Why Doctors Don’t Want Unvaccinated Children in Their Practice

This is a good read by Russell Sanders from The Daily Beast. Here’s the link along with an excerpt:

http://thebea.st/1lpV5Wl  (link from Atul Gawande’s twitter feed)

No contemporary phenomenon confounds and confuses me more than seemingly sensible people turning down one of the most unambiguously helpful interventions in the history of modern medicine.

There are few questions I can think of that have been asked and answered more thoroughly than the one about the safety and effectiveness of vaccines.

The measles-mumps-rubella vaccine does not cause autism.

The HPV vaccine is safe.

There is no threat to public health from thimerosal.

I often wonder why a parent who believes vaccines are harmful would want to bring their children to a medical doctor at all…

If vaccines caused the harms Jenny McCarthy and her ilk claim they do, then my persistence in giving them must say something horrifying about me. Why would you then want to bring your children to me when you’re worried about their illnesses? As a parent myself, I wouldn’t trust my children’s care to someone I secretly thought was a fool or a monster.

It’s not merely that I don’t want to have to worry that the two-week-old infant in my waiting room is getting exposed to a potentially-fatal case of pertussis if these parents bring their children in with a bad cough. It’s not just that I don’t want their kid to be the first case of epiglottitis I’ve ever seen in my career. Those are reasons enough, to be sure. But they’re not all.

What breaks the deal is that I would never truly believe that these parents trust me. Giving kids vaccines is the absolute, unambiguous standard of care, as easy an answer as I will ever be able to offer.

If they don’t trust me about that, how can I hope they would if the questions ever got harder?

Related blog entries:

Unrelated link: Medical app (from Kipp Ellsworth twitter feed): http://goo.gl/pV4vJC :BabyGrow App Enables Parents to Track Children’s CDC/WHO Growth Curves.

 

Superiority of Anti-TNF Therapy in Children

This study’s conclusion comes as no surprise:

“In children newly diagnosed with comparably severe CD, early monotherapy with anti-TNFα produced better overall clinical and growth outcomes at 1 year than early monotherapy with an immunomodulator. Further data will be required to best identify children most likely to benefit from early treatment with anti-TNFα therapy.”

Here’s the reference:

Gastroenterology Volume 146, Issue 2 , Pages 383-391, February 2014

Here’s a link to the full text article:  Increased Effectiveness of Early Therapy with Anti-Tumor Necrosis Factor-α Versus an Immunomodulator in Children with Crohn’s Disease

Methods: “From 2008 through 2012 at 28 pediatric gastroenterology centers in North America. Patients were managed by physician dictate. From 552 children (median age, 11.8 y; 61% male; 63% with pediatric CD activity index scores >30; and median C-reactive protein level 5.6-fold the upper limit of normal), we used propensity score methodology to identify 68 triads of patients matched for baseline characteristics who were treated with early anti-TNFα therapy, early immunomodulator, or no early immunotherapy.”

Another reference/link from same issue:

Accuracy of Magnetic Resonance Enterography in Assessing Response to Therapy and Mucosal Healing in Patients with Crohn’s Disease

Does Sun Exposure Lower the Risk of Crohn Disease?

An intriguing recent study suggests that individuals who spend more time outside are less likely to develop Crohn disease (CD) (Inflamm Bowel Dis 2014; 20: 75-81).

In this prospective cohort study from France, 123 cases of inflammatory bowel disease (45 CD, 71 ulcerative colitis, and 7 indeterminant colitis)  developed among the 91,870 women in the study.  The study period had a mean followup of 13.1 years and followed women between 40 and 65 years. The authors estimated residential sun exposure by utilizing a database (derived from satellite collection) containing the mean daily ultraviolet radiation dose for each French county.

Key findings:

  • Higher levels of sun exposure were associated with a decreased risk of Crohn disease with a Hazard Ratio (HR) of 0.49.
  • Sun exposure did not affect the likelihood of developing UC (HR 1.21).
  • In women with information about dietary vitamin D intake, higher sun exposure had a HR of 0.29 for developing CD.  That being said, the authors note a low dietary vitamin D intake in their population.

Despite the large cohort, this study has a number of limitations. The absolute number of IBD patients can lead to a Type 1 error (false-positive conclusion).  In addition, the age of the study population and the lack of data regarding individual sun exposure limit the conclusions as well.  Besides these factors, there may be confounders such as changes in diet and soil exposure which are not accounted for.

At the same time, there have been other studies which have shown a latitude effect.  As with this study, those living in sunny areas had a lower incidence of CD.

Bottomline: This study suggests that additional sun exposure is associated with a lower risk of developing Crohn disease.  Whether this lower risk is directly through better vitamin D levels or simply an epiphenomenon is unclear.

Other recent unrelated studies:

Gut 2013; 62: 1122-30.  A randomized phase 1 study of etrolizumab (rhuMAb β-7) in moderate to severe ulcerative colitis.  Etrolizumab is an adhesion cell molecular blocker.

Inflamm Bowel Dis 2014; 20: 21-35.  Meta-analysis of 23 randomized controlled trials of probiotics for UC, Pouchitis, and CD.  Probiotics, in particular VSL#3, increased UC remission rates and helped maintain remission in patients with pouchitis.

Inflamm Bowel Dis 2014; 20: 213-27. Review article of cutaneous manifestations of inflammatory bowel disease.  Good pictures of multiple problems including metastatic Crohn disease, erythema nodosum, pyoderma gangrenosum, Sweet’s syndrome, aseptic abscess syndrome, and epidermolysis bullosa acquisita.

Inflamm Bowel Dis 2013; 19: 1753-63.  Review on hair loss associated with inflammatory bowel disease. Remember telogen effluvium?

Related posts:

For those who read from the top to the very bottom, here’s a tangential question: Do you know what a “sun dog” is?   Sun dog – Wikipedia, the free encyclopedia

What to Make of Dr. Oz and his Detox? Not much

Although my exposure to Dr. Oz has been limited, he is not one of my favorite TV doctors. He often offers opinions in areas where he clearly is not an expert.  By presenting himself as a doctor who is knowledgeable in so many areas, he has the potential of undermining the credibility of physicians more broadly.  A recent report provides some welcome pushback and at the same time indicates that “detox” treatments are unlikely to be helpful.

Here’s the link: Detox treatments by Dr. Oz and others lack evidence, benefit … – CBC

An excerpt:

Despite bold promises that the treatments would purify, detoxify and boost energy and optimize organ function, the cleanses lacked any scientific evidence of efficacy, or clear idea of what toxins they would actually diminish…

“In looking at the medical literature on these things, there has never been a properly conducted scientific investigation of any of these treatments that I’ve been able to find,” Dr. George Dresser, a toxicologist, pharmacologist and an internal medicine specialist at London Health Sciences Centre, told Marketplace co-host Tom Harrington. “It’s an intensely popular topic. And it’s popular because people are interested in a quick fix to health ”

A group of sorority sisters from Western University volunteered to help Marketplace test the cleanse. Half of the group participated in the Dr. Oz cleanse, which required that the students observe a strict diet and refrain from alcohol and caffeine, and not eat any food after 7 p.m. They also drank detoxifying teas and took soothing baths as prescribed by the diet, while the other students ate and drank normally.

To test the efficacy of the cleanse, all students had their liver and kidney functions tested both before and after the 48-hour period. At the end of the 48-hour period, however, Dr. Dresser was unable to detect any physiological benefit at all, or even tell which students had participated in the cleanse.

Despite a CV that boasts degrees from Harvard and the University of Pennsylvania medical school, Dr. Oz has been the target of growing criticism from fellow medical and science professionals for his promotion of products and methods that lack evidence.

Bottomline: “Given his education and influence,” wrote Erin May on the Harvard University science research blog Policylab, “there’s no excuse for the unsubstantiated claims and sensational language that is so pervasive on his show.”

Perhaps Dr. Oz can garner additional publicity by placing his detox on the following website:  Quackwatch (He’s already frequently cited on this website.)

Do Probiotics Really Help Crying Infants?

This is the question from a recent meta-analysis (JAMA Pediatr 2013; 167: 1150-57 -thanks to Ben Gold for this reference).

Table 1 details the study designs, probiotic intervention, and outcomes.

Results: “Of the 12 eligible studies (1825 infants), 6 suggested that probiotics reduced crying and 6 did not…Meta-analysis of 3 small trials of breastfed infants with colic found that Lactobacillus reuteri markedly reduced crying time at 21 days…However, all trials had potential biases.”

In the three breastfed trials alluded to above, there were concerns regarding inadequate blinding of the intervention, unequal baseline characteristics, and use of non validated crying “diaries” which could be prone to recall bias.

More data are needed; fortunately there are several ongoing trials.

Bottomline (from the authors’ conclusion): “Although L reuteri may be effective as treatment for crying in exclusively breastfed infants with colic, there is still insufficient evidence to support probiotic use to manage colic, especially in formula-fed infants.”

Previous  related posts:

Cost of Email

While email has been considered “cost-free,” a recent JAMA Peds letter titled “Metastasis of E-mail at an Academic Medical Center,” identifies a significant opportunity cost.  Think twice about sending that email to everybody! Here’s the link (from John Pohl’s twitter feed): http://dlvr.it/4lD22K 

“If 30 seconds were spent per e-mail, the annual cost per physician to read these mass distribution emails was $1641.”  If 90 seconds each, then $4923.

Tobacco 21 & ENDing Combustible Tobacco Use

While “some 6 million [deaths] globally every year and 400,000 in the United States” are tobacco-related, the best way to reduce these statistics is unclear.  Currently, nearly 50 million Americans continue to use some form of tobacco. A couple important ideas are discussed in a few recent perspective articles:

  • NEJM 2014; 370: 293-4
  • NEJM 2014; 370: 295-7  bit.ly/P6LiF4 
  • NEJM 2014; 370: 297-9

In my view, the most promising idea is “Tobacco 21.”  Starting in May, in New York City, it will be illegal to sell tobacco products and electronic cigarettes to persons younger than 21 years of age.  While the FDA set a national minimum of age 18 years, states and localities can set a higher age.

Although there are those who decry the ‘nanny state’ interfering in adults who are capable of enlisting in the army, there are compelling arguments to ignore these nihilists.

  1. In 2005, Needham, Massachusetts became the first town with a Tobacco 21 statute.  What has happened?  Youth smoking rate has fallen by nearly half to 6.7% (previously 12.9%).  The surrounding communities have a rate of 12.4% (previously 14.9%). Thus, the rate of decline was nearly triple.  This counters the notion that most of these youths will purchase in adjacent areas.
  2. 80% of adult smokers began smoking daily before 20 years of age.  In addition, “90% of persons who purchase cigarettes for distribution to minors are under 21.”  Thus, Tobacco 21 could make a big dent in a minor’s ability to buy from other students/youths.  Furthermore, 90% of U.S. adults smokers have indicated that “if they had to it over again, they would not have started.”
  3. The “adolescent brain has a heightened susceptibility to the addictive qualities of nicotine.”  Also, adolescents are more impulsive and risk takers which increase the likelihood that they would discount the potential consequences of tobacco experimentation.
  4. Checking age of purchasers is already needed for anyone “who appears younger than 27.” Thus, this does not increase regulatory burdens significantly.

Even though Tobacco 21 is the most logical next step in reducing the dangers of tobacco, a much more visible and controversial measure has been ENDs or electronic nicotine delivery systems.  E-cigarettes have been widely advertised.  The opponents of e-cigarettes object because they have the potential to diminish the stigma of smoking and serve as a gateway product, leading to more smoking (JAMA 2013; 310: 685-6).

On the other hand, advocates suggest that “the majority of e-cigarette users treat them as cessation aides.” Ultimately, these products will improve health only if it helps reduce use of combustible products.

Bottomline: Tobacco 21 has the best potential to reduce the mortality and morbidity of smoking, but ongoing efforts with warning labels, tax increases, clean-indoor policies, cessation programs, and public-service campaigns need to continue.

From NEJM twitter feed: Listen now to audio interview w/ TobaccoFreeKids’ Matthew Myers on efforts to reduce, eliminate, prevent smoking. http://nej.md/LKTV7F 

Related blog posts:

HCV Website -No “Cat on The Roof”

A joke I heard a long time ago:

A guy asks his friend to check up on his cat while he is away on a trip.  He calls to see how kitty is doing.  His friend says, “Sorry but she died.”  In response, he tells his friend, “you should have broken me the news a lot more gently.  Maybe you could have said she was up on the roof and the next time I called it would have been easier to accept the news.”  A few years pass and he again asks his friend for a favor, this time to check up on his grandmother while he is away on a trip.  He calls to see how granny is doing.  His friend says, “Oh, she is up on the roof.”

The AASLD and “the Infectious Diseases Society of America (IDSA), in collaboration with the International Antiviral Society-USA (IAS-USA), announced the launch of a new website,HCVguidelines.org, that offers up-to-date recommendations for testing, managing, and treating hepatitis C virus (HCV) infection.”

The website clearly dismisses the previous established breakthrough treatments of telaprevir and boceprevir “because they are markedly inferior.”

For anyone who has been confused with the onslaught of new work on HCV, the website spells out in clear detail the best regimens for HCV treatment now that both sofusbuvir and simeprevir are available.

Bottomline: The website makes it clear that both telaprevir and boceprevir are up on the roof.

Related blog posts:

MD Job Dissatisfaction –Million $ Mistake?

A recent report indicates a high level of job dissatisfaction among physicians, leading some to conclude that it could be a million dollar mistake: http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor … (from Eric Benchimol’s twitter feed)

Here’s an excerpt:

If you are brilliant, ambitious and gifted in science, you may consider becoming a doctor. If so, think twice. According to a new survey by personal finance site NerdWallet, most doctors are dissatisfied with the job, and less than half would choose a career in medicine if they were able to do it all over again….

Worse, the cost of becoming a doctor has soared, with higher education expenses leaving the average newly minted physician with $166,750 in medical school debt, while average salaries are declining. Nearly one-third of doctors — 28 percent – saw a cut in pay last year, according to NerdWallet’s research….

To be sure, pay is still high, with of six-figure positions in the country, according to government data. But it also takes between 11 and 14 years of higher education to become a physician. That means the typical doctor doesn’t earn a full-time salary until 10 years after the typical college graduate starts making money. 

That lost decade of work costs a cool half-million dollars, if you assume this individual could have earned just $50,000 annually, and the typical medical school candidate is smart and successful enough to earn considerably more.  Add in the time and cost it takes to pay off medical school debt and a dissatisfied physician may well consider pursuing medicine a $1 million mistake.

Take-home message: Financial considerations are probably the wrong reasons to to pursue a career in medicine.

Related blog posts:

Brain Response to Physical Activity different in Obesity

From NY Times (http://nyti.ms/1afnEyJ) review of the following article:

Int J Obes (Lond). 2013 Dec 24. doi: 10.1038/ijo.2013.245. [Epub ahead of print]

Differences in neural activation to depictions of physical exercise and sedentary activity: An fMRI study of overweight and lean chinese women. Jackson T, Gao X, Chen H.

An excerpt:

Overweight women’s brains respond differently to images of exercise than do the brains of leaner women…

The scientists asked their volunteers to complete two questionnaires, one of which probed the extent to which they considered exercise desirable; would they agree, for instance, that, “if I were to be healthy and active, it would help me make friends”? The other set of questions examined whether they expected exercise to be unpleasant; if they were to be physically active on most days, for example, would they expect to wind up feeling sore, or maybe even embarrassed by exercising in public?

The researchers next had each woman lie inside a functional magnetic resonance imaging machine, which scans blood flow to specific areas of the brain, indicating areas of increased activity. Then they started a slide show.

For some time, scientists have known that many overweight people’s brains operate differently than the brains of thinner people when they look at images related to eating. In previous neurological studies, when heavier volunteers viewed pictures of food or food preparation, they typically developed increased activity in portions of the brain involved in reward processing, or an urge to like things, including in an area called the putamen. At the same time, their brains showed relatively blunted activity in areas that are thought to induce satiety, or the ability to know when you are full. These changes generally are reversed in the brains of thinner people shown the same images.

But no brain-scanning studies had examined whether being heavy might also affect people’s brain responses — and presumably their attitudes — toward physical activity.

So, to address that gap, the researchers now flashed a series of photographs before their volunteers. Ninety of the images showed people being joyously active by running, dancing, leaping, playing tennis and such. The women were asked to vividly imagine themselves performing the same actions, using hand gestures and limited bodily contortions, to the extent possible within the confines of the scanner.

Ninety additional images featured relaxed, sedentary behaviors, including stretching out on a sofa and sitting in a desk chair. Again, the women were directed to imagine themselves similarly lounging. The various images of activity and quiet were interspersed with photographs of landscapes.

While the women viewed the pictures, the functional M.R.I. machine monitored their brain activity.

The resulting readouts revealed that overweight women’s brains were put off by exercise. Shown images of people being active, these women developed little activation in the putamen region of the brain, suggesting that they did not enjoy what they were seeing. At the same time, a portion of the brain related to dealing with negative emotions lit up far more when they viewed images of moving than of sitting. Emotionally, the brain scans suggested, they anticipated disliking physical activity much more than they expected to disdain sitting.

Leaner women’s brain activity, by and large, was the opposite, with the putamen lighting up when they watched others work out and envisaged doing the same themselves.