POEM vs Surgical Myotomy for Achalasia -Randomized Trial

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A recent randomized trial (YB Werner et al. NEJM 2019; 381: 2219-29) compared peroral endoscopic myotomy (POEM) and laparoscopic Heller’s myotomy (LHM) for idiopathic achalasia in 221 patients.

Key findings:

  • Clinical success at 2-year followup was observed in 83% in the POEM group and 82% in the LHM group. Clinical success was defined as Eckardt score of 3 or less without the use of additional treatments.
  • Serious adverse events occurred in 2.7% of POEM group and 7.3% of LHM group
  • At 3 months following procedure, 57% of the POEM group and 20% of LHM group had reflux esophagitis; the rates were 44% and 29% at 2 years, respectively.

My take: This study demonstrates similar outcomes between POEM and LHM.  As a practical matter, local expertise is likely a crucial component in choosing between these options.

Related blog posts:

Another Study Questions the Efficacy of Drip Feeds for Reflux

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Several years ago, a small study showed that bolus feeds were as well-tolerated in premature infants as drip feeds: Which is Safer -Drip Feeds of Bolus Feeds for Preterm Infants?

Now, a retrospective study (LB Mahoney, E Liu, R Rosen. JPGN 2019; 69: 678-81) found no difference in the rate of reflux in 18 children who were with gastrostomy-tube dependent.

In this study, 24-hour multichannel intraluminal impedance with pH monitoring (MII-pH) examine reflux events in children receiving exclusive enteral nutrition with a combination of daytime bolus feeds and overnight continuous feeds; each patient served as their own control.  this included 6 with prior fundoplication.

Key finding:

  • There was no difference in rate of reflux events when comparing bolus feedings and drip (aka continuous) feedings.

The limitations in this study include the small sample size and retrospective design.  The authors estimate that to achieve adequate power (80% power) to detect a risk ratio of 1.2 would require 211 patients.

My take: This study and other small studies challenge the assumption that drip feedings are safer. Though, until a larger prospective study is performed, we will not know.

Quebec City

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Outcomes of Liver Transplantation in Small Infants

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A recent study (H Yamamoto et al. Liver Transplantation 2019; 25: 1561-70) provides data on the outcomes of infants who underwent liver transplantation (LT) in the United Kingdom (King’s College Hospital).

A total of 64 infants underwent LT (1989-2014) at a single institution. The authors compared “extra-small” (XS) infants in the first 3 months of life to “small” (S) who were 3-6 months of age.

Key findings:

  • Acute liver failure was the main indication for LT in the XS group (n=31, 84%) compared to the S group (7, 26%)
  • Hepatic artery thrombosis and portal vein thrombosis were similar in both groups: 5.4% and 10.8% in the XS and 7.4% and 11.1% in the S group
  • Bilary stricture and leakage were similar: 5.4% and 2.7% in the XS and 3.7% and 3.7% in the S group
  • 1-, 5-, and 10-year survivals were 70.3%, 70.3% and 70.3% in the XS group and 92.6%, 88.9%, and 88.9% in the S group (not statistically significant)

Related blog posts:

Quebec City, Frontenac Hotel and Boardwalk (early in the day)

How Benign Are Juvenile Polyps?

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A recent retrospective study (N Ibrahimi et al. JPGN 2019; 69: 668-72) reviewed juvenile polyp characteristics over a 14 year period (2003-17) from 213 pediatric subjects who underwent 326 procedures.  The authors state their review was intended for nonsyndromic juvenile polyps, though 23 of the patients had ≥5 polyps (which is incongruous with their presented methods of including children with less than 5 polyps).

Key findings:

  • The authors state that polyp recurrence rates on repeat colonoscopy were 1.5% if one polyp, 19.2% if 2-4 polyps, and 82.6% if 5-10 polyps
  • Juvenile polyps harbored adenomatous changes in 26 (12%) of patients
  • The presence of adenomatous changes did not correlate with polyp number; however, a polyp on the right-sided was more likely to harbor adenomatous changes

It is possible that some of the ‘recurrent’ polyps were missed polyps, as polyps can be easily overlooked.  I had a recent experience of removing numerous polyps (14) from a child recently and some were identified in part due repeated visualization of several colonic segments.  The recent ESPGHAN position paper is useful in children with multiple polyps; their recommendations include: In a child with a single JP, a repeat colonoscopy is not routinely required. (Weak recommendation, very low quality of evidence).

My take: This report is notable for the following:

  1. a fairly high rate of adenomatous changes in juvenile polyps.
  2. a high recurrence rate for children with multiple polyps

Related blog posts:

Quebec City

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Healthcare: “Where the Frauds Are Legal”

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A recent NY Times commentary: “Where the Frauds Are Legal” details another group of problems with health care economics.  These problems are on top of a long list of other problems which at their core relate to lack of price transparency/hidden charges and excessive charges for some services.

Here’s an excerpt:

Much of what we accept as legal in medical billing would be regarded as fraud in any other sector…

Medical Swag…Companies are permitted by insurers to bill for “durable medical equipment,” stuff you receive for home use when you’re in the hospital or doctors’ office. That yields some familiar marked-up charges, like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care…

The Cover Charge…Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of “readiness.”…

Impostor Billing…We received bills from doctors my husband never met… for bedside treatment from people who never came anywhere near the bed to deliver the care…

The Drive-By…There was no significant health service given. Just an appearance and some boxes checked on a form. It’s a phenomenon called drive-by doctoring.

The Enforced Upgrade…[like meeting] in the emergency room [because clinic is closed]

Why do insurers pay? Partly because insurers have no way to know whether you got a particular item or service. But also because it’s not worth their time to investigate the millions of medical interactions they write checks for each day. Despite the advertised concern about your well-being, as one benefits manager enlightened me: They’re “too big to care about you.”…these are all everyday, normal experiences in today’s health care system, and they may be perfectly legal. If we want to tame the costs in our $3 trillion health system, we’ve got to rein in this behavior, which is fraud by any other name.

My take: I find it troubling to be a cog in a system that has such devious billing practices.  This particularly relates to my interactions when providing hospital-based care.  In our office, we have at least some measure of control and we can offer services like outpatient endoscopy at one-third of the cost compared to hospital-based endoscopy; similarly, our outpatient infusions are much more cost-effective than hospital-based infusions.

In terms of the health care system, my expectation is that there is not a strong enough incentive or empowerment for physicians to tackle rising health care costs (& low value care) and as such the industry will face a reckoning from outside forces.

Related blog posts:

Marketing of Insulin Explains a Lot About Our Health Care System

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A recent commentary (M Fralick, AS Kesselheim. NEJM 2019; 381: 1793-5) describes the U.S. Insulin Crisis.

Background: 

  • In 1922, insulin was first injected into a 14-year-old boy with severe type 1 diabetes mellitus (T1DM). Prior to this, T1DM had been considered a universally fatal disease
  • Frederick Banting, John Macleod, and members or their team that discovered insulin sold their patent for $1 to assure it could be widely affordable
  • “U.S. law allows pharmaceutical manufacturers to price their products at whatever level they believe the market will bear and to raise prices over time without limit”
  • “Direct competition in the insulin market is lacking”
  • Since insulin is a biologic drug, this necessitates “additional testing beyond what is usually required for generic drugs before approval by the” FDA.

Current Situation:

  • A carton of insulin that sells for $300 in the U.S. could be purchased in Canada for $20 (in U.S. dollars)
  • Nearly 100 years after the development of insulin, “insulin is inaccessible to thousands of Americans because of its high cost.”

My take: Why does insulin cost 15 times more in the U.S. than Canada?   These excess costs with insulin are occurring despite a great deal scrutiny; unfortunately, U.S. consumers are paying extra for a wide range of pharmaceuticals.  Going from the Nobel discovery of insulin to our current state is a clear indication of the need to reform of our healthcare system.

Related blog posts:

Mural in Quebec City: La Fresque des Québécois

More Frequent Foreign Body Ingestions

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A recent retrospective study (D Orsagh-Yentis) Pediatrics 2019; 143: pii:320181988) examined children <6 years of age (n=759,054) and presentation to an emergency department in the U.S. for a foreign body ingestion (FBI) from 1995-2015. This study was reviewed at our recent national meeting by David Brumbaugh -related blog post: #NASPGHAN19 Postgraduate Course (Part 1) (Slides below).

Key findings:

  • FBI rates increased from 9.5 to 18 per 10,000 during the 20 year study period
  • Coins accounted for 61.7% of FBI
  • Most children (89.7%) were able to be discharged after their suspected ingestion
  • Battery ingestion represented 0.14% of all ingestions in 1995  to 8.4% in 2015

Related blog posts:

 

Hidden Costs of Medical Schools

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From NY Times: ‘I Have a Ph.D. in Not Having Money’

An excerpt:

Medical school is expensive for everyone. But for low-income students, the hidden costs can be prohibitive…

American medical schools are the training grounds for a white-collar, high-income industry, but they select their students from predominantly high-income, and typically white, households…Between 1988 and 2017, more than three-quarters of American medical school students came from affluent households…

Students from low-income families who choose to apply to medical school find the path lined with financial obstacles. The application phase entails MCAT registration ($315) and preparation, application fees ($170 for the first school and $40 for each additional one), travel and attire for interviews (on average more than $200 per school). After enrollment, students are expected to purchase equipment and study aids. Each year brings new certification tests, with registration fees running upward of $600.

Aspiring doctors know that tuition is costly; the median educational debt held by medical school graduates in 2018 was $200,000, up 4 percent from the previous year. But less advertised are all the hidden costs of a medical education.