Understanding New Risks for Clinicians Under Utah’s Health Law

Posted on February 20, 2025 by gutsandgrowth

K Underhill, KM Nelson. NEJM 2025; 392: 523-525. Legal Threats to Clinicians and Patients

An excerpt:

In January 2023, Utah added a section to its Health Care Malpractice Act (see box). The change was part of Senate Bill 16, a larger package of laws targeting gender-affirming care. The new Malpractice Act language specifies that for “hormonal transgender treatment” and surgery on “sex characteristics,” patients treated when they are minors have the option to disaffirm — revoke — their consent before 25 years of age...

Although patients consent at the time of treatment, Utah’s new law enables them to withdraw their informed consent retroactively, even years later, and pursue legal claims based on being treated without consent...

Utah’s new law places a tremendous burden on clinicians…

It is unrealistic and unreasonable to expect clinicians to predict which patients may later reverse their consent to treatment. Clinicians who undertake these predictions will make mistakes in both directions — either failing to predict regrets (which are rare²) or, more likely, erroneously denying medically necessary care to minors who would benefit from it…

Allowing minors to recant their consent undermines the efforts that many states have made to strengthen minors’ independent access to care for sexual health, mental health, and substance use. Laws that have a chilling effect on medical services can also interfere with the pipeline of clinicians who have the training and experience to deliver care, reducing access for all patients…

Utah’s law is more worrisome, however, as a potential harbinger of things to come…As legislators develop and test state laws interfering with gender-affirming care, the same strategies become available for other politically contested forms of health care.

My take: Allowing individuals to recant consent for treatment years later will undermine access to all types of health care.

Related article: DG Aaron, C Konnoth. NEJM 2025; 392: 526-528. This article explains the flawed “Cass Review” which was a a 388-page report commissioned by England’s National Health Service (NHS) concluded that “there is not a reliable evidence base upon which to make clinical decisions” regarding gender-affirming care (GAC).

“Our concern here is that the Review transgresses medical law, policy, and practice, which puts it at odds with all mainstream U.S. expert guidelines. The report deviates from pharmaceutical regulatory standards in the United Kingdom. And if it had been published in the United States, where it has been invoked frequently, it would have violated federal law because the authors failed to adhere to legal requirements protecting the integrity of the scientific process..³ The Review calls for evidentiary standards for GAC that are not applied elsewhere in pediatric medicine.“

Managing Drug-Induced Acne in IBD: A Guide for Gastroenterologists

Posted on February 19, 2025 by gutsandgrowth

MJ Temido et al. Am J Gastroenterol 2025;120:125–134. Drug-Induced Acne in Inflammatory Bowel Disease: A Practical Guide for the Gastroenterologist

“Corticosteroids and Janus kinase inhibitors (JAKi) are commonly used for the treatment of inflammatory bowel disease (IBD) and are known to aggravate a prior tendency to acne or trigger the development of new acneiform eruptions. Both randomized controlled trials and real-world studies have identified acne as one of the most common treatment-emergent adverse events in JAKi… This review examines the characteristics of drug-induced acne in IBD treatments, provides a practical guide for gastroenterologists to manage mild-to-moderate occurrences, and highlights when to seek specialist dermatology advice.”

My take: This is a helpful review of acne management in the setting of IBD.

ACG 2025 Guidelines for Eosinophilic Esophagitis

Posted on February 18, 2025 by gutsandgrowth

ES Dellon et al. The American Journal of Gastroenterology 2025;120(1):p 31-59. Open Access! ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis or bit.ly/acg-eoe-2025.

Related blog posts:

The Future of Medicine: AI’s Role vs Human Judgment

Posted on February 17, 2025 by gutsandgrowth

Pranav Rajpurkar and Eric J. Topol. NY Times Feb 2, 2025: The Robot Doctor Will See You Now

An excerpt:

“The medical community largely anticipated that combining the abilities of doctors and A.I. would be the best of both worlds, leading to more accurate diagnoses and more efficient care…That assumption might prove to be incorrect. A growing body of research suggests that A.I. is outperforming doctors, even when they use it as a tool…

Simply giving physicians A.I. tools and expecting automatic improvements doesn’t work. Physicians aren’t completely comfortable with A.I. and still doubt its utility, even if it could demonstrably improve patient care…

Medical training will need to adapt to help doctors understand not just how to use A.I., but when to rely on it and when to trust their own judgment…But the promise for patients is obvious: fewer bottlenecks, shorter waits and potentially better outcomes. For doctors, there’s potential for A.I. to alleviate the routine burdens so that health care might become more accurate, efficient and — paradoxically — more human.”

In a related Substack article (open access: Opinion | When A.I. Alone Outperforms the Human-A.I. Partnership), Dr. Topol and Dr. Rajpurkar list several studies showing that AI alone may be better than physicians with AI under some circumstances:

My take (borrowed from the authors): “The future of medicine won’t be shaped by a simple choice between human or artificial intelligence, but by our ability to understand their respective strengths and limitations, and to orchestrate their collaboration in ways that truly benefit patient care.”

Related blog posts:

Early Management of Caustic Ingestions in Children

Posted on February 16, 2025 by gutsandgrowth

Briefly noted: ES Gordon, E Barfiedl, BD Gold. J Pediatr Gastroenterol Nutr. 2025;1–12. Early management of acute caustic ingestion in pediatrics

Congratulations to my partner Dr. Gold and his coauthors.

Key points:

In symptomatic patients, EGD within 24‐hours is most optimal to evaluate the degree of injury and for prognostication
Further research is needed on the use of steroids, antibiotics, and acid‐suppression
Early placement of NGT under direct visualization during endoscopy may help prevent stricture formation and allow for enteral nutrition in cases of significant injury (Zargar grade 2b and above)

Related blog posts:

Henoch-Schonlein Purpura Findings in the Duodenum

Posted on February 14, 2025 by gutsandgrowth

L Torelli et al. J Pediatr Gastroenterol Nutr. 2025;80:242–244. Gastrointestinal involvement in Henoch–Schönlein purpura

A 10 yo underwent an EGD due to nausea, melena and abnormal CT (showing thickening in the the duodenum and first jejunal loop. Two days later, she developed a cutaneous rash appeared on her legs, buttocks, and elbows.

Mucosal congestion with shallow ulcerations in the descending duodenum.

Related blog posts:

PICNIC Trial Results: Can Antimicrobial PICC Lines Reduce Central Line Infections?

Posted on February 13, 2025 by gutsandgrowth

AJ Ullman et al. NEJM 2025; 392: 161-172. A Comparison of Peripherally Inserted Central Catheter Materials

Background: Advances in material technology have introduced coatings and altered surfaces with purported antithrombotic and antiinfective properties to be used with polyurethane PICCs…A Cochrane review¹¹ that included data from 42 randomized, controlled trials and 10,405 patients concluded that there was high-quality evidence showing that antimicrobial central venous catheters reduced the risk of bloodstream infections (risk ratio, 0.62)…On the basis of this indication, chlorhexidine-coated PICCs have been introduced to clinical practice… We conducted the Peripherally Inserted Central Catheter Innovation to Reduce Infections and Clots (PICNIC) trial to test the hypothesis that the risk of device failure due to complications would be lower with two technological innovations (hydrophobic and chlorhexidine PICCs) than with standard polyurethane PICCs.”

Methods: The authors conducted a randomized, controlled, superiority trial in three Australian tertiary hospitals. Adults and children (n=1098) who were referred for PICC placement were assigned in a 1:1:1 ratio to receive a hydrophobic or chlorhexidine PICC or a standard polyurethane PICC and were followed for 8 weeks

Key findings:

Device failure occurred in 21 of 358 participants (5.9%) in the hydrophobic group, in 36 of 363 (9.9%) in the chlorhexidine group, and in 22 of 359 (6.1%) in the standard-polyurethane group
Complications from any cause during the period of PICC placement occurred in 77 participants (21.5%) in the hydrophobic group, in 140 (38.6%) in the chlorhexidine group, and in 78 (21.7%) in the standard-polyurethane group (odds ratio, hydrophobic vs. standard polyurethane, 0.99)

Discussion point: This trial was conducted during the COVID epidemic which may have altered the results due to a focus of mitigating infectious exposures.

My take (borrowed from authos): “The risk of device failure due to noninfectious or infectious complications was not lower with hydrophobic or chlorhexidine PICCs than with standard polyurethane PICCs.”

Related blog posts:

The Alarming Impact of Microplastics on Human Health

Posted on February 12, 2025 by gutsandgrowth

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 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

Posted on February 11, 2025 by gutsandgrowth

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 pollution^5,6 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.

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A ‘good demon’ at The Grand Palace in Bangkok

Understanding Alpha-Gal Syndrome: Key Symptoms and Findings

Posted on February 10, 2025 by gutsandgrowth

E Lesmana et al. Clin Gastroenterol Hepatol 2025; 23: 69-78. Open Access! Clinical Presentation and Outcomes of Alpha-Gal Syndrome

This was a retrospective chart review of patients who underwent serological testing for suspected Alpha-Gal Syndrome (AGS) between 2014 and 2023 at Mayo Clinic. Of 1260 patients who underwent testing,124 tested positive for AGS. –matched with 380 seronegative control subjects. 40 patients had long-term followup data available

Key findings:

AGS patients reported a higher frequency of tick bites (odds ratio [OR], 26.0)
AGS patients reported a higher prevalence of urticaria (56% vs 37%; P = .0008)
A total of 47% experienced at least 1 GI symptom, such as diarrhea, nausea, vomiting, abdominal pain, abdominal cramps, bloating, heartburn, and constipation, in descending order of frequency
11% of AGS patients presented solely with GI symptoms
After institution of red meat restriction, 22 of 40 were asymptomatic at followup, 14 of 40 were improved, and 4 of 40 reported no improvement. 7 of the asymptomatic group were able to resume a diet without restrictions.

Discussion point:

“Symptom onset in AGS typically occurs more than 4 hours after allergen exposure, with studies emphasizing a tight association with delayed reactions within the 3- to 6-hour range.”

My take: This study provides some more granular data on Alpha-gal and highlights the importance of asking about tick bites and urticaria in patients with possible AGS.