Parenting wisdom from Teddy Roosevelt: A very short post

Posted October 30, 2014 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2014 Roy Benaroch, MD

“Comparison is the thief of joy.”

Games insurance companies play

Posted October 28, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Here I am, on my “day off,” trying to get an insurance company to pay for something for one of my patients. Or not pay for something—honestly, they’ll do whatever they’re going to do, they don’t care what I say—but I need to at least make it look like it’s not my fault. That’s the game, see. Confused? Let me explain.

Bob has been in speech therapy for a year, and has been doing well and making good strides. Though they had been paying for the therapy, now the insurance company is balking—their letter to mom says that they don’t feel that the therapy is “medically necessary” any more. (I suppose it’s not medically necessary to talk. Maybe they’ll give him a little chalk board to tie around his neck instead.)

So mom, understandably, contacts the insurance company. They tell her their decision is based on information they got from me. Me! They didn’t ask me for any information, and I haven’t heard a word about this. Anyway: Insco tells mom that they’ll have to start a peer-to-peer review, alleging that one of their doctors will speak with me. Mom calls me to pass along their phone number. I’m supposed to call them. That very phrase gives me chills. You’ll see why.

By the way, this is one of the biggest insurance companies in Georgia. I suppose I can’t say directly who they are, but their name rhymes with “Goo Moss/Goo Field”, if you catch my drift.

Anyway: I call “Rue Toss”, and find out that they’ll only accept phone calls between 9-12 and 2-5. When I’m most busy with, you know, scheduled patients. The sick kids I trained to take care of. These phone calls should take priority over patient time, if you ask “Moo Floss”.

I finally did get a chance to call them, this morning, of course on my day off (that’s pretty much the only time I could possibly be free during those hours.) And I listened to a 5 minute message—which ended with a recording for me to leave my name and number. I had to call at a specific time just to leave a message that could have been left at 2 AM! They promise to call me back within 48 hours.

And I guarantee they’ll call me right when I’m seeing actual patients. Or they won’t call me at all, though they’ll tell mom they tried to. Golly, your doctor just won’t speak with us!

The saddest part: they’ve already decided that they’re not paying for this service. I know this. In all of my years, these phone calls and appeals for things like speech therapy have never worked. This whole game has been created by the insurance company to make mom think that this is all my fault. Oh, says the insurance company, we decided this based on what your doctor told us. If he’ll just call us, we’ll reconsider. That’s a load of shit. They’ll waste my time, hope I give up, and do anything they can to make doctors look like the bad guys.

Man up, insurance. If you won’t pay, just tell your “members” that it’s not a covered service, and leave me out of it. You obviously don’t care what I recommend, so stop pretending that you do.

Is the FDA’s antidepressant warning killing people?

Posted October 27, 2014 by Dr. Roy
Categories: In the news, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

In 2004, the FDA launched a program to “strengthen safeguards for children treated with antidepressant medication.” Among other steps, they started requiring manufacturers of several kinds of antidepressants to include a warning in their product labeling, a so-called “black box,” that explicitly and loudly proclaimed a risk for children taking these medications. The warning said that children taking these medications were at an increased risk of suicidal thoughts and behaviors. Later, the black box warning was expanded to include young adults. The warning was required to be added to the labeling of medications including Prozac, Zoloft, Celexa, Wellbutrin, and several other medications.

What prompted this action was an observation from studies of children taking these medications that in the weeks after starting them, there seemed to be increased thoughts of suicide. Not suicide attempts, and not deaths from suicide (there were actually no suicide deaths at all among the study groups), but self-reported thoughts about suicide.

Now, depression is a serious illness—and suicide is a very serious consequence of depression. People with major depression have about a 15% cumulative lifetime risk of death by suicide, so this is a very significant and serious problem not to be taken lightly. We know that people with depression often think of suicide, and are at grave risk for attempting suicide—is it possible that anti-depressant medications actually make this risk worse?

A June, 2014 study from The British Medical Journal has looked at the consequences of the FDA’s decision (and the ensuing broad media coverage.) Researchers examined data from a total of 2.5 million teens and young adults from 11 health care plans in the United States. After the warning, the use of these medications dropped by about 24-31% (depending on age grouping.) This was accompanied by an increase in the rate of suicide attempts, by 22-34%. The rate of deaths from suicide did not change at all—just the rate of attempted suicides.

So, no, the FDA’s warning, based on this study, didn’t increase actual deaths. But it did increase suicide attempts, which likely means it increased the rate and severity and consequences of depression. It certainly hasn’t done any good. The warning has scared many families and doctors away from one mode of therapy for depression. Antidepressant medications aren’t perfect—they do have important side effects, and they don’t always work, and they’re certainly not for everyone with symptoms of depression—but they can be one important part of the treatment of some depressed adolescents. It’s a shame that this misguided “black box warning” is doing more harm than good.

Serious side effects of vaccines are rare. What does that mean?

Posted October 23, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

“Serious side effects of vaccines are rare.”

Vaccines are not 100% safe. Like any medical intervention, there’s some risk (honestly, like anything at all, anything we do, there’s some risk. But let’s not get sidetracked here.) Side effects, including serious side effects, can happen after vaccines. What are these reactions, really? How often do they occur?

Here, I’m only talking about genuine, established side effects. Things are genuinely, scientifically, reliably linked to vaccines. Some things that had once been thought be a potential side effect of vaccines are now known to have been caused by other conditions (like seizures and encephalopathy after DTP, now known to be most-often caused by a rare genetic condition called Dravet Syndrome, that would have occurred whether the child was immunized or not.) There are also side effects reported that are clearly unrelated, like choking on a bean in the trachea or turning into the Incredible Hulk. We’ll ignore those, and concentrate on the real, serious, potentially deadly side effects that have been documented to be caused by vaccines. I’m going to list all of them, for every vaccine. If I missed any, please add in the comments.

Any vaccine – Serious allergic reactions can occur. These do happen, though the rate of serious reactions depends on the vaccine. For most immunizations, the rate is less than 1 in 1 million; however, some very-rarely used vaccines can have a higher rate. The yellow fever vaccine, for instance, causes severe allergic reactions in about 1 in 55,000 people; anthrax vaccine is estimated to cause severe reactions in 1 in 100,000. Almost all severe allergic reactions occur within minutes of vaccination, and health care facilities who give vaccines should have people trained to treat rare reactions like these.

Influenza – The Pandemrix brand of influenza vaccine, which was never licensed or used in the United States, has been linked as a cause of narcolepsy in about 1 in 55,000 vaccine recipients in several countries in Europe. This product was only used during the 2009-2010 season. The CDC is currently sponsoring an international study to try to better understand this, and why that one formulation seemed to be a unique trigger for this rare condition.

In 1976, a different specific Swine Flu vaccine was linked to about 450 cases of Guillian-Barre Syndrome (GBS), a neurologic disorder that was estimated to occur in about 1 in 100,000 people who got that specific vaccine that year. The baseline rate of GBS is probably 1-2 per 100,000, so when 45 million doses of vaccine were given in 1976, some cases were going to occur coincidentally. Substantial studies have shown that other flu vaccines from more-recent years do not cause GBS. Ironically, influenza disease itself causes more GBS than even the 1976 Swine Flu vaccine is purported to have caused, and even if that association were true influenza vaccination would prevent far more GBS than it would trigger.

Japanese encephalitis – Rarely used in the United States, the Japanese Encephalitis vaccine has been linked to prolonged arm and shoulder pain among vaccine recipients. I could not find an exact rate, but this appears to be an uncommon reaction.

MMR – About 1 in 30,000 people given a dose of MMR will have a drop in their platelet count, which can predispose to bleeding. The rate of low platelets is much higher in real measles than after the vaccine, so, again, ironically MMR probably prevents more cases of low platelets than causes it. This condition is temporary and almost always requires no treatment at all.

Polio – The oral polio vaccine, no longer used in the United States, could trigger genuine, full-blown polio in some people—probably about 8 per year in the entire US, back when we used the oral version. We’ve been using only the injected polio since the mid-1990s, which carries zero risk of causing polio.

Rotavirus – Rotavirus vaccines carry a small risk of causing an intestinal blockage called “intussusception.” This condition is treatable, though it often requires a brief hospitalization. The risk was highest after the first doses of the original brand of vaccine, Rotashield, which was withdrawn from the market; the risk after current brands is probably in the range of 1-3 in 100,000. However, rotavirus itself, the real infection, is also a cause of intussusception. To put this in perspective: using the high end of the risk estimates, about 40-120 vaccinated infants may develop intussusception each year in the USA, compared to 65,000 infants who had been hospitalized for rotavirus illness each year prior to the vaccine becoming available.

Smallpox – Routine smallpox vaccinations stopped by 1970 in the US, but a smallpox vaccine is available for high-risk researchers and military people and others thought to be at risk of exposure. The vaccine can cause heart problems in 1 in 175 people, and there is a risk that the vaccine virus can spread on the skin of a vaccinated person or contacts, especially when the skin is damaged or there are immune problems.

Yellow fever – Used only in certain travelers, some kinds of typhoid vaccine can causes severe neurologic problems (about 1 in 125,000) or death, especially in elderly people (1 in 500,000).

That’s it—that’s the list. All of the serious, lasting, you-need-to-worry about side effects. You’ll notice that almost all of the really serious side effects occur only with vaccines that aren’t likely to be recommended for your children. Most of the routine childhood vaccines (DTaP, HIB, pneumococcal conjugate, hepatitis B, hepatitis A, chicken pox, meningococcal conjugate, human papilloma virus) only carry a very rare risk of allergic reactions, and even those are entirely treatable and temporary. In other words, science has failed to find any evidence for any real, lasting, serious vaccine reactions among any of the vaccines currently recommended for routine use in children in the United States.

When we say “serious side effects are rare,” we mean “serious side effects are very very very rare, and really only happen with vaccines that we don’t even use.”

What parents need to worry about are diseases, not vaccines. Don’t let the scaremongers and internet rumors sway you. The risk of a serious, lasting side effect from any routine childhood vaccine is just about zero. Make sure your children are safe and protected. Vaccinate!

Defeating Ebola: Nigeria did it, so can we

Posted October 21, 2014 by Dr. Roy
Categories: In the news

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The Pediatric Insider

© 2014 Roy Benaroch, MD

In June, a man became very ill during a flight into Lagos, Nigeria. On the plane, he developed vomiting and diarrhea, and he collapsed in the very busy airport. Contacts on the plane and on the ground had no idea that he had Ebola—initially, he was treated for malaria—and many healthcare workers and bystanders on the plane and in the airport were exposed to his infectious body fluids. One of his close contacts, while ill, flew across the country to consult with a private physician.

A nightmare? Well, it wasn’t good. But health officials in Nigeria stepped up to the plate and dealt with it. Following protocols (yes, protocols) recommended by the WHO and CDC, and relying on a fairly meager public health infrastructure built to track polio cases, workers carefully tracked every single contact, and kept tabs on all potential cases. People who became sick were then isolated. In total, Nigeria experienced 19 cases of Ebola (including 7 deaths), all traceable to the single imported case.

Nigeria has not had any new diagnoses of Ebola disease in 42 days, twice the maximum incubation period of 21 days. The WHO has declared Nigeria Ebola-free.

No special medicines, no vaccine, no high-tech anything. Nigeria is Africa’s largest country, and the case was imported through a planeload of about 50 people, all potentially exposed to infectious material. All of these people then traveled through the country’s largest airport in its largest city. Yet there was no widespread illness—the outbreak was contained through the boring, tedious, essential work of screening and following. And it worked.

The media are in an absolute frenzy over Ebola in the US, pointing fingers and practically frothing at the mouth. I realize that in the noisy world of the internet, one has to shout to sell, and shout to be heard; I also realize that there’s an election coming up in just a few weeks, so anything that makes someone else look bad is going to be a tool that just has to be used. Politicians are doing what politicians do (grandstanding), and journalists and those-pretending-to-be-journalists aren’t far behind.

One example: everyone seems to clamoring for us to shut down flights from countries affected by the epidemic (Liberia, Sierra Leone, and Guinea). Politicians from both sides and pundits on the TV news are blasting the administration and public health authorities:

 “Of course we should ban all nonessential travel…” – Bret Stephens, Wall Street Journal

“…we should not be allowing these folks in. Period.” – Rep Fred Upton (Republican, MI)

“It starts with a travel ban for non-citizens coming to the US from affected areas…” – Sen. Mark Pryor (Democrat, AR)

But a widespread travel ban will do more harm than good. There already are no direct flights from any affected countries into the USA—anyone getting here will actually be coming from somewhere else. If a travel ban is in place, people who are potentially exposed will do what humans do: they’ll lie. And they’ll get here anyway, from Morocco or France or wherever. (The Liberian man who flew into Dallas, starting our only outbreak here, flew from Belgium). A travel ban will create a panic and a logistical nightmare. We won’t be able to know who is actually coming from where, and people who need to be tracked (maybe including people already sick with disease) may end up hiding from authorities. What happens then?

There are other reasons why a travel ban is a bad idea. It will prevent aid from getting where it’s needed (and the longer the epidemic brews in Africa, the longer we are at risk.) It will further destabilize struggling governments in the heart of the crisis. We should not take steps that will prolong the primary source of cases in West Africa. In fact, the most effective way to end this mess is to end it in Africa. We need to be there, helping with the fight.

None of that seems to matter—it’s all about the symbolism and messaging. Politicians want to look like they’re taking a Tough Stand to Protect America, and journalists want to sell their stories and newspapers. Shut the border! Meanwhile: there have been no further cases of Ebola from the small Texas outbreak. Though infection-control procedures needed to be tighter at first, it looks like health authorities have quickly adjusted their response to contain the spread, and it worked.

There will be more cases of Ebola appearing in the USA. We’re a big country, and we cannot practically just stop travel from an entire side of a continent. Despite what’s being screamed in the media, the CDC has done a good job at responding to this crisis. Future cases will be identified, and spread will almost certainly be limited to a handful of people genuinely at risk (not you, and not your kids.) There’s no need for panic. If Nigeria can do it, so can we.

Previously:

USA Ebola cases double. Media goes nuts, and still misses the point

Ebola and you

USA Ebola cases double. Media goes nuts, and still misses the point

Posted October 13, 2014 by Dr. Roy
Categories: In the news, The Media Blows It Again

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The Pediatric Insider

© 2014 Roy Benaroch, MD

Technically, it’s true: the prevalence of Ebola infection just doubled in the USA, as news spread that a nurse in contact with the first case in Texas has come down with the disease. Technically, that’s not true. The first man died, which dropped the prevalence of Ebola to zero, then it went back up to one. But let’s not split hairs. The total cases just went from 1 to 2, which is a DOUBLING! Clearly, it is time for panic.

No, it is not. Ebola remains difficult to catch, requiring direct contact of either broken skin or mucus membranes (eyes, nose, mouth) with infectious fluid from a victim. And victims don’t become contagious until they’re sick, which explains why the planeload of passengers who accompanied Mr. Duncan from Liberia remain healthy. The people at the most risk aren’t you, or your children—unless they’re healthcare workers, and, really, unless they’re working in West Africa.

That’s where the tragedy is, and that’s where the international community needs to concentrate its resources. Until the epidemic is stopped in Sierra Leone, Guinea, and Liberia, a few cases are going to trickle out and potentially spread to a handful of people wherever they end up. The next case could be in Baltimore or Santiago or Moscow—but, as long as there’s a reasonable health infrastructure, cases can be identified and contained. It takes legwork and money and a grinding, relentless attention to detail, but it can be done. I doubt fancy-pants new vaccines or medicines are going to make much of a difference, here. This one’s got to be surrounded and defeated by old fashioned record keeping and case tracking and isolation by people right there where the action is.

Back to the unfortunate nurse in Texas: The CDC has blamed the spread on a “breach of protocol”. That’s an awkward, weird phrase—and it strikes me as odd that the director of the CDC, Dr. Tom Frieden, would so blithely blame the staff there. Dr. Frieden himself is an internist and infectious disease specialist, and he is no dummy. Any smart doctor knows you never toss your nurse under a bus. It may just be the jet lag talking, but I think there is more to this story, and more to this “breach”.

Stay tuned, though if you’re smart you’ll disregard the media blowhards. Ebola is a huge problem, and a huge human tragedy, but it’s still not something to panic about.

Infection Report 5: What you really should be worried about

Posted October 10, 2014 by Dr. Roy
Categories: Medical problems, The Media Blows It Again

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

This week’s posts have all been about infections, new and old—infections newly found, and infections sneaking back. On the one hand, the media is agog with news of Ebola and the mysterious paralysis virus; on the other hand, threats that are far more likely to kill us are being largely ignored.

One infection is on the verge of sneaking back, which is a shame. We had it beaten, and now we’re allowing it to gain a foothold. We’ve got a great way to eradicate measles, but fear and misinformation have led to pro-disease, anti-vaccine sentiment, especially among those white, elite, and wealthy. As we’ve seen, we’re all in this together—so those anti-vaccine enclaves are going to affect all of us.

Measles, itself, is just about the most contagious disease out there. You don’t need to have infected fluid splashed on you (Ebola), and you don’t need to actually even touch a contaminated surface (influenza). All it takes to catch measles is to breathe the same air as someone with the disease. The measles case doesn’t even still have to be in the same room—particles of infectious measles can float around long after the patient has left. Measles can also be transmitted from contaminated surfaces (and even if person A who touches the surface is immune, he can spread it later on to person B.) Measles is so transmissible that 90% of non-immune people who come near someone with measles will themselves get it. To make matters worse: a person with measles starts spreading virus 4 days before they get sick (compare that to Ebola, which has no transmission until symptoms appear.)

And it’s serious, too. Measles is far more than spots. In the USA, about 1 in 20 people with measles require hospitalization for pneumonia; about 1 in 1000 get brain swelling, which can lead to permanent disability. Measles still kills close to 200,000 people, worldwide, every year (about 1 in 4 people with measles die in the developing world.)

While no vaccine is 100% effective, the measles vaccine is pretty darn close. About 95%-100% of people develop lifelong protective antibodies after the two-dose series. Unfortunately, not everyone can be vaccinated—the vaccine isn’t routinely used less than 12 months, and some people with certain health conditions and immune problems can’t safely be vaccinated. Still, when vaccine uptake rates were strong throughout the developed world in the 1990s, there was very little transmission of measles in the United States, just a handful of cases each year.

And now, it’s back. 2014 is going to have by far the most measles cases in 20 years. Though overall rates of vaccination remain strong, some neighborhoods have immunization rates poorer than third-world countries. And cases that begin or are imported into those areas become outbreaks that public health officials struggle to contain.

Think about this: in west Africa, thousands of people are dying of Ebola, for the lack of rubber gloves and other ways to isolate cases. Here, we do have a safe and effective vaccine against a disease that’s far more transmissible—and some people choose not to get it. There, they battle a lack of basic health resources. Here, our enemy is fear and misinformation. That’s what American families really need to worry about.

This week’s posts about infections new and old were meant to contrast the kinds of challenges faced here, versus the challenges faced in most of the rest of the world. We’re so safe and rich that we can afford to be afraid of things that really shouldn’t scare us (vaccines), while the media becomes preoccupied with things that aren’t likely to become a threat here (Ebola.) We don’t get our flu vaccines because “I heard the flu vaccine can give you the flu” – an utter falsehood that is probably contributing to thousands of deaths. At the same time, we guzzle unnecessary antibiotics for viral infections that do us far more harm than good.

Preventing infections is always the best strategy. Wash your hands, stay away from sick people, keep your kids home when they’re ill, and listen to what every legitimate health authority on the planet says: get yourself and your kids vaccinated. As long as we get them, vaccines are one thing you do not have to worry about.

This week’s posts: The Infection Report

Why are infections such a problem again?

Ebola and you

The single biggest infectious health risk is preventable

Two newcomers and the importance of paying attention

What you really should be worried about


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