This May, Georgia Gov. Brian Kemp, a Republican, signed a law that boosts criminal penalties for assaults against hospital workers and allows health care facilities in the state to create independent police forces. The law is a response to that testimony as well as hospital lobbying and data documenting a rise in violence against health care workers. In enacting the law, Georgia joined other states attempting to reverse a rise in violence over the last several years through stiffer criminal penalties and enhanced law enforcement…
Health care workers are five times as likely to experience violence as employees in other industries, according to federal data. On May 3, the day after Kemp signed the Safer Hospitals Act into law, a person opened fire in a midtown Atlanta medical office, killing one woman and injuring four others, including workers at the medical practice…
Health centers say they are better able to retain workers and improve patient care when they can reduce the number of violent incidents,
In this study, sixty-six of 339 (19%) HSCT needed an “endoscopy episode.” Key findings:
Four of 119 (3%) endoscopies had complications: septic shock (1), duodenal hematoma (1), GI bleeding (1), and colonic perforation (1).
Fifty-seven of 62 (92%) endoscopy episodes were “clinically useful,” and 41 of 62 (66%) had a change in immunosuppressive treatment.
My take: Endoscopy provides useful information in children following HSCT. However, the consent needs to reflect the much higher risk in this population.
Liver biopsy risk in children Fox VL, Cohen MB, Whitington PF, Colletti RB. Outpatient liver biopsy in children (n=450). J Pediatr Gastroenterol Nutr 1996;23:213-6. High mortality rate reported, primarily in bone marrow transplant patients
In previous posts, this blog (see below) has examined the potential bias of studies reporting better outcomes in breastfed infants along with issues of maternal guilt. A recent commentary explores the issue of feeling guilty when breastfeeding does not go well.
AJ Kennedy. NEJM 2023; 388:1447-1449. Breast or Bottle — The Illusion of Choice
Some excerpts:
Only about 25% of women in the United States exclusively breast-feed for the recommended period.2 After my struggles, these statistics seem realistic to me, but before I went through it myself, I had no concept of how hard it could be…
Around the time my son turned 6 months old…my primary care doctor… gave me the courage to start taking medication and to stop breast-feeding that very week. Though the guilt about stopping has never fully gone away, the joy and happiness in my life quickly returned…
Even after I’ve told them that I might not choose to breast-feed this time around [with 2nd child], multiple doctors have “reminded” me that breast milk has been shown to carry Covid-19 antibodies — yet another reason to feel ashamed if I choose not to breast-feed…I am hopeful that this time around I can embrace formula feeding more quickly if that is the path that works best for me and my baby,…
I encourage the AAP and other national health organizations to consider how their statements on exclusive breast-feeding are perceived by the public. If 75% of us are not meeting this goal [6 months of exclusive breastfeeding], a more patient-centered approach and recommendation is needed.
My take: Breastfeeding does not work for everyone. Parents often feel guilty about perceived short-comings and we need to find a balance in encouraging breastfeeding but acknowledging that formula feeding is a good alternative.
Related blog posts:
Feeling Guilty about Stopping Breastfeeding?Geoff Der, a statistician at the University of Glasgow who has worked with the same data in previous studies, said that the findings in the present study were robust and the authors’ method for eliminating selection bias was powerful…“In a society with a clean water supply and modern formulas,” he said, “a woman who isn’t able to breast-feed shouldn’t be feeling guilty, and the likelihood that there’s any harm to the baby is pretty slim.”
Methods: The study used data from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study of children born in 20 US cities. Study outcomes were “based on age-15 interviews with the focal children and their caregivers with sample sizes ranging from 2088 to 2327 across outcomes. The relationship between CPS contact and child wellbeing was estimated using the propensity score method of inverse probability of treatment weighting.”
Key findings:
“Despite a federal mandate to improve child wellbeing, we found no evidence that contact with the child welfare system improves child outcomes. Rather, CPS contact was associated with worse mental health and developmental outcomes” including associated increases in smoking (88% increase), in being expelled from school (18% increase), in depression (7.5% increase, and in anxiety (6.9% increase).
My take: While protecting children and reporting abuse/neglect are mandated, it is not clear that involvement of CPS results in better outcomes.
E Tobin-Tyler. NEJM 2023; 388: 1345-1347. Courts’ Disregard for Women’s Health and Safety — Intimate Partner Violence, Firearms, and “History and Tradition”
A few excerpts:
In June 2022, the Supreme Court issued its opinion in New York State Rifle & Pistol Association v. Bruen, which left the door open for constitutional challenges to virtually any state or federal firearm restriction. One of these restrictions is a federal law passed in 1994 as part of the Violence Against Women Act (VAWA) that makes it unlawful for people subject to certain domestic violence–related restraining orders to possess a firearm or ammunition for the duration of the order.
Writing for the majority in Bruen, Justice Clarence Thomas struck down New York’s restrictions on who may carry a firearm in public. In doing so, he declared that a government arguing in support of a restriction on firearm possession has the burden of showing that its regulation “is consistent with the Nation’s historical tradition of firearm regulation.”..
On the heels of the Supreme Court’s decision in Bruen, a federal district judge on November 10, 2022, held in United States v. Perez-Gallan that the VAWA’s restriction on firearm possession by people subject to restraining orders is unconstitutional…
Searching for relevant laws from the 18th and 19th centuries to justify current laws protecting people who have experienced IPV (intimate partner violence) obscures the fact that married women weren’t even considered legal subjects until the late 19th century. Instead, they were understood to be the property of their husbands.1 Black women who were enslaved, married or not, had no legal rights. “Wife beating” did not become illegal in some states until the late 19th century…
In Rahimi, the court applied Bruen’s “history and tradition” analysis to a case involving a person who not only was subject to a restraining order because he had allegedly assaulted his ex-girlfriend, but also had been involved in incidents in which he had fired a gun at people and at a constable’s car…The court determined that under Bruen’s analysis, there is no reason to consider the potential consequences for people experiencing IPV of permitting their abusers to possess guns.
My take: Deciding gun ownership laws solely on the basis of ‘history and tradition’ is incredibly stupid. Research shows that restriction of access to firearms by domestic abusers results in lower rates of gun deaths. This supreme court will allow anyone to possess a firearm, except those in their vicinity.
Related article: The Hill (5/11/23): Federal judge rules adults ages 18-20 cannot be blocked from purchasing handguns. “A federal judge in Virginia has ruled that federal laws prohibiting 18-to-20-year-olds from getting handguns at federally licensed firearms dealers are unconstitutional…The judge concluded that the Second Amendment’s “right of the people to keep and bear Arms” applies to people in that age group. “Because the statutes and regulations in question are not consistent with our Nation’s history and tradition, they, therefore, cannot stand,” Payne wrote.
Also, I want to give a shout out to Ajay Kaul (who completed his training in Cincy one year after I did) and his recent Bowel Sounds Podcast. Ajay is a terrific person. This was a good review on Achalasia and a reminder of the improvements in motility testing. A good clinical pearl was to ask anesthesiology to intubate patients with suspected achalasia to protect their airway.
My 35 years living with two different donor hearts (I was 25 at the time of the first transplant) — finishing law school, getting married, becoming a mother and writing two books — has felt like a quest to outlast a limited life expectancy. With compulsive compliance, I adhered to the strictest interpretation of transplant protocols. I honored my gifts of life with self-discipline: not one pat of butter; not one sip of alcohol; running mile after mile hoping to stave off vasculopathy, an insidious artery disease that often besets transplanted hearts within about 10 years...
But now I lower my chin and whisper the words malignant … metastatic … lungs … terminal. It is the end of the road for my heart and me…
Organ transplantation is mired in stagnant science and antiquated, imprecise medicine that fails patients and organ donors. And I understand the irony of an incredibly successful and fortunate two-time heart transplant recipient making this case, but my longevity also provides me with a unique vantage point...
Over the last almost four decades a toxic triad of immunosuppressive medicines — calcineurin inhibitors, antimetabolites, steroids — has remained essentially the same with limited exceptions. These transplant drugs… cause secondary diseases and dangerous conditions, including diabetes, uncontrollable high blood pressure, kidney damage and failure, serious infections and cancers...
Transplantation is no different from lifelong illnesses that need newer, safer, more effective medicines. Improvements in drug regimens are needed for lupus, Parkinson’s and a host of others. The key difference is that only in transplantation are patients expected to see their disease state as a “miracle.” …But this narrative discourages transplant recipients from talking freely about the real problems we face and the compromising and life-threatening side effects of the medicines we must take.
This “gratitude paradox,” as I’ve come to think of it, can manifest itself throughout the transplant professional communities as well. Without vigorous pushback, hospitals and physicians have been allowed to set an embarrassingly low bar for achievement.
My take: Though organ transplantation has extended lives, this touching first-hand account outlines important obstacles/challenges that transplant medicine continues to face. For pediatric providers, the article is even more sobering as good outcomes need to last even longer.
From Roger Mills:The procedure is not a cure, but a trade. Patient and physician agree to manage a short-term life-threatening illness by substituting a long-term life-threatening illness — immunosuppression…I take issue only with her understandably harsh words about “stagnant science and antiquated, imprecise medicine that fails patients and organ donors.” Early on, many thought the immune response would yield to targeted therapies using relatively nontoxic small molecules. But experience has taught us that managing the immune response is like peeling back layers of an onion. There are more layers than we ever dreamed of, and each one brings more tears.
From Judith Hale: Here is another story: I’m a healthy, happy 74-year-old who received a heart transplant at the age of 56. I live a normal life: I walk at least two miles a day, cross-country ski in the winter, and tend my garden the rest of the year. I’m not on any special diet: I eat butter and drink an occasional glass of wine with dinner. I have virtually no side effects from the medications.I couldn’t be more grateful for the advances in medical science that have, so far, given me 18 healthy years of life.
From Ronald Kalen: In fact, the advances of transplant medicine have been remarkable given the complexity of the immune system. It is not a trivial problem for research. Dedicated scientists have spent careers in prolonging the life of the transplanted organ, as well as the life of the person receiving that organ, and are as aware as Ms. Silverstein of the “deeply entrenched problems” that remain. Their research is not “mired in stagnant science and antiquated, imprecise medicine that fails patients and organ donors.”
In this prospective study (n=198), the authors examined lipid profile changes at week 10 in patients starting IBD medications: corticosteroids, thiopurines, methotrexate, anti-TNF-α agents, vedolizumab, ustekinumab, and tofacitinib.
Key findings:
Relative increases in total cholesterol, HDL-c, and LDL-c were significant after prednisone (+26%, +31%, +12%) and tofacitinib therapy (+20%, +25%, +26%), respectively
No changes were observed in other drug classes
Findings did not correlate with calprotectin or CRP values, likely indicating a direct medication effect
My take: Recent studies have provided some reassurance regarding tofacitinib and the risk of major adverse cardiovascular events (MACEs) (see posts below). Nevertheless, it seems prudent to monitor lipids in patients receiving JAK inhibitors.
The Oro Valley/Tucson Loop shared use bike path extends over 130 car free miles throughout unincorporated Pima County, Marana, Oro Valley, and Tucson. We managed a 40 mile bike trip.
This article is an excellent review of Wilson disease (WD). It reviews clinical manifestations, disorders with overlapping findings and recommendations for diagnosis/management. “This executive summary provides a condensed overview, including the clinical algorithms, tables, and full complement of guidance statements.” Though this ‘summary’ is a lengthy publication, “the full Guidance document with comprehensive text, complete references, and supplementary materials (“A Multidisciplinary Approach to the Diagnosis and Management of Wilson Disease: 2022 Practice Guidance on Wilson Disease from the American Association for the Study of Liver Diseases”) is available on the American Association for the Study of Liver Diseases (AASLD) website (https://doi.org/10.1002/hep.32801).”
Some of the recommendations:
The Leipzig score for diagnosis of Wilson disease may aid in diagnosis
My take: This is a useful guidance and the tables/algorithms should help with both diagnosis and treatment adjustment. In my limited experience with WD, I have had a lot of difficulty with adherence to treatment in the small sample of patients under my care.
In this multicenter retrospective cohort (n=42), the authors examined the efficacy and safety of fecal microbiota transplantation (FMT) in immunocompromised (IC) children with Clostridioides difficile infection (CDI). Etiology of IC included: solid organ transplantation (18, 43%), malignancy (12, 28%), primary immunodeficiency (10, 24%), or other chronic conditions (2, 5%)
Key findings:
23 (55%) of FMT was delivered via colonoscopy, 17 (40%) were delivered via enteric tube, and 2 (5%) via capsule
Success rate was 79% after first FMT and 86% after 1 or more FMT.
There were serious adverse events (SAEs) in 13 out of 42 (31%) patients; 4 (9.5%) of which were likely treatment-related (all patients recovered). These events included cecal perforation, aspiration pneumonitis, diarrhea and fever. Given retrospective design of study, AEs were likely underreported
My take: Though there are the potential for significant adverse effects, FMT is effective in a high percentage of immunocompromised children with CDI.
