The following link (from Jeff Lewis’ twitter feed) provides a terrific review and summary of the effectiveness of vaccines, the debunked myths, and how “anti-vax” movement hurt not just themselves but others too.
Vaccines Work, Here Are the Facts -Cartoon
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A concise review (NJEM 2014; 371: 2526-28) quickly describes the latest science on microbiota, antibiotics, and obesity chiefly by summarizing the work of Cox LM et al (Cell 2014; 158: 705-21).
Key points:
Take-home message: Understanding the microbes in our bodies may lead to much more than curing intestinal infections and intestinal maladies.
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Dr. Oz, “America’s doctor,” while wildly popular, continues to receive bad press regarding the accuracy of his advice. Recent Washington Post link: “Half of Dr. Oz’s Medical Advice is Baseless or Wrong” (Thanks to Eric Benchimol’s twitter feed for this link)
An excerpt:
The British Medical Journal, which on Wednesday published a study analyzing Oz’s claims along with those made on another medical talk show. What they found wasn’t reassuring. The researchers, led by Christina Korownyk of the University of Alberta, charged medical research either didn’t substantiate — or flat out contradicted — more than half of Oz’s recommendations. “Recommendations made on medical talk shows often lack adequate information on specific benefits or the magnitude of the effects of these benefits,” the article said. “… The public should be skeptical about recommendations made on medical talk shows.”
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In a recent study (Hepatology 2014; 60: 815-22), data from the National Health and Nutrition Evaluation Survery (NHANES) 1988-94 was compared with the NHANES 2009-2010 with regard to Hepatitis E virus (HEV) epidemiology. In addition, the most recent surgery coupled with a high performance HEV assay. A total of 8,814 individuals were included in the analysis.
Key findings:
Also noted: Hepatology 2014; 60: 1082-89. “Liver transplantation in the management of porphyria” –useful review.
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According to a recent BMJ study, the Mediterranean diet may protect your chromosomes. From the NY Times link –here’s an excerpt:
They found that the diet is associated with longer telomeres, the protective structures at the end of chromosomes. Shorter telomeres are associated with age-related chronic diseases and reduced life expectancy.
Researchers used data on 4,676 healthy women, part of a larger health study, whose diets were ranked on a scale of one to nine for similarity to the ideal Mediterranean diet. Researchers measured their telomere lengths with blood tests and followed them for more than 20 years with periodic examinations.
The study, published in the journal BMJ, controlled for body mass index, smoking, physical activity, reproductive history and other factors, and found that the higher the score for adherence to the diet, the longer the telomeres. The difference in telomere length for each point on the adherence scale, the researchers estimate, was equivalent to an average 1.5 years of life.
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A recent commentary (NEJM 2014; 371: 2145-47) describes some early successes and failures with efforts at “getting more performance from performance measurement.”
The authors note that “the current measurement paradigm..does not live up to its potential.” There have been a proliferation of measurements “without commensurate results.”
Areas of progress:
Reducing hospital readmissions: “national readmission rates, which hovered around 19% between 2007 and 2011, had dropped to approximately 17.5% by 2013…recent research suggests that the measured decrease resulted from actual changes in care and not simply greater use of observation units or emergency department care.”
Rates of early elective deliveries: “the rate of early elective deliveries had stayed fixed for many years, even though there was evidence that the practice led to a greater need for neonatal intensive care, higher risks of maternal and neonatal complications, and health problems later in the children’s lives…the rates of early deliveries fell from 17% in 2010 to 4.6% in 2013 (www.leapfroggroup.org/tooearlydeliveries)” This change happened due metrics in pay-for-performance or not paying for such deliveries along with educational efforts.
Areas Were Not Helpful (aka The Road Paved with Good Intentions)
“Unfortunately, for every instance in which performance initiatives improved care, there were cases …[that] simply enraged colleagues or inspired expenditures that produced no care improvements.”
Early Antibiotics for Community-Acquired Pneumonia: Due to data suggesting that antibiotics within 6 hours of presentation positively influenced the outcome of community-acquired pneumonia (i.e. lower in-hospital mortality), this became a Centers for Medicare and Medicaid Services (CMS) metric. “The measure led to inappropriate antibiotic use in patients without community-acquired pneumonia, had adverse consequences such as Clostridium difficile colitis, and did not reduce mortality.”
Bottomline: More work is needed to avoid needless busy work and improve patient outcomes.
As quoted in a previous blog entry:
“Not everything that counts can be counted, and not everything that can be counted counts.” –Albert Einstein
A recent policy article (JAMA Pediatr 2014; 168: 1155-63 –thanks to Ben Gold for this reference) outlines “10 urgent priorities for the health and health care of US children.” These priorities and some of the action steps are as follows:
The problems faced by this nation’s children will reverberate for a long time. For example, with childhood poverty, it is “associated with substantially higher mortality rates in adults, regardless of adult socioeconomic status (i.e., even affluent adults who were poor as children have elevated death rates), and this increased mortality risk extends across 2 generations.”
Bottomline: Children receive a disproportionately low share of federal expenditures and this extends to healthcare. In addition, federal spending on children in 2014 has decreased by more than $20 billion (14%) since 2010.
Blog post:
A recent study (Am J Gastroenterol dii:10.1038/ajg.2014.355) from Helsinki examined 177 patients with celiac disease. Their goal was to investigate whether altered intestinal microbiota may be associated with persisting gastrointestinal symptoms in celiac patients who had been following a strict gluten-free diet (GFD) for at least 3 years.
After administering a questionnaire (Gastrointestinal Symptom Rating Scale or GSRS) to those with negative celiac antibodies and normal small bowel mucosa (n=164), the researchers identified the 18 subjects with the highest total score (persistent symptom group) and compared them to the 18 subjects with the lowest total score. Three duodenal biopsies during endoscopy had been frozen and were subsequently analyzed for their microbial DNA. In each group, one microbial profile was unsuccessful.
Key findings:
Some of the strengths of this study include the normal villous architecture for all of the patients; this helps exclude refractory celiac disease as an etiology for the persistent symptoms. In the discussion, the authors note that the “intestinal microbiota composition in healthy adults is relatively stable and can tolerate normal stress in the intestine caused by, e.g. daily changes in diet.” The speculate that long-term untreated celiac disease “may disrupt a stable intestinal microbiota community that, in some patients, could then reform in a dysbiotic state.”
The limitations of this study include the difficulty of excluding small intestinal bacterial overgrowth which could be related and the difficulty of excluding coexisting irritable bowel syndrome. Like most studies regarding the micro biome, this study cannot “show causality or distinguish the effects of different bacteria to the persistent symptoms.”
Bottomline: Treated celiac patients with persistent symptoms have a different duodenal microbiome compared to treated celiac patients whose symptoms resolved with a gluten-free diet.
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A recent review (JPGN 2014; 59: 429-39) regarding imaging for inflammatory bowel disease reiterates the accepted view that magnetic resonance enterography (MRE) is typically the most useful imaging test for children with inflammatory bowel disease; in Table 5, MRE is listed for each indication, though CT scan is recommended “if emergent or after hours.” The review reviews prior pediatric publications, radiation risks (with non-MRE studies), and alternative imaging. The discussion on costs is minimized, though the authors note that MRE is the most expensive and can be compromised by motion artifact. As a practical matter, I think giving a typical charge (or range) for each of the imaging techniques would be helpful. Also, another important issue is assuring that radiologists have the technical expertise to obtain quality imaging.
Another study (Clin Gastroenterol Hepatol 2014; 12: 1702-07) retrospectively looked at 1095 emergency room visits by 613 individuals (average age ~40 years) to determine if they could develop a model to limit unnecessary CT scans. Of the 1095 CT scans, 24.8% were normal; 10.9% had either perforation or non-perianal abscess. In their discussion, they note that the equation “no scan for ESR (mm/h) + 5*CRP (mg/dL) ≤10” would avoid 18.5% of CT scans. Implementation of a more complex model could eliminate up to 43% of the CT scans. The algorithm (Figure 2) suggested by the authors:
Here’s the link to the abstract –supplementary materials can be obtained by those who log in. http://dx.doi.org/10.1016/j.cgh.2014.02.036
Bottomline: Cross-sectional imaging is particularly helpful at determining whether complications are developing in patients with inflammatory bowel disease. Increasing use of MRE will reduce radiation risks.
With regard to costs, a recent NPR story discussed “How Much Is That MRI, Really? Massachusetts Shines A Light.” While this story discussed costs related to a Massachusetts law which mandates that insurers reveal the costs of various tests, it did not relate any information regarding quality. The study implied that an MRI at one institution would be equivalent to an MRI at another. This is not the case.
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A recent study (J Pediatrics 2014; 165: 773-8) highlighted the clinical problem of discrepant hepatitis B virus (HBV) testing in pregnant women.
Design: The Centers for Disease Control and Prevention analyzed a nonrandom sample of discordant cases of HBV reported by US Perinatal Hepatitis B Prevention Program. Discordant cases indicated that there were differences between an initial HBsAg result and a subsequent test. Among 142 cases, 89 had sufficient information to determine accuracy of the initial test.
Key finding: 14 (15.7%) of these cases were true positives, the remainders were false-positives.
How did authors sort out cases?
Negative testing for “total anti-HBc or no detectable HBV DNA result indicating no HBV infection…A positive total anti-HBc indicates current or past HBV infection, is not elicited by vaccination, and usually persists for life.”
Pointers regarding serology:
It is important to sort out patients with discrepant HBV serology. In infants who are not identified with HBV testing (false-negatives), this results in suboptimal post exposure prophylaxis and increased likelihood of chronic HBV. Whereas, infants with false-positive results, incur unnecessary prophylaxis and costs. The authors note that “total anti-HBc was the most useful single test to resolve HBsAg discrepancies.
Also noted: J Pediatr 2014; 165: 767-72. “Factors Affecting the Natural Decay of Hepatitis B Surface Antigen in Children with Chronic Hepatitis B Virus Infection during Long-Term Followup” This study followed 349 Taiwanese children over 20 years and noted annual HBsAg clearance of 0.58% (42 cleared HBsAg). Spontaneous clearance was more common in HBeAg-seroconverters, infants with low initial HBsAg level <1000 IU/mL, and to those born to non-HBsAg-carrier mothers.
gutsandgrowth 