My take: It is disgraceful that a prominent physician would jeopardize the health of children and worsen vaccine misinformation more broadly. I think his actions merit review by the ABIM. If you want to share your views with the ABIM: Contact ABIM
“The AAP recommends COVID-19 vaccination for all children and adolescents 5 years of age and older who do not have contraindications using a COVID-19 vaccine authorized for use for their age.”
“Children with previous infection or disease with SARS-CoV-2 should receive COVID-19 vaccination, according to CDC guidelines.”
“Given the importance of routine vaccination and the need for rapid uptake of COVID-19 vaccines, the AAP supports coadministration of routine childhood and adolescent immunizations with COVID-19 vaccines (or vaccination in the days before or after).”
Also, more data on vaccine effectiveness from Eric Topol’s Twitter feed):
“When faced with someone in a white coat, don’t go mute. Assert yourself, particularly if you’re confused. Try repeating what you’re hearing”
“People recalled less than half of what their doctors told them a week earlier”
”In practice, though, patients bring up as many as 15 different issues during a visit. Show up with a list of the three main things you want to talk about, and go over all three before your doctor starts talking.”
“Communication onus should be on medical providers. Still, as a patient, you have agency. ‘When people participate, they remember better'”
My take: This article makes some good points. I think in this era, more written information (after visit instructions) are being provided which helps as well.
Background: MALS is generally considered after other more common conditions. Typical symptoms include abdominal pain after eating or exercise and often weight loss due to fear of eating. The pain is often positional and may improve with leaning forward. The diagnostic finding of celiac artery compression may be identified in many healthy individuals (10-24% of population); thus, only severe compression, which is seen in a small number, can result in symptomatic MALS.
In this study, the key findings:
31 patients with both MALS and OI were identified from 2014-2019. Median f/u after surgery was 22 months.
Based on questionnaires, gastrointestinal symptoms of abdominal pain, nausea, and vomiting improved in 63% (P = .007), 53% (P = .040), and 62% (P = .014) of patients, respectively.
Based on questionnaires, cardiovascular symptoms of dizziness, syncope, chest pain, and palpitations improved in 45% (P = not significant), 50% (P = not significant), 54% (P = .043), and 54% (P = .037) of patients, respectively.
Importantly, the authors could not demonstrate a “statistical relationship between a postoperative decrease in celiac artery Doppler velocity and improvement in clinical symptoms.”
In an effort to gauge for a potential post-surgical placebo effect, the authors determined the degree of improvement in musculoskeletal symptoms. There was a 24% improvement which was much less than the improvement in GI symptoms.
One useful feature of this article is that the authors explicitly state how they arrive at the diagnosis of MALS. They start with an abdominal ultrasound with doppler. Criteria for suspected MALS include supine celiac artery peak systolic velocity of >300 cm/s, celiac artery/aoritic peak systolic ratio of >3:1, neutral position celiac artery peak systolic velocity of >200 cm/s, and a change in the celiac artery deflection angle of >50 degrees between inspiration and expiration. If ultrasound is abnormal, the authors obtained an enhanced CT to image inspiratory and expiratory changes in the celiac artery deflection angle, the area of stenosis, poststenotic dilation, and the collateral blood vessels. If there are discrepancies between U/S and CT, a celiac arterial angiogram is obtained.
The authors conclude that there “were minimal improvements in neurologic or psychological symptoms after MALS surgery, despite their common occurrence among patients with POTS.”
My take: This study, in agreement with others, showed that about 60% had improvement in GI symptoms including pain, nausea and vomiting. In those with OI, most continued with impaired health. Overall, MALS as a clinical entity remains a ‘needle in a haystack.’
The investigators enrolled 53 adults with celiac disease (CD) for at least two years and followed symptoms as well as stool/urine testing for gluten immunogenic peptide (GIP). “GIP in stool can detect gluten consumption of more than 40 mg/d and the urine tests are positive from 40 and 500 mg/d of gluten.”
Over the 4-week study period, weekend samples (urine) identified 70% of patients excreted GIP at least once, compared with 62% during weekdays (stool).
Patients had a median of 3 exposures during the 4 weeks.
Also, the authors noted increases in GIP excretion towards the end of the study. “This suggests a potential Hawthorne effect that could be explained by a decrease in hypervigilance that often is seen in a context of research studies.”
The authors note that GIP “excretions of greater than 2 mcg/g in stool or greater than 12 ng/mL in urine can induce mucosal damage in almost 100% of patients.”
My take: This study adds to the body of literature emphasizing the high rate of inadvertent gluten exposure.
This prospective observational study provides helpful outcome data for infants (n=80) born with congenital duodenal obstruction (CDO).
Key findings (also see infographic below):
Though there was an 8.4% overall mortality, there were no deaths directly attributed to CDO. 69% had associated anomalies.
Median length of stay after repair was 20 days; at 28 days following repair, 76% had been discharged home
Failure to achieve full enteral feeds was NOT related to CDO (due instead to other gastrointestinal anomalies). Mean time for full feeds was 13 days post-op; 90% reached full enteral feeds at 28 days.
Repair type: 80% had duodenoduodenostomy, 14% had duodenojejunostomy, the others: membrane incision (n=1), membrane resection (n=2), and duodenoplasty (n=2)
My take: This data will inform clinicians of expected outcomes in this population. I hope this cohort is followed long-term to provide more information about long-term outcomes including frequency of pancreatitis.