Category Archives: General Health

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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What do I want to accomplish?

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“Is it good to try to live as moral a life as possible –a saintly life? Or does a life like that lack some crucial human quality? …Is it presumptuous, even blasphemous, for a person to imagine that he can transfigure the world –or to belive that it really matters what he does in his life when he’s only a tiny flickering speck in a vast universe?”

—Strangers Drowning, Larissa Macfarquhar

Frequently I think about the question of what I want to accomplish in my role as a physician.  Sometimes the answer is to get home at a reasonable hour that day.  However, when looking past the day-to-day, I definitely strive for more, even if I am only a tiny fleck in the universe.

I like to think that I’ve tried to help families that see me as best as I can.  I try to make sure that I am not overbooked so that I have enough time to think about problems carefully and perhaps have an opportunity to make a connection/have a conversation with families who come to see me.

So much of what I do everyday becomes fairly routine, particularly when in the office.  For a family who has a child with severe stomach pain and is missing school, this is a critical problem. Yet, I may see several similar children each day of the week.  I know that the child will improve, but I don’t know exactly how long it will take and how difficult it will be.

Most of the problems that I see are alarming for parents, including the following:

  • severe stomach pain
  • rectal bleeding
  • poor growth
  • difficulty feeding
  • soiling
  • vomiting

Yet, very few patients who come to our office need to be admitted to the hospital.  Most of the time, some fairly routine advice and/or treatment will resolve (or at least improve) these problems.

In clinical care, what really stands out for me is when a rare medical problem is quickly identified and treated.  I was delighted recently when I helped establish a diagnosis of chronic granulomatous disease in one child when he was seen at his first encounter with me.  In the previous week, I identified a child with familial Mediterranean fever.  Both of these problems are extremely rare and can be difficult to diagnose.

But truly, how often does it matter if a child sees me compared with another pediatric gastroenterologist?  My suspicion is that most of the time it does not matter; though this opinion may be due to the fact that I’ve had the chance to work with some truly terrific colleagues.  So while it is gratifying to help families, I am often thinking about what I can do to accomplish more.  I am sure others struggle with the same issue of trying to do meaningful work.  Some may leave a legacy through their focus on research, teaching or charity.

In some ways, I have considered my participation in the AAP, my blog, my role at the hospital, and (at times) research/teaching as important opportunities for different types of work to keep everyday a little more exciting and to make a useful contribution.

What are you trying to accomplish?

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NEJM Presidential Candidate Health Proposals

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Full text: My Vision for Universal, Quality, Affordable Health Care –NEJM

From NEJM: The editors invited the Democratic and Republican presidential nominees, Hillary Clinton and Donald Trump, to answer the following question for Journal readers: What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation? Secretary Clinton responded. Mr. Trump did not respond.

The main topics in Hillary Clinton’s commentary include expanding insurance coverage through the affordable care act (i.e. Obamacare), improve affordability in health care with proposals that affect both insurance companies and pharmaceutical companies, improve access to primary care/community care, and to continue to promote innovation/research.

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One of 340,000 Followers of NEJM

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A recent editorial (EW Campion et al. NEJM 2016; 375: 993-4) made a few worthwhile points and shows how NEJM has been successful and innovative over 20 years of using the web and social media.

  • This has allowed more widespread access to its content, even by resource-poor countries.
  • The use of the web has facilitated quick distribution of multiple resources for outbreaks like  Ebola and Zika.
  • Currently, every article back to 1812 is available online (over 173,000 with more than 570,000 pages)
  • NEJM has 340,000 twitter followers and 1.3 million followers on facebook
  • Despite the importance of NEJM, as well as other healthcare media, important caution is needed.

“We do need to be wary of challenges and dangers that the new media have created.  On the Internet, speed and simplicity often displace depth and quality, especially on complex subjects.  Our privacy is increasingly vulnerable. Misinformation, misrepresentation, and piracy are common.  There are health scams and even sham medical conferences and fake medical journals.”

My take: Careful use of internet resources has been incredibly helpful.  But, beware of the inherent hazards that have accompanied these advances.

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Balancing Rock, Bar Harbor

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The Indispensable Physician

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A recent pair of commentaries (RM Wachter, L Goldman. NEJM 2016; 375: 1009-1011, R Gunderman. NEJM 2016; 375; 1011-13) provides some insight into what has been gained and what has been lost with the proliferation of hospitalist care in the past 20 years.

The growth of hospitalist care has developed due to numerous factors:

  • evidence of cost savings/better outcomes
  • need for rapid evaluation of acutely ill patients/repeated evaluations which would be disruptive to efficient outpatient physician practices

Decline of comprehensive care:

  • at times of extreme vulnerability when admitted to the hospital, patients have a physician assigned to them who they have probably never met.  This has led to a diminishment of the patient-physician relationship.
  • increasing number of physicians creates opportunities for miscommunication, particularly on admission and discharge, but also at every step of hospital care during “handoffs”

The second commentary, in particular, challenges the way medicine is evolving.  This article stresses the central role of the physician as opposed to the hospital filling that role.

“The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians.”

The goal of developing personal relationships with our patients is often at odds with work-life balance.  Thus, having hospitalists and other ways of having cross-coverage, when we are unavailable, often conflict with being able to provide the best care.

My take (from 2nd commentary): “The true core of good medicine is not an institution but a relationship — a relationship between two human beings.”

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Glacier Nat'l Park

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