Archive for the ‘Medical problems’ category

It’s time to rethink pertussis prevention

February 8, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A large, sobering study published in the March, 2016 edition of Pediatrics illustrates just how far we still need to go to effectively control pertussis.

Pertussis, also known as ‘whooping cough’, is a serious illness. Older children and adults get to enjoy a horrible cough for about three months—a cough that sometimes makes people vomit, break ribs, or pass out. Seriously. You haven’t seen a “bad cough” until you’ve seen the cough of pertussis. Worse: in little babies pertussis can cause breathing problems, seizures, and death. Though its caused by a bacteria, antibiotics (unless given very early) are ineffective at reducing the length or severity of pertussis. Prevention, in this case, is worth far more than a pound of cure.

Up until the mid-1990s, infants and children routinely received the whole-cell DTP vaccine (DTP = diphtheria, tetanus, pertussis.) It worked at preventing all three of these diseases, but had a relatively high rate of side effects, mostly fevers. Many of the suspected more-serious side effects (like encephalopathy and seizures) are now known to have been caused by genetic conditions, not the vaccine, but nonetheless parents and doctors alike welcomed a newer vaccine, the acellular DTaP. This newer vaccine, which replaced DTP in the United States by around 1998, caused fewer fevers, and was thought to cause fewer serious reactions, too.

The problem is that it just doesn’t work as well. And as the first generation of infants to get an all-DTaP series starts to go through adolescence, we’re starting to see the unintended consequence of that vaccine change.

In the current study, researchers used a huge database of information from the Kaiser Permanente system of Northern California. We’re talking solid, big-data research, here, the kind of study that requires consistent and reliable data across a huge set of patients. In this case, about 3.5 million patients across 55 medical clinics and 20 hospitals, using centralized labs and an integrated medical records system. If health things happen to this population, Kaiser knows it.

In 2010 and again in 2014, California experienced large epidemics of pertussis. A total of 1207 cases were among Kaiser teenagers, all with complete records of their pertussis vaccination status. And the results aren’t anything to be happy about. In the first year after an adolescent pertussis (Tdap) booster, the vaccine was about 70% effective in protecting against pertussis. Not great, but not terrible, either – until you look a few days down the road. The vaccine effectiveness drops off dramatically, year after year, down to only about 9% by four years after receipt of the vaccine.

Why does Tdap seem to provide such poor protection—much worse than was seen in the original licensing studies? It’s a generational change, and it goes back to the shift from DTP to DTaP in the mid-1990s. By now, these teens in California are old enough to have received DTaP, not DTP, as infants. The authors looked at the specific ages of pertussis cases during the 2010 and 2014 outbreaks, and the trends support the conclusion that teens who received DTP as infants get good, lasting protection from Tdap; teens who got DTaP do not.

Now what? Clearly, we need a more-effective vaccine, perhaps even resuming the use of whole-cell pertussis vaccine, at least for the earlier doses. But in the meantime, we have to do the best we can with what we have. Vaccinating pregnant women with Tdap does effectively prevent pertussis in their babies, especially when they’re the youngest and most-vulnerable. And adults (who got DTP as children) should get Tdap boosters too, to protect the children around them. Another idea (floated by the study authors) is to use Tdap in teens not as a routine booster, but as a strategy to control local outbreaks, taking advantage of the higher effectiveness seen for the first year after vaccination.

I don’t have the answers. I’m not happy to see studies like these, but examining and re-examining vaccine safety and effectiveness is something we need to continue doing, with an open mind, relying on solid evidence. Bottom line: with pertussis, we need to do better.

Whooping crane

Which doctors get sued the most?

February 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

A study published this week in the New England Journal of Medicine can teach us a few things about doctors and lawsuits. While many docs will go their entire careers without a single malpractice suit, a small proportion seem to attract a whole lot of litigation. There might be a lesson there.

It’s a big-data study, to say the least. Professors from both the Stanford, CA medical and law schools put their huge-brained heads together, along with collaborators from Australia and the US Department of Health and Human Services. They used the National Practitioner Data Bank (NPDB), a “confidential” depository of all paid lawsuits in the US, along with American Medical Association data on every single doctor, MD and DO. 10 years of data, from 2005 through 2014, were examined, including information on 66,426 malpractice suits from 915,564 physicians. The NPDB only includes information on “paid claims”—meaning a verdict or settlement that results in money going to a plaintiff. Lawsuits that were dismissed or dropped could not be included in this study.

Some interesting findings:

  • Only 6% of physicians, overall, had a paid claim in the 10 year study period. In other words, the vast majority of docs don’t settle or lose lawsuits.
  • Only about 30% of filed claims result in any payments at all—most lawsuits are just dropped without money changing hands (this was not from the data of the current study, but from a reference in the ‘discussion’ section.)
  • Only 3% of paid claims went to satisfy court verdicts. When malpractice suits end with money changing hands, it’s nearly always as a settlement, not as a verdict. These things, it turns out, rarely “go to court.”
  • The mean claim payment was $371,000; the median was $204,000. If you wish to learn more about the difference between mean and median, go back to middle school.
  • Though most physicians had zero claims, a disproportionate number accounted for multiple claims. Approximately 1% of all physicians owned 32% of all monies paid to plaintiffs, and just 0.2% accounted for 12%.
  • A physician’s risk of future claims – of being successfully sued ‘again’ – increased by more and more as the number of previous lawsuits accumulated. Compared with physicians who had been sued once previously, physicians who had been sued twice had twice the risk of a subsequent lawsuit; physicians with three previous claims had three times the risk of another recurrence. It goes up even more from there.
  • Male physicians had about a 38% higher risk of a subsequent lawsuit, and younger physicians had a lower risk than older docs.

What can we learn from all of this? Though malpractice litigation and a “fear of lawsuits” is a frequent topic of discussion among physicians, most of us don’t get sued, most suits don’t get paid, and even suits that do get paid are usually in settlements, not at the end of court dramas. And a relatively small number of docs seems to account for a disproportionately large percentage of legal action.

The authors of this study didn’t speculate on why some docs are sued more frequently than others. An overly-simple answer is that some docs just aren’t very good—but that misses some important truths. The risk of a lawsuit is only partially related to bad medicine and bad outcomes. A lot of the risk, really, comes down to poor communication, and sometimes bad luck. It’s also likely that some of these “frequent targets” are docs who serve the riskiest, sickest patients that no one else will touch. Those very fragile patients likely have the worst chance of a good outcome, even though thy might be under the care of the most talented and smartest docs. No good deed goes unpunished, you know. Still, if you learn that your doc has been sued 7 times, it might be time to go looking for another physician. You don’t want to end up on the plaintiff’s side of the table.

I fell asleep.

Vitamin D for winter eczema – Try it

January 28, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Eczema is a chronic, itchy skin condition seen in about 1 in 3 children. The skin is dry and scaly, and often red and inflamed. Eczema often seems to get worse in winter, in part because hot dry air from the furnace further dries out the skin.

Or, maybe, there’s another reason. Researchers in Ulaanbaatar, Mongolia (which, by the way, looks lovely) postulated that another reason for eczema to worsen in winter was decreased vitamin D levels. Most of us get our vitamin D from sunshine, and in the cold winters people spend less time outside. Less outside, less sunshine, less vitamin D. So what happens if you supplement children with eczema, and have them take a drop of extra vitamin D in the winter?

107 children were enrolled in the study, which was published in 2014. The average age was 9, and almost all of the children had what the authors characterized as “moderate” eczema. Half of the children were randomized to receive a vitamin D supplement (1000 IU once a day), and the other half a placebo drop; all of them were instructed to continue their typical eczema care, which usually consistent of skin moisturizers. A simple, clean study.

A month later, data were collected. There were no significant (or even mild) side effects in either group. 64% of the children who received extra vitamin D had improved skin, versus 43% in the control (placebo) group. Not a huge difference, but with an intervention that’s safe and cheap, that’s an important result that can potentially help a lot of children.

Some criticisms of the study: the authors didn’t check vitamin D levels before or after the intervention—so we don’t know if the children were actually vitamin D deficient, or if vitamin D supplementation was more likely to work in children with low levels. And the study didn’t involve many younger children (who are more likely to have eczema), and didn’t include any children less than 2 years of age.

Still: many children, we know, are vitamin D deficient, especially in the winter; and many children suffer from itchy eczema. At usual doses (like 1000 IU a day), vitamin D supplements are virtually free of risk. Worth a try, if your child has winter eczema? You bet.

Mongolia

Parents are tired

January 27, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

This just in, from the CDC: many adults wake up not feeling well-rested, especially those with children, and especially-especially those with young children. Here’s the graph:

I need a nap

See? Of adults surveyed, aged 18-64, about 35% said that they often wake up unrested. That increases to about 40% if they’ve got school-aged children, and 50% if they have children in the house less than 3. Women in every category feel less well-rested than men.

Glad that’s settled.

Norovirus: The real “stomach flu”

January 21, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Informally, it’s sometimes mistakenly called “the stomach flu” or “a tummy bug”—an illness with some aches and fevers, but mostly vomiting and diarrhea, that often occurs in mini-epidemics in households, daycares, and schools. One kid gets it, and the rest of the dominoes fall, in a most unpleasant and stinky manner.

Yuck.

The illness has nothing at all to do with influenza, by the way. Influenza is a respiratory virus, spread by mucus, that mainly causes aches and fever, along with cough and sometimes some vomiting or abdominal pain. Influenza cases are concentrated during a few months of winter, and there’s a vaccine that can prevent at least some cases.

The “stomach flu” isn’t a flu at all. Technically, we call it an “acute gastroenteritis”, with inflammation of the stomach and intestines, sometimes shortened to just a “gastro” or “AGE”.  These days, the most common cause, year-round, is a nasty and clever little virus called “norovirus”, or “noro” for short. (Docs are always in a hurry. We prefer short words.)

Here’s a lovely thought: volunteers who touched a surface smeared with 30 microliters of infected feces—that’s about half of a drop—all got enough virus on their hands to potentially make them sick. And, get this, if they then touched a doorknob or telephone or another surface, that would transfer enough virus to get the next person sick. In fact, 10 people in a row, serially touching surfaces one after another, would all potentially get sick after the first person touched that first surface, with half a drop of stool. Seriously. Someone did this experiment.

The incubation period between contact with the virus and symptoms is 12-48 hours, though people who are becoming sick become contagious before symptoms start. Though the illness itself is usually brief, typically lasting only a few days, virus continues to be shed in the stool for several weeks, and maybe at low levels for even longer. Both vomit and diarrhea can be loaded with infectious viral particles – and it’s so contagious that documented transmission has occurred in people just walking through an emergency department near someone who has been vomiting.

There is some good news. The virus itself cannot make you sick if it just gets on your skin. It has to invade your body through a “mucus membrane,” like your mouth or nose or eyes (this is true of almost all infectious, by the way—they need a break in the skin barrier or a wet membrane to get through). So as long as you wash your hands well before you eat or drink or touch your face, you ought to be OK.

“Wash your hands well” – that’s not so easy. A CDC-recommended decontamination handwash is 60 seconds of rubbing with soapy water, a 20 second rinse, and drying with disposable paper towels. Do that before and after every patient (as every health care worker should), and by the end of the day your hands will be bloody cracked dry stumps (OK, maybe it’s not that bad. But my knuckles get pretty raw. I know, boo hoo me.) Hand sanitizers containing 70% alcohol help, some, though they’re no substitute for full-on soapy water hand washes.

If vomiting and diarrhea does strike your children, here’s what you ought to do:

  • Keep them home. Please, please keep them home.
  • Wash hands well, and wash hands frequently.
  • Decontaminate surfaces with diluted bleach. Standard detergent sprays help, but bleach is da bomb.
  • Offer frequent, small sips of fluids. They don’t have to eat (and don’t make ‘em eat if they don’t want to), but continued fluid intake is essential.
  • Seek medical attention if your child shows signs of significant dehydration, especially listlessness, an inability to drink, or very little urine output.

Get me a bucket

New Zika travel alerts especially for pregnant women

January 18, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

What animal kills more people, year to year, than any other on the planet? The lowly, annoying mosquito. They fly around poking their snouts (I think) into person after person, spreading infections like malaria, yellow fever, and dengue. And new infections, too—like West Nile virus, which first appeared in Uganda in 1937. Infections don’t seem to recognize the borders of countries and continents, and West Nile has now become the most common mosquito-borne encephalitis in the US.

Now, the CDC is warning travelers against an even newer virus named “Zika”. Like West Nile, Zika was first found in Uganda, in a research station in the Zika rainforest (Zika means “overgrown” in the local language.) It remained an uncommon cause of human infection until the mid-2000’s, when the virus was first spotted outside of Africa and Southeast Asia. Since then, it has spread worldwide, throughout the warmer areas of the globe, leading to a large outbreak in Brazil that may have started with visitors to the 2014 Soccer World Cup. Brazil has probably had 500,000-1.5 million cases of Zika virus infection in the last few years.

Zika had been thought to cause only mild disease, with fever, rash, and joint pains. But at around the same time as the cases spiked in Brazil, health authorities there noted an alarming increase in health problems in newborns, especially a failure of brain growth called “microcephaly.” It’s since been shown that an unborn fetus can catch Zika virus across the placenta, and it’s very likely that the Zika virus infection is causing problems in the developing baby. We don’t know exactly how that’s happening, or when, or exactly when pregnant moms and babies are vulnerable.

What we do know is that like malaria, dengue, West Nile, and Chikungunya, Zika virus is spread by mosquitoes, and the best way to prevent transmission is to prevent mosquito bites. Stay inside at dusk, wear protective clothing, and use a chemical mosquito repellant containing DEET or picaridin.

The CDC has also now issued a “Level 2 Travel Alert” for areas with active Zika transmission, including Brazil, Puerto Rico, Mexico, and most of the rest of Central and South America. That means “practice enhanced precautions”, and applies especially to pregnant women.

Meanwhile, in the US, the first reported case of Zika virus infection occurred in Texas in November, 2015, in a woman who had recently traveled to El Salvador. And a resident of Puerto Rico recently developed Zika with no history of travel off the island—meaning that Zika is probably being transmitted by local mosquitos, now. It is only a matter of time for mosquitos in the rest of the warmer parts of the US to start spreading it around here.

It’s a big world, and the health problems of Africa are our health problems, too. New infections will continue to emerge. We’d better keep paying attention, and keep an eye on those mosquitoes.

Ew, Zima

Can medicines relieve coughing?

January 4, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Wzrd1 asked, “What are your thoughts on expectorants?”

One of the most common reasons for office visits to me, especially in the winter, is coughing. No one really likes to cough – not the kids, and certainly not their parents. Everyone wants the coughing to stop.

First, though, think about what a cough is – it’s a forceful pop of an exhale that can bring up mucus from the airways. If you’ve got a cold with excessive mucus, or you’ve inhaled some dust, or there’s a bacterial infection with pus down in your lungs, the only way to get that stuff out is to cough it up (and, typically, swallow it back down into your stomach. From there it can be digested on its way out of your body. Isn’t science fun?) The alternative to coughing is to just let the yuck sit down there. Coughing has a purpose, and it’s a good thing.

Yeah, I know. Try telling that to a parent or child at 2 AM. Besides, no one wants a coughing person at school or at work, spraying their mucus around. I get it. So it sure would be nice to have something, anything, to at least slow that cough down some.

Now, if your child has asthma or cystic fibrosis or some other lung thing, it’s best to treat the underlying cause of the cough. For the rest of this post, I’m talking about only non-specific, mild, ordinary coughing. The kind that goes with an ordinary “cold” or “chest cold” or “bronchitis” (which, by the way, are all the same thing. But that’s a topic for another time.) If your child has a cough with a high fever or trouble breathing, or has chronic lung problems or heart disease, go get it checked out.

Most of the time, though, a cough is just a cough. Medicines available to help with cough fall into just a few categories:

Cough suppressants, like dextromethorphan (OTC) or the narcotic codeine (Rx). These either make you too sleepy to cough, or somehow “suppress” the cough centers of your brain to trick you into not coughing. Stronger ones, like codeine and similar compounds, can cause respiratory depression and death, which is bad.

Expectorants, like guaifenesin (OTC). These supposedly “thin the secretions”, making them easier to cough up. Sometimes, expectorants and suppressants are combined into one product, which I suppose makes it easier to cough while simultaneously stopping your cough. Honestly, I get a headache just thinking about why that would be a good idea.

Antihistamines, which block many allergic reactions. These will help if a cough is caused by allergy (clue: if there is also runny/itchy eyes and nose, that might be the case.) Older antihistamines like Benadryl also make people sleepy, so they won’t notice the cough. Maybe that’s good.

Do these medicines work? There are dozens of studies out there, using a variety of doses and ways to measure coughing. The bottom line, summarized here, is that better-quality studies with more-objective measures of coughing and appropriate use of placebo comparators have not consistently shown any effectiveness for any “cough medicine”, used alone or in combination. And there have been significant side effects, especially from antihistamines and narcotic-based cough suppressants.

About expectorants specifically: basic science studies, like this one, have failed to show that expectorants change the way mucus appears or is cleared by cilia. And clinical studies from the 1980’s showed no change in objective or subjective cough scores.  There have been zero—zero!—good quality studies of expectorant use in adults or children for coughing in the last 20 years. I did find one case report of a man who had improved sperm motility when he was treated for infertility with guaifenesin, but I don’t think that’s exactly what most parents are looking for.

In fact, the only positive news about cough treatment I found in the recent literature was in support of honey for the relief of coughing in children one year and up. Three good randomized trials have been published in the last few years, all showing that honey is better than either placebo or “cough medicine”.  We’re not talking honey-based “medicine”, here – that’s for sale, but you don’t need it. Just good old honey, typically from a bottle shaped like a bear. It works, it’s cheap, it’s safe for children 1 year and up. Give it a try. And teach your children to cough into their elbows. That’s honestly the best you can do.

Honey badger don't care

 

 

 

 

 

 

 

 

 

 

 

 


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