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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Sunrise at Spruce Point, Maine

Sunrise at Spruce Point, Maine

What’s Often Missing in Vegan Diets

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From NPR: Can A Vegan Diet Give You All You Need? German Nutritionists Say ‘Nein’

An excerpt:

“With a pure plant-based diet, it is difficult or impossible to attain an adequate supply of some nutrients,” states the German Nutrition Society’s new position on the vegan diet. “The most critical nutrient is B-12,” which is found in eggs and meat. The group says if you follow a vegan diet, you should take supplements to protect against deficiencies.

According to the German nutritionists, other “potentially critical nutrients” that may be a challenge to get in a vegan diet include omega-3s — found in fatty fish — as well as minerals such as calcium, iron, iodine, zinc and selenium. So the group recommends that vegans get advice from a nutrition counselor and be “regularly checked by a physician.” In addition, the society recommends against a vegan diet for pregnant women, women who are breast-feeding, children and adolescents…

“B-12 only comes from animal products,” says Cimperman. “It’s necessary for proper red blood cell formation, as well as normal neurological function.”

Many foods — including some breakfast cereals, as well as some nondairy creamers and milks — are fortified with B-12. So it’s possible to get all the nutrition you need this way, if you eat enough of these fortified foods regularly.

But to make sure you’re covering all your bases, “I would recommend [taking] a standard multivitamin,” Cimperman says. It’s a good insurance policy for vegans.

Pat O'Brien's Patio, New Orleans

Pat O’Brien’s Patio, New Orleans

 

Need Liver, Will Travel

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A recent commentary (G Cholankeril et al. Gastroenterol 2016; 151: 382-86) provides a succinct summary regarding the trends in liver transplantation multiple listing and its implications on notions of utility and justice.

Key points:

  • UNOS was established based on Congressional act in 1984: 42 U.S.C. § 274.  The principles of “justice” and “utility” were to be key in governing an equitable  allocation system.
  • Due to allocation inequities, however, some prospective liver transplant candidates seek multiple listings. From 2010 to 2015, 1082 of 70,080 (2%) liver transplant candidates on the waitlist had multiple listings. During that same time frame, 862 (multiply-listed) of 32,431(total transplants) (3%) underwent liver transplantation.
  • Candidates who migrated had “shorter waiting time before liver transplantation and higher probability of receiving an organ (multiple listings 80% versus primary listing 46%; P<.001)”
  • Multiple listing candidates had lower severity of illness and lower MELD score at time of liver transplantation (multiple listings 25 versus primary listing 28; P<.001)

Regional distribution:

  • 46% of the 862 multiply-listed patients who underwent liver transplantation received their organ in UNOS region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico)
  • 67% of those 862 emigrated away from Regions 2, 5, and 9 -which have the longest waiting times. Figure 1 shows the 11 Regions.  Region 2 & 9 include New York, New Jersey, Delaware, West Virginia, Maryland, and Pennsylvania.  Region 9 includes California, Nevada, Arizona, New Mexico, and Utah.

My take: Under the current system, liver transplant candidates capable of travelling/multiple listing, are rewarded with earlier liver transplantation & higher likelihood of receiving a liver transplant.  Thus, until inequities in organ distribution are better addressed, patient’s may need to consider telling their transplant team: ‘Need Liver, Will Travel’

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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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Molecular Panels for Identifying Etiology with Acute GI Symptoms

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A recent study (MR Nicholson et al. J Pediatr 2016; 176; 50-6) examined the use of multiplex molecular testing to determine the etiology of acute gastroenteritis in children.  It is interesting that little has been published about this increasingly common practice of sending a 12 to 15 panel PCR assay when faced with acute GI symptoms, mainly diarrhea.

This study was a prospective population-based study of children <6 years with acute gastroenteritis (2008-2011).

Findings:

  • 70.4 % (152/216) samples tested positive for a pathogen, with norovirus the most frequent (n=78, 36.1%). Clostridium difficile was next at 16.2% (n=35).
  • 22.7% (n=49) tested positive for more than 1 pathogen including 25 with a C difficile detection
  • In this study, the authors noted C difficile colonization in 8% of healthy children aged 0-51 months and in 14% of children <12 months

Implications of this study and this technology:

  • Prior to this technology, traditional approaches typically identified less than 15% of the cases of acute gastroenteritis.  Thus, this new technology increases the likelihood of a definitive diagnosis.
  • Multiple pathogens, particularly with C difficile, illustrate how this new technology will present some difficulties with interpretation.  C difficile has very high rates of colonization in infants (anywhere from 25-80%) without AGE symptoms and lower rates of colonization in toddlers.  High colonization/detection has been noted in inflammatory bowel disease patients (17%) and pediatric oncology patients (30-55%).
  • For C difficile, molecular testing is much less likely to correlate with clinical disease than toxin-based assays. “A recent study in adults found that virtually all CDI-related complications occurred in patients with a positive toxin immunoassay.” (JAMA Intern Med 2015; 175: 1792-801)

My take: These panels are helpful in identifying infectious etiologies of AGE and may help prevent unnecessary endoscopic procedures.  Due to their limitations, careful selection of which patients to test and cautious interpretation of the results are needed.

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Sunset from Bar Harbor, ME

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