-12) highlights the substantial and accelerating progress in lowering the use of tobacco/smoking.

The author notes that the rate of decline in smoking is now about 0.78 percentage points per year during the Obama administration which is more than double the rate during the prior 16 years.  This decline, if continued, could mean that the current rate of smoking of 15.3% of U.S. adults could be zero by around 2035.

The author notes that the current administration likely deserves some of the credit for this progress due to legislative acts and leadership.  Legislation has included increases in federal cigarette excise taxes, more FDA oversight of thousands of tobacco products, and better insurance coverage of smoking cessation through the Affordable Care Act. Leadership has involved the CDC, FDA and HHS.  This has led to comprehensive strategic plans which have developed effective educational campaigns, including “Tips from Former Smokers” and “The Real Cost.” More steps to build on this progress has been outlined in the 50th-annisversary of the Surgeon General’s report, The Health Consequences of Smoking (2014).

Potential Further Actions:

  • Further increases in cigarette excise taxes
  • Sustain high-impact national media campaigns
  • Public housing mandates to make smoke-free
  • Federal legislation to ban any tobacco products to persons younger than 21 years
  • Extend smoke-free indoor-air protections to all Americans

My take: This is great news.  Hopefully, there will be a big drop from >36 million Americans who smoke to many fewer in coming years.  This can reduce premature deaths which are expected for about half of people who continue to smoke.

New Family Member: Charlie!

New Family Member: Charlie!

The Narrow Path of Personalized Cancer Medicine

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Since I’m not directly involved in oncology care, I have a limited perspective on how quickly molecular medicine may transform cancer care.  A recent commentary (IF Tannock, JA Hickman. NEJM 2016; 1289-94) explains the “Limits to Personalized Cancer Medicine.”

While the idea of careful molecular characterization of tumors that lead to targeted therapy with better survival and better patient quality of life has been proven effective in several circumstances, there are a number of reasons why this approach will not be useful for most cancers.

Key points:

  • Examples of current personalized cancer Rx: trastuzumab for HER2-expressing breast cancer and vemurafenib for BRAF-mutated-expressing melanomas.
  • Very few studies have shown feasibility/effectiveness of targeted drug treatment
  • There has been limited success with targeted drugs within and outside studies
  • Though proponents of targeted therapy expect further advances, tumors typically have heterogeneity which allows a Darwinian evolution to evade these new therapies. “Cancer cells have an almost universal capacity to develop resistance to a single molecular targeted agent by means of upregulation of the partially inhibited pathway, mutation of the target, or activation of alternative pathways.”
  • Targeted therapies are usually limited by only partial inhibition of the signaling pathways and by toxicity when used in combination therapy.
  • In some cases, a clonal driver mutation may be present which would be present in all cell lines –however the authors note that success from this approach is likely to be rare.
  • Cost: “new drugs to treat cancer are marketed at ever-increasing prices…unrelated to value (i.e. to clinical effectiveness)….but the development and marketing of expensive drugs with marginal effectiveness diverts resources from the development of more effective therapies.”

My take (borrowed from authors): “The concept of personalized medicine is so appealing…[but] there should also be a clear message to patients that personalized cancer medicine has not led to gains in survival…and is an appropriate strategy only within well-designed clinical trials.”

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University of Virginia

The Lawn, University of Virginia