Category Archives: General Health

The Alarming Impact of Microplastics on Human Health

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Yesterday’s post described the problems than pollution and chemicals are associated with in children.

Today’s post reviews data that microplastics accumulate in the brain and are associated with dementia in adults. A thorough review of this topic from Eric Topol 2/3/25: The Microplastic Concerns Elevate—To the Brain

Some excerpts:

Background: Last March a landmark prospective study of microplastics found nearly 60% of patients undergoing an artery operation (carotid endarterectomy) 58% had microplastics and nanoplastics (MNPs) in their plaque. Their presence was linked to a subsequent 4.5 -fold increase of the composite of all-cause mortality, heart attack and stroke…A multi-center study from China showed microplastics were present in the semen and urine of all 113 men assessed and were associated with reduced sperm count and semen quality The CDC data indicate they are likely present in the bodies of all Americans. As you know by now, MNPs are pervasive in our air and water, there’s currently an annual output of 400 million tons of plastics, and the burden of MNPs is expected to double by 2040 if nothing is done to change course.

The main sources of MNPs

The New Study

As reported in today’s Nature Medicine, Alexander Nihart and colleagues assessed concentrations of MNPs in the brain, liver and kidney…To emphasize, the MNP concentration in the brain was 7-30 times greater than the concentration in the liver or kidneys...the increased concentration of MNPs was considerably greater in the people with dementia. Even at the most recent, higher MNP concentration, the brains without dementia averaged ~5,000 μg g−1 whereas the brains from individuals with dementia has MNP concentrations that were 2 to 10-times higher…

Another study published on 22 January in Science Advances demonstrates, in the mouse model, that MNPs in the bloodstream cross the blood-brain-barrier, activate the immune system (schematic below) and result in stagnation of blood flow, culminating in blood clots, also resulting in neurological abnormalities…

Some practical tips were, however, provided: “Reducing exposure to microplastics is feasible, by avoiding food and drinks packaged in plastics, using less synthetic fabric and cleaning up household dust. Heating plastic containers leaches lots of microplastics, so avoiding microwaved ready-meals and plastic kettles should help too.”

The essential point of this post is that the striking brain accumulation of MNPs is paralleled by the overwhelming accumulation of evidence for their toxicity to human health. 

Related blog posts:

Urgent Need for New Chemical Regulations For Kids

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The Consortium for Children’s Environmental Health. NEJM 2025; 392: 299-305. Manufactured Chemicals and Children’s Health — The Need for New Law

This review article explains the worsening toll that chemicals in our environment are exacting on the health of children.

Here are some of the key excerpts:

  • “An estimated 350,000 manufactured chemicals, chemical mixtures, and plastics are currently listed in global inventories.3 Most are produced from fossil fuels — gas, oil, and coal. Production has expanded 50-fold since 1950, is currently increasing by about 3% per year, and is projected to triple by 2050.4 Environmental pollution5,6 and human exposure7 are widespread.”
  • In the past half-century, “the incidence of childhood cancers has increased by 35%.10 Male reproductive birth defects have doubled in frequency.11 Neurodevelopmental disorders now affect 1 in 6 children, and autism spectrum disorder is diagnosed in 1 in 36.12 Pediatric asthma has tripled in prevalence.13 Pediatric obesity has nearly quadrupled in prevalence and has driven a sharp increase in type 2 diabetes among children and adolescents.14 In adults, by contrast, illness, disability, and death due to cardiovascular disease, stroke, and many cancers have decreased.15,16“
  • “Research in environmental pediatrics has flourished over the past 25 years. Two key catalysts of this growth were the 1993 publication of the National Research Council report, Pesticides in the Diets of Infants and Children21 which elucidated the biologic bases of children’s heightened susceptibility to toxic chemicals, and the passage in 1996 of the Food Quality Protection Act (FQPA), the U.S. law on pesticides. The FQPA made protecting children’s environmental health a national priority and required generation of data on chemical hazards to children, stimulating substantial expansion of federally funded research in environmental pediatrics…Prenatal exposures are particularly hazardous…diseases associated with early-life exposures can manifest any time during the life span.23“
  • “Prospective, birth-cohort epidemiologic studies that measure chemical exposures in pregnant persons and fetuses and follow children longitudinally over many years are particularly powerful platforms for discovering associations between synthetic chemicals and disease because they link exposures to outcomes in individual children and eliminate recall bias.”
  • “Widespread childhood exposure to a toxic chemical can damage the health, economic viability, and security of an entire society. For example, each year from the 1950s through the 1970s, about 100,000 tons of tetraethyl lead were added to gasoline in the United States to enhance automotive performance, causing massive environmental lead contamination and extensive human exposure… The average IQ among U.S. children was reduced by an estimated 2 to 5 points,32 the number of children with an IQ above 130 decreased by more than 50%, and the number with an IQ below 70 (the criterion used in the International Classification of Diseases to define intellectual disability) increased by more than 50%…reducing toxic chemical exposures can produce major economic benefits…because each additional IQ point is associated with an increase of 1.8 to 2.4% in lifelong earning potential.
  • “Chemicals should no longer be presumed harmless until proven otherwise…National chemical policies should take into consideration findings from animal and mechanistic toxicology studies, which are highly predictive of human health risks, including risks to children.49“

My take: Pollution from chemicals and plastics is worsening and resulting in worsening health/intellectual outcomes for children. I doubt any legislation will be forthcoming to improve the situation. It is unfortunate that protecting profits is prioritized over protecting our health.

Related blog posts:

A ‘good demon’ at The Grand Palace in Bangkok

The Pediatrician’s Role in Vaccination and Trust

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Two recent commentaries on “hot button” issues:

  • ER Menzin: The Pediatrician’s Lament. NEJM 2025; 392: 320-321
  • PMG Santos et al. Texas Executive Order GA-46 and the Erosion of Trust in Health Care. NEJM 2025; 392: 108-109

An excerpt from the first commentary:

“Throughout my career, I have seen new vaccines approved: pneumococcus, rotavirus, meningococcus, and human papillomavirus. In each case, I have studied the data, reviewed published recommendations, and adjusted my language to encourage vaccination. I consider the high immunization rate in my patient panel to be one of my greatest professional accomplishments — a quantitative metric of the benefit I provide…

Every so often, parents will look at me over a smiling infant and tell me they want their child to have only one or two recommended vaccines. Can I choose the most important? I tell them the question is akin to asking me to pick my favorite child — an impossible task…

Some will ask, “Can you recommend a good pediatrician who does not believe in vaccines?” No, I say, no more than I can recommend a good physicist who does not believe in gravity…

Even if patients are skeptical of the alphabet soup of institutions designed to protect and safeguard their health, they still have confidence in the long-standing relationships with their clinicians. To deserve that trust, we are obligated to raise our collective voice in defense of science, health, and vaccines.”

From the 2nd Commentary:

“On Halloween morning, 2024, Texas physicians received disturbing news about hospital policies set in compliance with Governor Greg Abbott’s Executive Order GA-46 — a rule that mandates the collection and reporting of information on patient citizenship status during intake…

Throughout medical training, physicians learn that trust is a cornerstone of patient care: we ask patients to share deeply personal information about themselves and their loved ones, with the assurance that legal and ethical safeguards protect against the misuse of such information. Chief among these safeguards is the Health Insurance Portability and Accountability Act (HIPAA), which restricts physicians from disclosing protected health information (PHI) without a person’s consent. Citizenship status, though not traditionally considered PHI, may be treated as such when it is paired with medical information obtained during patient encounters…

GA-46 … will deter immigrants, both documented and undocumented, from seeking help for serious medical concerns… Under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals are required to provide emergency care to all patients, regardless of citizenship status. GA-46 indirectly conflicts with EMTALA’s intent to guarantee access to emergency services for all people by discouraging undocumented people from seeking care…

From an economic standpoint, Texas officials have stated that the goal of GA-46 is to protect the financial solvency of public hospitals; however, federal financial support covers most uncompensated care costs. Moreover, contributions from immigrants help sustain the viability of public health insurance programs. In 2017, immigrants helped offset a $67 billion deficit in health care costs for U.S.-born citizens by paying $58 billion more in taxes and premiums than was spent on their health care; 89% of this surplus was attributed to contributions made by undocumented immigrants…

Physicians in Texas and Florida must continue to inform patients of their right to refuse disclosure of their citizenship status.”

Related blog posts:

Understanding Patient-Specific Blood Count Setpoints

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BH Foy et al. Nature (2024). https://doi.org/10.1038/s41586-024-08264-5. Haematological setpoints are a stable and patient-specific deep phenotype

Background: The complete blood count (CBC) is an important screening tool for healthy adults and a common test at periodic exams. However, results are usually interpreted relative to one-size-fits-all reference intervals1,2, undermining the precision medicine goal to tailor care for patients on the basis of their unique characteristics3,4.

Key findings:

  • Routine CBC indices fluctuate around stable values or setpoints5, and setpoints are patient-specific, with the typical healthy adult’s nine CBC setpoints distinguishable as a group from those of 98% of other healthy adults, and setpoint differences persist for at least 20 years.
  • Setpoints also define patient-specific reference intervals and personalize the interpretation of subsequent test results. In retrospective analysis, setpoints improved sensitivity and specificity for evaluation of some common conditions including diabetes, kidney disease, thyroid dysfunction, iron deficiency and myeloproliferative neoplasms

This study is discussed by Eric Topol: Your Lab Tests. “This [individualized setpoints] enabled the ability to differentiate increased risk of progression to Type 2 diabetes in people as a function of MCHC setpoint, likelihood of hypothyroid status (elevated thyroid stimulating hormone (TSH) from the current MCV, low iron storage (ferritin) from the drop in hemoglobin, and even a mutation in Janus Kinase (JAK2) in people with high platelet setpoints (>9-fold higher rate of mutations, which are associated with several blood cancers.).”

My take: This study indicates that for each individual there past test results are more useful than establised normative values. Deviation from a person’s setpoint, even if in the normal range, is more indicative of development of a medical problem. However, this type of data is not always utilized. This study focused on CBC values, but there may be setpoints with other common labs as well; more studies are needed.

Understanding Alcohol’s Cancer Risks and Warnings

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NY Times and USAToday both reported on this topic earlier this month:

An excerpt from USAToday report:

According to the Centers for Disease Control and Prevention, alcohol consumption is the third-leading preventable cause of cancer in the United States, after tobacco and obesity. And according to the report released by Murthy’s office, it increases the risk for at least seven types of cancer…

In a post on X, Murthy said alcohol contributes to about 100,000 cancer cases and 20,000 cancer deaths annually in the U.S., a number greater than the 13,500 alcohol-related traffic accidents each year.

Murthy is calling on Congress to act to update the labels to include an increased risk of the following cancers linked to alcohol consumption:

  • Breast
  • Colon
  • Throat
  • Liver
  • Voice box
  • Esophagus
  • Mouth

From NY Times:

While most cancer deaths occur at drinking levels that exceed the current recommended dietary guidelines, the risk for cancers of the breast, the mouth and the throat may rise with consumption of as little as one drink a day, or even less, Dr. Murthy said on Friday.

Overall, one of every six breast cancer cases is attributable to alcohol consumption, Dr. Murthy said. …

The World Health Organization says there is no safe limit for alcohol consumption…The most widely accepted theory is that inside the body, alcohol breaks down into acetaldehyde, a metabolite that binds to DNA and damages it, allowing a cell to start growing uncontrollably and creating a malignant tumor.

My take: It is surprising that alcohol is attributed to causing more deaths due to cancer than due to motor vehicle accidents.

Related blog posts:

Atlanta Botanical Gardens

Ponsegromab: A Breakthrough for Cancer Cachexia Treatment

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JD Groarke, et al. NEJM 2024; 391: 2291-2303. Ponsegromab for the Treatment of Cancer Cachexia

Background: “Growth differentiation factor 15 (GDF-15) is a stress-induced cytokine that binds to the glial cell–derived neurotrophic factor family receptor alpha-like protein (GFRAL) in the hindbrain.12 The GDF-15–GFRAL pathway has emerged as a main modulator of anorexia and body-weight regulation and is implicated in the pathogenesis of cachexia.13 …Ponsegromab (PF-06946860) is a potent, highly selective, humanized monoclonal antibody that binds to circulating GDF-15, thereby inhibiting the interaction with its GFRAL receptor.”

“A recent guideline supports low-dose olanzapine to improve appetite and weight in patients with advanced cancer,3 a recommendation that is largely based on a single-center study.4 Safe, effective, and targeted therapies for cancer cachexia are needed.10,11“

Methods: In this phase 2, randomized, double-blind, 12-week trial, we assigned patients with cancer cachexia and an elevated serum GDF-15 level (≥1500 pg per milliliter) in a 1:1:1:1 ratio to receive ponsegromab at a dose of 100 mg, 200 mg, or 400 mg or to receive placebo, administered subcutaneously every 4 weeks for three doses. N=187. Of these patients, 40% had non–small-cell lung cancer, 32% had pancreatic cancer, and 29% had colorectal cancer.

Key findings:

  • Over the 12-week trial, patients treated with ponsegromab had as much as a 2.8 kg weight gain compared to placebo.
  • Improvements were observed across measures of appetite and cachexia symptoms, along with physical activity, in the 400-mg ponsegromab group relative to placebo. 

My take: This study explains a key driver of cachexia in cancer and shows that inhibition of GDF-15 can improve weight gain and physical activity.

Conversations on Palliative Care for Children

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K Wu. NEJM 2024; 391; 2288-2289. Well Known to Us.

This commentary focuses on the personal experience of being an hospital-based physician tasked with taking care of chronically-ill complex and neurologically-compromised children through recurrent and prolonged admissions.

An excerpt:

Teetering on the precipice of death at every admission, they are a testament to how far medicine has come in keeping people alive — and how far it still has to go in treating their underlying conditions. Having realistic conversations about long-term outcomes and palliative care for these patients remains difficult, with pediatricians afraid of disrupting fragile relationships with parents who have endured so much.1

With increasing numbers of such children being admitted to PICUs and limited expansion of capacity,2-4 questions have been raised about the value and necessity of the care provided to them — not in terms of their condition in isolation, but in terms of who else is being deprived of care. Patients with complex, chronic, life-limiting, multiorgan conditions are often described as “well known to us,” but they’re also called “bed blockers” — a label reflecting one answer to the uncomfortable ethical question of which patients are most deserving of limited resources.5 …

Often all I could do was bear witness to their sickness and wellness, their deterioration and recovery, again and again. But in their short lives filled with suffering and struggle and a constant parade of caregivers, I was their pediatrician, and I had become well known to them.

Related blog post: Navigating Difficult Conversations in Children’s GI Healthcare

Cultivating Compassion in Pediatric Care

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Yesterday’s post discussed communication strategies for GI patients with severe underlying diseases. A related article (S McCarthy. NEJM 2024, 391: 2072-2073. The Care That Saved Me) provides additional insight into the importance families place on the care that they receive.

The author is a pediatric psychologist at a large academic medical center. One of her daughters died at 5 years of age from cancer and she reflects on her experiences and what she learned; though, she states it is a “knowledge I wish I didn’t have.”

An excerpt:

As a clinician, I have identified four practices that I now prioritize in my work, emerging from Molly’s illness and death and my bereavement.

First, strive to illuminate the patient’s personhood… I do make sure to include information that helps me and other clinicians see each patient as an individual,1 illuminating their unique personhood...

Second, make an effort to understand life outside the hospital…“What do you want your health care team to know about you?” and “What makes you happy?” …

Third, cultivate practical compassion…First, I ask parents when they last ate, drank something other than coffee, or slept. If a parent has not eaten or slept, I pause my interview…

Fourth, learn how to sit with darkness, while allowing for light… don’t try to fix a pain I know is unbearable, but I let parents know that they are not alone, that their love for their child is seen and their grief is witnessed...

The biggest thing I have learned is this: our work matters. Those small acts of kindness and moments of connection, seeing the children for who they are, make a difference. Patients and families do not forget them. And during the absolute hardest times, these acts sustain them...the best medical care in the world, the most advanced science, could not save Molly, but the compassionate care that our family received saved me.

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Sandy Springs, GA

Navigating Difficult Conversations in Children’s GI Healthcare

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Recently, Dr. Laurie Jacobs from CHOA’s palliative care team gave our group a provocative update on communication strategies in children with severe illness.  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

  • Having a pre-meeting with other members of health care team is a key part in setting up an effective meeting with parents
  • Delivering news: 1) Provide a straightforward Headline: ‘We are here to discuss xyz’ 2)Be clear. ‘To be clear is to be kind’ 3) Then STOP TALKING.  This let’s the family process
  • Sometimes even delivering bad news can be met with relief by families who have been waiting for a diagnosis
  • Respond to emotion with NURSE mnemonic: Name, Understand, Respect, Support, Explore
  • What if the ‘family doesn’t get it?’ Do they understand (can they repeat back)?  Most often the family has a different perspective; they may think we are wrong
  • Be careful to avoid offering decisions where there are not actual decisions to be made
  • Our own values/beliefs are often introduced even though quality of life is in the eye of the beholder
  • Tube feeds can be considered forms of ‘artificial nutrition.’  There are situations in which families need to know that it is not always required
  • Parenteral nutrition is more invasive and associated with more active parental decision-making
  • Decisions may change based on change in patient circumstances
  • There is not a single right answer with difficult decisions.  There are trade-offs between longevity and QOL
  • Anything that we would allow parents not to start, can be stopped at any time from an ethical standpoint
WOLST =withdrawal of life-sustaining therapies

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Ten Americas: Examining Health Disparities and Life Expectancy

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L Dwyer-Lindgren et al. The Lancet; 2024. Online first. Open Access! Ten Americas: a systematic analysis of life expectancy disparities in the USA

Background: Nearly two decades ago, the Eight Americas study offered a novel lens for examining health inequities in the USA by partitioning the US population into eight groups based on geography, race, urbanicity, income per capita, and homicide rate. That study found gaps of 12·8 years for females and 15·4 years for males in life expectancy in 2001 across these eight groups. In this study, we aimed to update and expand the original Eight Americas study, examining trends in life expectancy from 2000 to 2021 for ten Americas (analogues to the original eight, plus two additional groups comprising the US Latino population), by year, sex, and age group.

Methods: The authors tabulated deaths from the National Vital Statistics System and population estimates from the US Census Bureau and the National Center for Health Statistics from Jan 1, 2000, to Dec 31, 2021.

Key findings: .

  •  At the beginning of the 21st century, there was already a 12.6-year gap in life expectancy among Americas, but this gap grew even larger during the 2000s and 2010s and accelerated to 20.4 years after the first 2 years of the COVID-19 pandemic.
  • One’s life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one’s racial and ethnic identity.
  • There are limitations with the data that were used. For example, there is known to be substantial misreporting of race and ethnicity on death certificates

My take (borrowed from the authors): “The extent and magnitude of health disparities in the USA are truly alarming. In a country with the wealth and resources of the USA, it is intolerable that so many are living in conditions and with health outcomes akin to those of an entirely different country.”

Related blog posts:

Unrelated link: N Kristof NY Times, Gift Ideas That Push Back the Darkness

Gift ideas included the following charities

  • ‘Fistula Foundation which arranges obstetric fistula repair. This restores a woman’s life after this life-altering complication –a corrective surgery that costs just $619 per person
  • Muso Health helps reduce childhood mortality. In Mali, this organization reduced childhood mortality by 95%. The cost of bringing one more person into the Muso health care network is only $22 per year.
  • Reach Out and Read. This U.S-based charity allows doctors to “prescribe” reading to the child. This promotes reading as well as childhood well-child visits.
  • Crisis Text Line is for those who want to volunteer, rather than donate. This organization trains (15-20 hrs) volunteers to help individuals needing mental health support. “More than 90 percent of the volunteers report that their own mental health improves as a result of their participation.”