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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.”

Improvements in Toddler Diet Quality: 1999-2018 Study

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M Zimmer et al. Pediatrics 2024; 154: e2024067783.

Methods: This serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data was performed with 2541 toddlers from 10 NHANES cycles from 1999 to 2018.

Key findings:

  • Toddler diet quality improved significantly from 1999 to 2018 (P < .001), from 63.7
    points on average in 1999-2000 to 67.7 points in 2017-2018
  • A significant positive linear trend in total diet quality was observed for all socioeconomic status groups (P < .05)
  • Several dietary component scores improved, as follows: Whole Fruits (P < .001), Whole
    Grains (P 5 .016), Fatty Acids (P 5 .002), Refined Grains (P 5 .009), and Added Sugars
    (P < .001)
HEI-Toddlers -Healthy Eating Index has total score ranging from 0-100 points with higher score indicating healthier diets.

In the discussion, the authors note that other age groups besides toddlers have seen modest improvements in diet. Even small improvements can be consequential on a population-basis. In adults, a 4-point increase in HEI scores has been associated with a reduced risk of cardiovascular disease. The strongest improvement between 1999 and
2018 in toddler diet quality was in scores for added sugars…attributed to declines in
added sugars from sweetened beverages. “A heightened awareness of added sugars in sweetened drink products among caregivers themselves may have led to a cultural shift
around feeding toddlers less sweetened drinks.”

While in toddlers there was no significant difference in dietary scores based on socioeconomic status, “, the diet quality gap for adults has widened over time by SES,14,15
race and Hispanic origin, and Supplemental Nutrition Assistance Program participation status.”

“Although toddlers do not receive school meals, their diets can be similarly impacted by other large-scale programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the Child and Adult Care Food Program. Changes to the WIC food package have been consistently linked to improved child diet quality, and may have contributed to the gains in toddler diet quality observed in this study.”

Study limitations are related to self-reported dietary intake.

My take: It feels like improving diet quality is like swimming against a strong tide. Yet, this study shows improvements can happen. Ongoing efforts are needed to encourage healthier diets.

Related blog posts:

When Is It OK To Ignore Laryngeal Penetration?

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AL Miller et al. Dysphagia 2024; 39: 33-42. Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients

This was a retrospective study with 97 patients over a 6 month period in 2018. The authors note that “there is no universally accepted protocol for pediatric video swallows across ages and conditions.”

Methods: Depth of penetration and/or aspiration and reaction were classified according to the 8-point Penetration–Aspiration scale [JC Rosenbek, et al. Dysphagia 11, 93–98 (1996). https://doi.org/10.1007/BF00417897]. The frequency of penetration events and aspiration was grouped into categories: none (1); infrequent or occasional episodes (at least 1 event to less than 30%) (2); intermittent episodes (30–40% of total swallows) (3); frequent episodes
(50% or greater of total swallows) (4). Data for all swallowing parameters was stratified by bolus type (thin liquid, thickened liquid, puree solid). All VFSS were independently
scored by two speech-language pathologists and two radiologists.

Key findings:

  • Aspiration was seen in 21% of patients (n=20 of 97).
  • Penetration events were more frequent and occurred in 64% of participants (n=62 of 97). . Of patients with any penetration events, 30% also had documented aspiration
  • Frequency of penetration and aspiration: 80% of patients showing frequent penetration [frequency 4] demonstrating aspiration compared to 2.3% of patients with isolated penetration [frequency 1]. There was a higher risk of aspiration at lower frequency penetration if this occurred with thicker liquids (see below)
  • Depth of penetration and aspiration:. For patients with penetration contacting the vocal folds [depth 5], nearly 95% demonstrated documented aspiration within the same study; however, those with depths 1-3 had minimal risk of aspiration (see below). There was a higher risk of aspiration at shallow depths with thicker liquids.


My take (borrowed from authors): “children with shallow, intermittent penetration events
without associated aspiration are likely to be demonstrating clinically insignificant events. Such children are therefore not appropriate candidates for compensatory or alternative feeding strategies such as changes in mode of delivery (e.g., gastrostomy tube), alteration of flow rate, or modification of liquid viscosity, such as thickened feedings.”

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Endoscopically-Identified Incidental Appendicitis

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There are a lot of interesting recent case reports on the JPGN Reports website. A recent example includes the following:

Mostafavi et al report (JPGN Reports 2024; 5:511–513. Open Access! Endoscopic diagnosis of asymptomatic appendicitis in a pediatric patient) on the incidental diagnosis of appendicitis. A followup colonoscopy in a 14 year-old with ulcerative colitis identified purulent fluid from the appendiceal orifice after ileal intubation; subsequently, after MRI imaging, an appendectomy was performed. The appendicitis was thought to be unrelated to the ulcerative colitis.

Other examples of some recent JPGN case reports:

Efficacy and Safety of Odevixibat with Alagille Syndrome (ASSERT Trial)

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N Ovchinsky et al. The Lancet Gastroenterology & Hepatology, Volume 9, Issue 7, 632 – 645. Open Access! Efficacy and safety of odevixibat in patients with Alagille syndrome (ASSERT): a phase 3, double-blind, randomised, placebo-controlled trial

Methods: “The ASSERT study was a phase 3, double-blind, randomised, placebo-controlled trial that enrolled patients at 21 medical centres or hospitals in ten countries” with 52 patients (enrolled 2021-2022). “The primary efficacy endpoint was change in caregiver-reported scratching score (on the PRUCISION instrument; range 0–4) from baseline to weeks 21–24.” The treatment group received odevixibat 120 µg/kg per day.

Key findings:

  • There were improvements in both scratch scores and bile acid concentrations
  • There were improvements in sleep parameters including falling asleep and ability to sleep without a caregiver
  • Adverse events: diarrhea was reported in ten (29%) of 35 patients who received odevixibat and in one (6%) of 17 patients who received placebo; all cases were mild in severity and no cases of diarrhea led to treatment interruption or discontinuation

Scratch Scores:

Bile Acid Levels

Other points:

  • Overall, 50 (96%) of the 52 patients chose to enter the open-label extension study
  • The authors note that this is the first randomized placebo-controlled trial for Alagille syndrome
  • A direct comparison of odevixibat and maralixibat in patients with Alagille syndrome is complicated by differences in study design and endpoints across the their studies

My take (borrowed in part from authors): “As pruritus is a major driver of liver
transplantation in patients with Alagille syndrome, these results suggest that odevixibat could have the potential to delay or prevent liver transplantation”

Related blog posts:

Hollywood Beach, FL

Safety of JAK Inhibitors Compared to Anti-TNF Agents

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C Crist. GI & Hepatology News; 11/20/24: In IBD Patients, No Increased Risk for MACE Seen for JAK Inhibitors vs Anti-TNF

Background: There have been concerns that JAK inhibitors (JAKi), like tofacitinib (Xeljanz) and upadacitinib (Rinvoq) could increase the risk of major adverse cardiovascular events (MACE); as such, the FDA has placed warnings on these medications (see blog post: FDA Slaps Restrictions on JAK Inhibitors Over Serious Safety Risks).

An excerpt:

According to a study presented at the American College of Gastroenterology (ACG) 2024 Annual Scientific Meeting, .

Alsakarneh and colleagues conducted a retrospective cohort study using the TriNetX database to identify adult patients with IBD who were treated with JAKi or anti-TNF therapy after diagnosis. After matching patients in the JAKi cohort [n=3740] with patients in the anti-TNF cohort [n=3740], the research team looked for MACE and VTE within a year of medication initiation…

After excluding those with a history of a prior cardiovascular event, 57 patients (1.76%) in the JAKi cohort developed MACE, compared with 63 patients (1.94%) in the anti-TNF cohort. There weren’t significant differences between the groups in MACE (adjusted hazard ratio [aHR], 0.99) or VTE (aHR, 0.9).

Among patients aged ≥ 65, 25 patients (5.3%) in the JAKi cohort developed MACE, as compared with 30 patients (6.4%) in the anti-TNF cohort.

My take: Several studies now have not identified an increased risk of JAKi compared to other therapies for IBD. Perhaps, this will lead to a change in labeling by the FDA which has stated that JAKi should be used only in those with prior anti-TNF failure.

Related blog posts:

Museum of Illusions (Atlantic Station)
This “bulging squares” illusion has straight lines across and vertically when you are right in front of it.

Efficacy of Mirikizumab in Moderate-to-Severe Crohn’s Disease (VIVID-1 Study)

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M Ferrante et al. The Lancet 2024; https://doi.org/10.1016/S0140-6736(24)01762-8. Efficacy and safety of mirikizumab in patients with moderately-to-severely active Crohn’s disease: a phase 3, multicentre, randomised, double-blind, placebo-controlled and active-controlled, treat-through study

Methods: VIVID-1 was a global phase 3, randomized, double-blind, double-dummy, placebo-controlled and active-controlled, treat-through study which enrolled 1150 patients with moderate-to-severe Crohn’s disease. There were three treatment groups: mirikizumab group, ustekinumab group, and placebo group. In each group, 48-49%were considered “biologic-failures” including 45-46% who were anti-TNF failures.

Key findings:

Discussion points:

Early treatment effect: “Symptomatic improvement was evident as early as week 4 accompanied by a statistically significant reduction in high-sensitivity CRP and faecal calprotectin, and endoscopic response was seen at week 12.”

Compared to ustekinumab: “Mirikizumab reached non-inferiority versus ustekinumab for clinical remission by CDAI at week 52…mirikizumab showed statistically significantly greater improvements from baseline in fecal calprotectin and CRP compared to ustekinumab.
In addition, a greater percentage of patients reached the combination endpoint of endoscopic response and clinical remission by CDAI at week 52.”

Comparison across treatment trials: “. At week 52, 45∙4% of patients treated with mirikizumab met the endpoint of clinical remission by CDAI in the treat-through analysis with composite endpoint, 54∙1% met the endpoint in the treat-through analysis, and 64∙3% met the endpoint in the responder analysis. This example, with a range of nearly 20% percentage points depending on analysis type, shows the profound limitations in comparing
unadjusted outcomes across phase 3 trials.” The authors note other differences in trial design between VIVID-1 and SEQUENCE (risankizimab) and state “no conclusions on
relative efficacy can be drawn.”

My take: This study shows that mirikizumab is effective in adults with moderate-to-severe Crohn’s disease with and without prior biologic treatments. Pediatric studies are underway.

Case Study: Pediatric Emergency from Magnet Ingestion

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G Prasad, V Jain. N Engl J Med 2024;391: e48. Small-Bowel Obstruction and Intestinal Fistula from Accidental Ingestion of Magnets

Case presentation excerpt:

A previously healthy 18-month-old girl was brought to the emergency department with sudden-onset abdominal distention that had been preceded by 3 days of diarrhea and 1 day of vomiting…an emergency exploratory laparotomy was performed. An ileocecal fistula (Panel B, circle) created by the union of three magnetic beads was identified (arrow, cecum; asterisk, ileum), and dilated loops of bowel were noted. The bowel was repaired. The patient was discharged after five days.

My take: There are a lot kids admitted for multiple magnet ingestion. Even in well-appearing children, due to concerns for complications, they are often observed until progression of the magnets. However, it does seem that many do not advance well after working their way to the cecum.

Related blog posts:

Understanding Trichuriasis (Whipworm) in Young Children: A Case Study

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G Ding et al. N Engl J Med 2024;391: e34. DOI: 10.1056/NEJMicm2406623. Trichuriasis

Case report: A 2-year-old boy from a rural village in China was brought to the pediatric clinic with a 6-month history of diarrhea and poor weight gain. Laboratory studies showed iron-deficiency anemia, eosinophilia, and occult blood in the stool.

The worms, which were 3 to 4 cm in length, were identified as Trichuris trichiura — also known as human whipworm infection…Trichuriasis results from the ingestion of soil contaminated by whipworm eggs. Adult worms mature in the large intestine and affix themselves there by threading into the mucosa. Trichuriasis is usually asymptomatic but may result in diarrhea and growth retardation in cases of heavy infection, especially in young children. The child’s diarrhea resolved after treatment with albendazole.

CDC Link: Trichuriasis “The adult worms (approximately 4 cm in length) live in the cecum and ascending colon… The females begin to oviposit 60 to 70 days after infection. Female worms in the cecum shed between 3,000 and 20,000 eggs per day. The life span of the adults is about 1 year.”

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Dr. Neha Santucci: Management of DGBIs in the Post-Pandemic Era (Part 2)

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Recently, Dr. Neha Santucci gave our group an excellent update on disorders of gut-brain interaction.  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of her slides.

Key points:

  • Atlantis study showed that amitriptyline reduces IBS pain (Related blog post: Atlantis Study: Possibly Best Evidence That Tricyclics May Help Irritable Bowel)
  • Dr. Santucci reviewed the evidence for linaclotide, cyproheptadine, mirtazapine, prucalopride, and aprepitant. The latter was effective for CVS but not functional nausea.
  • Placebo has been shown to have some beneficial effects in DGBIs; this affects the results of clinical trials
  • Ginger may be beneficial for nausea
  • Intrapyloric botox has been associated with improvement in functional dyspepsia. Improvement did not correlated with gastric emptying
  • Percutaneous electrical nerve field stimulation (PENFS) is associated with improvement in multiple aspects of functional disorders including pain, nausea, somatization, sleep and anxiety.
  • The improvements in abdominal pain and functional disability with PENFS are still present at least 6-12 months afterwards
  • PENFS can be repeated and has similar effectiveness
  • PENFS can be used in children >8 yrs, can be used with other treatments (pharmacologic, psychologic, or dietary).
  • PENFS can be used as prophylaxis of CVS
Non-pharmacologic Treatments
Lancet Gastroenterol Hepatol 2017; 2: 727-737.

Related blog posts:

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