Vaccine Safety -Put into Perspective

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For anyone concerned about vaccine safety, putting the risks into perspective may be helpful:

“The most dangerous aspect of giving your child vaccines is driving to the office to get them,” according to Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia, in Vaccine Safety Article from USA Today.

With regard to exemptions, a recent study has shown that private schools have higher vaccine exemption rates (4.25%) than public schools (1.91%) (J Pediatr 2014; 165: 129-33).  Using CDC data for 35 states (& district of Columbia), the authors noted that there were 48,931 exemptions in 2009-2010 with only 7146 for medical reasons.  For individual states, Hawaii had the highest private school exemption rate at 14.88% and Washington had the highest public school exemption rate at 6.08%.

The authors note that parents with “higher income and educational levels expressed more concerns about vaccine safety.”  However, they state that “parents who object to immunizations have been considered ‘free riders’ as they take advantage of the benefit created by children who assume any potential risk of adverse reactions.”

In a brief summary, Sarah Long, an infectious disease expert and associate editor of The Journal of Pediatrics, questions how these parents can be “so mistrustful of doctors…and yet so confident in their own musings? At the same time that they are attempting to advantage their children by attendant a private school, they are putting their children in harm’s way.”

Related blog posts:

AASLD/NASPGHAN 2014 Guidelines for Evaluation of Pediatric Liver Transplantation

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I want to congratulate the authors of a recent AASLD/NASPGHAN report (Hepatology 2014; 60: 362-98 & JPGN 2014; 59: 112-31) and in particular Rene Romero who has been a terrific colleague in Atlanta.  I’m grateful for his timely advice to me and my colleagues along with the excellent care that he has provided to children referred for liver transplantation (LT).

The link to full article, Evaluation of Pediatric Liver Transplantation, and other AASLD practice guidelines can be accessed from this website: AASLD guidelines.

Some of the useful recommendations include the following:

  • For biliary atresia, “patients who are post hepatoportoenterostomy (HPE) should be promptly referred for LT evaluation if the total bilirubin is greater than 6 mg/dL beyond 3 months from HPE” and should be considered if total bilirubin is ≥2 mg/dL.  According to the authors in the Hepatology article, ‘84% of those with a total bilirubin <2 mg/dL will survive with native liver beyond 2 years of age whereas only 16% will if total bilirubin is >6 mg/dL.’ [Interestingly, this information is stated differently in the JPGN article where the authors state  “up to 70% of patients with BA may have prolonged transplant-free survival if the total serum bilirubin falls below 2 mg/dL” w/in 3 months following HPE.]
  • For biliary atresia: HPE is recommended as 1st line treatment except in infants with “evidence of decompensated liver disease.”
  • Ascites management: can be managed with an aldosterone antagonist.  Reserve more aggressive measures (paracentesis, TIPS, surgical shunt) for those with compromised respiratory effort or severely impaired quality of life.
  • Recurrent disease: families should be informed that autoimmune hepatitis, PSC, and bile salt excretory pump disease can recur post-LT.
  • Recommends screening with use of pulse oxygen with the patient in upright position in all patients with possible portosystemic shunting.
  • Discusses immunizations for child and for family members (all family members need to fully immunized).
  • The review provides recommendations specific for virtually each liver condition, including Alagille, Wilson’s, Tyrosinemia, PFIC, hemangioendothelioma, Cystic fibrosis, urea cycle defects, autoimmune hepatitis, PSC, Hepatoblastoma, Alpha-1 Antitrypsin deficiency, Bile Acid Synthesis Disorders, Glycogen Storage Disease, Fatty Acid Oxidation defects, Parenteral Nutrition-Associated Liver Disease (PNALD), and many others.
  • Contraindicated for LT:  Alper’s syndrome/valproate-associated liver failure, mitochondrial disease with severe extrahepatic disease, Hepatocellular carcinoma with extrahepatic disease and rapid progression, uncontrolled systemic infection, Niemann-Pick Disease Type C, and severe medically-refractory portopulmonary hypertension

Take-home message: This practice guideline is an excellent resource in the evaluation of pediatric liver transplantation and pre-transplant management.  The ease of accessing the entire report online is a big plus too.

Related posts:

More Data on Early-Onset Pediatric Inflammatory Bowel Disease

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In 2009, a large prospective database involving Italian Pediatric Gastroenterologists was established.  A recent study describes the classification (Paris) and phenotype of early-onset pediatric inflammatory bowel disease (EO-IBD) (Inflamm Bowel Dis 2014; 20: 597-605).

In 506 consecutive patients, 224 had Crohn’s disease (CD), 245 ulcerative colitis (UC) and 37 IBD-unclassified.

Key findings:

  • 11% were aged 0-5 years, 39% 6-11 years, 50% were 12-18 years.
  • UC was more frequently diagnosed in 0-11 years of age whereas as CD was more common in 12-18 years.
  • EO-Crohn’s showed more frequent isolated colonic disease
  • EO-UC noted 62% with pancolitis compared with 38% in 6-11 years and 31% in 12-18 year group

Take-home message: The authors conclude that “EO-IBD exhibits an extensive phenotype and benefit from aggressive treatment strategies, although surgical risk is similar to later-onset disease. A family history for IBD is not common in EO disease.”

Safety with Peripheral IVs

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Since completing my training at Cincinnati, I regularly receive a “staff bulletin.”  One item that I thought was particularly worthwhile in the June 2014 was a discussion on minimizing harm related to peripheral intravenous (PIV) access and infusions.

The Cincinnati Vascular Access Team has developed a protocol to assess PIV sites (hourly nurse checks) and has developed a list of medicines, with the idea that higher risk medications should be given via a central line. The lists that follow are based on this staff bulletin and should be useful references.

High Risk Medicines include the following:

  • acyclovir
  • amiodarone
  • caffeine citrate
  • calcium (all salt forms)
  • dextrose (>12.5%)
  • doxycycline
  • esmolol
  • mannitol (20% and 25%)
  • promethazine
  • potassium (>60 mEq/L)
  • Sodium bicarbonate
  • Sodium chloride ≥3%
  • TPN ≥950 mOsm/L
  • Vasopressors such as dopamine
  • Chemotherapy drugs

Intermediate Risk Medicines include the following:

  • Acetazolamide
  • Allopurinol
  • Amikacin
  • Amphotericin B
  • Arginine
  • Ciprofloxacin
  • Dextrose 10 to 12.5%
  • Diazepam
  • Erythromycin
  • Ganciclovir
  • Lorazepam
  • Midazolam
  • Morphine
  • Ondansetron
  • Nafcillin
  • Non-ionic Radiology contrast
  • Phenobarbital
  • Phenytoin
  • Potassium ≤60 mEq/L
  • TPN ≤950 mOsm/L
  • Vancomycin

Lower Risk for the following:

  • aminophylline
  • amphotericin B liposomal
  • ampicillin, ampicillin/sulbactam
  • cefazolin
  • cefotaxime
  • ceftazidime
  • ceftriaxone
  • cefuroxime
  • clindamycin
  • D5LR
  • dextrose <10%
  • fentanyl
  • forsphenytoin
  • furosemide
  • gentamicin
  • heparin
  • imipenem
  • IVIG
  • lactated ringer’s
  • lipids
  • magnesium sulfate
  • meropenem
  • normal saline
  • pentamidine
  • piperacillin, piperacillin/tazobactam
  • ticarcillin, ticarcillin/clavulanate
  • tobramycin

One further warning: “No intravenous infusate is ‘safe.’ Gross extravasation, even of normal saline, may result in serious harm, including compartment syndrome, ischemia, and loss of tissue or permanent loss of limb function.”

ACA -A Report Card

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A recent succinct commentary describes the ~20 million people who gained coverage as a result of the Affordable Care Act/Obamacare; the exact number who were uninsured prior is not known.  While the article provides a clearer picture of this expansion, it also makes the point that there are many issues that need to be addressed including cost containment.  Other subjects:

  • Cancelled policies
  • Risk pools and premiums (lower than projected thus far)
  • Narrow Provider Networks
  • Crucial Younger Age Group Enrollment
  • Small Business and Mandate
  • Individual Marketplaces
  • State Marketplaces
  • Medicaid Expansion (limited in many states)

Here is the link –the entire report is worth a read: ACA -20 million Americans

Here is an excerpt:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3 Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

No Habla Appendicitis

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Before today’s blog, I wanted to state that our physicians now can treat Clostridium difficile with fecal microbiota transplant (would have been more relevant to yesterday’s blog: “Gut Microbiome”) :

GI Care for Kids is one of the few places in the region to offer this capability for children (thanks to Jeff Lewis for working to navigate the logistics/regulatory burdens).

Today’s blog: Though physicians make efforts to combat language barriers with translators, the personal connection between physicians and patients is undoubtedly weakened in those with limited English proficiency LEP).  Recently, one of my emergency room colleagues explained that he had ordered a CT scan on a young man in part due to his hispanic ethnicity and concern that this would lead him to overlook a diagnosis of appendicitis.  According to a recent study, my emergency room colleague was right –hispanic ethnicity and language barriers increased the risk for appendiceal perforation (J Pediatr 2014; 164: 1286-91).

The researchers performed a secondary analysis of a prospective, cross-sectional, multi center study of children aged 3-18 years who presented with abdominal pain/possible appendicitis (2009-2010) at 10 tertiary care pediatric emergency departments in the U.S.

Results:

  • Of the 2590 patients enrolled, 1001 (38%) had appendicitis.
  • Hispanics with LEP had an odds ratio of 1.44 of having appendiceal perforation.  In addition, these patients were less likely to undergo advanced imaging (OR 0.64)

Bottomline: Patients/families who speak English are more likely to communicate the severity of their medical problem.  Those with limited English proficiency are at increased risk for complications and this extends beyond perforation with appendicitis.

Related blog post: How much radiation from your CT scanner? | gutsandgrowth

Why Dr. Oz Has Not Lost His Medical License

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An interesting article from Vox (link from retweet by Eric Benchimol) provides insight on why Dr. Oz can make numerous false claims of ‘miracle’ cures and not lose his medical license.

Here’s an excerpt:

The fact that Oz hasn’t lost any credentials speaks to a larger challenge in modern medicine: Once you get a medical license, its actually really difficult to lose it.

“This has been a longstanding complaint with medicine and the professional regulation. You either need to have sex with patients who file a complaint, be a really bad substance-using person… or you’re malpractice-level bad as a doctor,” David Jones, professor of culture of medicine at Harvard University, says. “Nothing in Dr. Oz’s conduct is even close to getting the attention of the state boards because they are dealing with sex criminals, alcoholics, and gross misconduct.”

Ouch!

The article details why the American Medical Association, New York State Dept of Public Health, Columbia University, and the Federal Trade Commission are all unable to take action against Dr. Oz.

Related blog posts:

Here’s John Oliver’s takedown of Dr. Oz: Dr. Oz on Last Week Tonight 

Probiotics for Hepatic Encephalopathy

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A recent open-label, randomized prospective study (Clin Gastroenterol Hepatol 2014; 12: 1003-08) indicates that probiotics (VSL#3) can be effective as primary prophylaxis of hepatic encephalopathy (HE) in at risk patients with cirrhosis.

While cirrhosis-related HE is an uncommon problem in pediatric gastroenterology/hepatology, there are few effective therapeutic options.  This study randomly assigned the 160 patients to groups given probiotics three times daily or to controls (no test article).  These patients were studied extensively including psychometric analysis, glucose hydrogen breath tests, critical flicker fusion, and lactulose hydrogen breath tests to assess orocecal transit time.

Key result: Three months of probiotics reduced HE scores.  Seven probiotic subjects developed overt HE which was significantly lower than the 14 patients in the control group (P<.05).

Bottomline: Probiotics may reduce the development of overt HE in patients with cirrhosis.

New Biomarker for Crohn’s Disease (Plus Two)

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A recent study identifies a new biomarker for Crohn’s disease (CD) (Inflamm Bowel Dis 2014; 20: 1037-48).

The authors examined a cohort of 208 newly diagnosed pediatric CD and 43 non-IBD controls for ileal/rectal expression of FcγRIA mRNA.  In addition, in a smaller cohort of 26 newly diagnosed CD patients, 83 established CD patients and 30 non-IBD controls the authors measured peripheral blood polymorphonuclear neutrophil (PMN) CD64 index.

Key findings:

  • Ileal FcγRIA mRNA expression was significantly elevated in CD compared with non-IBD controls
  • PMN CD64 was significantly elevated in CD compared with non-IBD controls and correlated with mucosal injury as measured by the simple endoscopic score for CD.
  • Patients in clinical remission with a PMN CD64 <1 had a high rate of sustained remission (95%) whereas only 56% had sustained remission if PMN CD64 was >1.

Take-home point: This study shows in pediatrics, as in adults IBD patients, that PMN CD64 index is associated with mucosal inflammation; high levels are associated with clinical relapse.  Serum biomarkers are likely to complement stool biomarkers like fecal calprotectin.

One other point the authors make: “studies have found that 57% to 59% of CD have concurrent IBS.”  Thus, there is a need for biomarkers to distinguish whether patients with clinical symptoms are experiencing an inflammatory relapse.

Related blog post: Calprotectin: Part of diagnostic algorithm for IBD …

Two other studies in same issue:

“Alterations in the Intestinal Microbiome (Dysbiosis) as a Predictor of Relapse After Infliximab Withdrawal in Crohn’s disease” pages 978-86.  N=33 CD patients. Key finding: “CD-associated dysbiosis, characterized by a decrease in Firmicutes, correlates with the time-to-relapse after infliximab withdrawal.”

“Tissue Studies in Screened First-degree Relatives Reveal a Distinct Crohn’s Disease Phenotype” pages 1049-56. N=38 asymptomatic relatives. Key finding: based on histologic scoring 61% were normal, 26% had minor lesions, and 13% had evidence of active disease. This study indicates that screening relatives may identify a subset with early biologic disease.