Archive for the ‘Medical problems’ category

Can a genetic test tell you if a medication will work?

January 14, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

“Personalized” medicine sounds appealing. Rather than just guessing at what medication to try, a genetic test can figure out, in advance, which medications will be effective and which medications are more likely to make you sicker.

Except it doesn’t work. It’s mostly marketing and hype.

The FDA has officially warned consumers and physicians that genetic tests sold to predict patient responses to medications shouldn’t be used. They’re not FDA approved, and in most cases there’s no reason to think that these tests can accurately predict how a medication is metabolized or what it’s likely to do when you take it. These tests are being aggressively marketed to the general public and to physicians, and they don’t deliver what they promise.

Medicines for conditions like depression, acid reflux, and heart disease have been highlighted by the FDA – though many other medicines have become targets for these tests, too. And these tests do reveal certain genetic “polymorphisms” (variations) that all of us carry, variations that affect the way medicines are metabolized and processed in our bodies.

The problem is that our knowledge about these polymorphisms is rapidly evolving, and it’s far from complete. It turns out that dozens or maybe hundreds of genes can have overlapping functions, and (with few exceptions) we don’t yet know all of the genes involved. And for each gene, there may be hundreds or thousands of variations in the general public. Or, maybe, some of us have a unique variant that hasn’t been seen before. These companies have no way to test the gene variants to know their function. They rely on proprietary databases, riddled with incomplete data and assumptions.

Just one example: when the MTHFR gene and its variants was first described, it seemed like MTHFR polymorphisms could have wide-ranging and significant health effects. It turned out that’s completely wrong. MTHFR “variations” are so common in the general public that it’s fair to say we all have polymorphisms, and almost none of these has any clinical importance. Even the 23andMe company, which makes money selling genetic tests, discourages MTHFR testing, saying “Despite lots of research – and lots of buzz – the existing scientific data doesn’t support the vast majority of claims that common MTHFR variants impact human health.” Still, many families are still relying on misguided MTHFR testing pushed by naturopaths and chiropractors to make health decisions. And this is just one of the hundreds of genes these kinds of tests rely on.

Genetics shows great promise, and I think the future includes a big role for genetic testing. But we don’t have the knowledge, yet, to use the results of these tests to better-guide therapy. But that doesn’t mean that therapeutic decisions, now, are entirely guesswork. Reviewing a family history and the exact nature of a problem often gives physicians some good clues to help guide decisions. I know, that sounds old-fashioned. But talking and listening remain the best ways for docs and patients to work together to make the best decisions.

 

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The safest peanut allergy policy for schools is …

January 3, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

Peanut allergies can be a serious problem, and many exposures happen when our kids are at school. On average, there are probably about 5 peanut-allergic children in each of our nation’s 100,000 school buildings. What’s the best policy for schools to use to help protect these kids from potentially fatal reactions?

Different schools have taken different approaches, and as far as I can tell there is no authoritative national guideline to tell them what to do. So they’re “winging it.” Choices include:

  1. Having a 100% peanut-free school – no peanuts served, no peanuts allowed to be brought in.
  2. Not allowing peanuts to be served, but allowing kids to bring their own peanut-containing foods if they wish.
  3. Setting aside peanut-free classrooms.
  4. Setting aside peanut-free lunch tables.
  5. Having no specific policy, and hoping for the best.

Some schools have combined or blended these policies, and (hopefully) most also include an educational component for both teachers and students not to share foods. But the question remains: which of these really works to help prevent serious allergic reactions?

An August, 2017 study in the Journal of Allergy and Clinical Immunology provides some clues. The study was done in Massachusetts, where school nurses are required to report any administration of epinephrine. Since epinephrine should always be used for serious allergic reactions, those reports are a good way to track what’s going on. The circumstances of every epinephrine administration were reviewed, and only those given for nut or peanut reactions were included in the analysis. The authors also surveyed all of the Massachusetts’ school nurses to compile feedback on each school’s peanut policies, to see which policies were most successful in reducing the need for epinephrine.

The results might surprise you. Self-designated “peanut-free” schools had higher rates of administration of epinephrine than schools without a peanut-free policy. Now, the numbers of reactions were small, here, and different schools defined or enforced their policy of “peanut-free” in different ways. Still, a “peanut-free” designation was no panacea. It did not make epinephrine unnecessary, and was associated with an increased rate of peanut reactions. The authors speculate that this may be because the “peanut-free” school label may lead to a false sense of security.

The only policy that was associated with a decreased rate of epinephrine use was setting aside peanut-free tables in eating areas. Perhaps that’s because this kind of policy is easier to enforce.

Peanut-restrictive policies are an important part of protecting allergic kids, but they may have some downsides. Peanut-allergic children may be socially excluded or suffer bullying. And non-allergic kids may rely on peanut products as a healthy and inexpensive part of their diet. Whatever policies are pursued, they should be guided by the best evidence – what really works, and what best promotes the overall health of all of a school’s students?

Blanket policies may be less effective than a combination of several elements. Schools at every grade need to teach their students and faculty about food allergies and how to avoid exposures. And every food-allergic child needs an individualized plan that considers their risk of a life-threatening reaction along with their own ability to monitor their food intake. Epinephrine should be readily available in classrooms and eating areas (without requiring each individual child to have their own personal devices – that’s wasteful and expensive and awkward.) I know, that’s complicated and takes work. Schools prefer an easy-to-spell, one-sized-fits-all approach. Kids deserve better.

Acute Flaccid Myelitis – what parents need to know now

November 16, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

You’ve probably seen it on the news – a rare, polio-like illness is causing cases of paralysis in children. Here’s the latest info, based on our best current knowledge from the CDC.

AFM is a sudden illness that causes weakness in one or more extremities – one arm or (less likely) a leg, or any combination of arms and legs. The words in the name express the key features: it’s acute, beginning over hours or sometimes a few days; it’s flaccid, meaning the affected body parts are floppy and weak; and it’s a myelitis, meaning the disease occurs in the spinal cord. The muscles are fine, the brain is fine, but the area of the spinal cord that carries signals to the muscles becomes inflamed and stops working. You can see distinctive changes on an MRI scan of the spine to help confirm the diagnosis.

The first cases of what was later named AFM were reported in California in 2012. The CDC started closely tracking cases of AFM in 2014, when a surge of reports about the illness began to appear in the United States and overseas. Since then, we’ve seen a striking pattern, with most cases occurring in the late summer and early fall, August through October. In the US, we’ve also seen an unexplained pattern where most cases occur in spurts every other year – in 2014, 2016, and now again in 2018. 2015 and 2017 had far fewer cases.

Over 400 cases of AFM have been reported in the US over the last four years, including about 80 in 2018 so far. Most states have reported at least one case, including Georgia. There doesn’t seem to be geographic focus in any area. Overall, the rate is less than one in a million people – AFM is a very rare disease. Almost all cases of AFM have occurred in children, at an average age of 4-6 years.

Several different viral infections have been found in children with AFM, though it’s unclear that these viruses were the cause of the symptoms. The most-commonly associated viruses are from a family called “enteroviruses”, including one that has been implicated in groups of acute severe respiratory disease called enterovirus D68. Other viruses have been investigated including West Nile or Japanese Encephalitis viruses, herpes viruses, and adenoviruses. Most commonly, no specific viral infection is found. The cause of most cases of AFM is unknown.

Still, it seems most likely that a viral infection is the trigger, because of the seasonality of the disease and its propensity to strike children rather than adults. Similar symptoms were once seen with the polio virus, and multiple tests for polio have been performed in  children reported with AFM. But it’s never been found — polio itself is not the cause AFM in the United States or abroad. The CDC is continuing to investigate the possibility of one or more viral triggers, an inflammatory condition triggered after a viral infection, or a possible environmental trigger as causes of AFM.

Children with AFM typically have a preceding illness with fever, runny nose, cough, vomiting, or diarrhea 1-2 weeks prior to the beginning of AFM symptoms. Often these common viral symptoms have resolved by the time AFM begins, with its rapid onset of limb weakness. There may be near-complete paralysis (inability to move the limb), or varying degrees of weakness. Sometimes, symptoms including stuff neck, headache, or pain in the limbs accompanies the weakness. It’s also sometimes possible for AFM to affect the nerves in the upper neck and head, causing a face or eyelid droop, difficulty swallowing or speaking, or a hoarse or weak voice.

Children with AFM need to be hospitalized. Many tests need to be done to narrow down the diagnosis and rule out other causes of weakness (including blood tests, a lumbar puncture, and MRI scans.) Children with AFM can develop weakness of the muscles that help them breathe, and may need to be treated in an ICU. Neurologists, infectious disease specialists, and public health officials will all help guide care.

There isn’t solid evidence that any specific treatment is effective, since good clinical trials of therapy haven’t been performed yet. It’s been difficult to study AFM because it’s so rare, and the disease progresses quickly. In addition to supportive care, many people with AFM have been treated with intravenous immunoglobulin, steroids, and plasmapheresis. Though some children with AFM have recovered quickly, many continue to have lasting paralysis requiring long term care.

So what should parents do about this? First, there’s no need to panic. The press and Facebook like to stir up trouble with blaring headlines and clickbait titles – but remember that AFM is really rare, with about 100 or so cases a year occurring across the entire country. Polio caused about 15,000 cases of paralysis a year in the 1950’s before a vaccine was introduced. We’ve come a long way, and your children are, overall, far safer than children have ever been from infections, environmental illnesses, and trauma.

Some common-sense steps can probably help. Most cases of AFM seem to have a viral trigger, so avoiding infections is a good idea. Teach your children to practice good handwashing, and keep them out of group care when they’re ill. Though we don’t have a vaccine to prevent AFM, vaccines can prevent the neurologic complications of other infections like influenza, measles, and mumps – so be sure to keep your child fully vaccinated. And seek care immediately if your child becomes weak in one or more limbs.

And, please, support your public health community and the scientists who work to keep your children safe. There’s always another new health challenge out there (Ebola, Zika,  SARS, and MERS, to name a few.) We need to keep our public health infrastructure strong to help tackle AFM and whatever the next challenge turns out to be. Go science!

More info from the CDC’s AFM home page, the October 2018 CDC press briefing, and the November 2018 webinar for clinicians

Support for HPV vaccination continues to grow

September 24, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Two new studies have added to the enormous weight of evidence in support of HPV vaccination.

From Pediatrics, September 2018, “Primary Ovarian Insufficiency and Adolescent Vaccination”. This study looked at almost 200,000 young women enrolled in the Kaiser health system from 2006 to 2014, looking at rates of ovarian failure in women who had received vaccines versus women who didn’t. The study was triggered by concerns about ovarian failure related to HPV vaccination – concerns that continue to swirl on Facebook and other social media sites. The study showed that HPV vaccine didn’t trigger ovarian failure, even after an exhaustive search allowing for an association at any time period after vaccination. It just isn’t there. And ovarian failure wasn’t caused by other teen vaccines, either.

And, from Pediatrics August 2018, “Legislation to Increase Uptake of HPV Vaccination and Adolescent Sexual Behaviors”. Another concern that’s been raised is whether encouraging HPV vaccination interferes with “safe sex” or abstinence messaging. By encouraging a vaccine to prevent a sexually transmitted infection, are we giving permission to our children to have sex? This study looked at that question through the lens of how the individual States have approached HPV vaccine legislation. Some states have passed specific laws to encourage HPV vaccines; others have not. It turns out that adolescent sex behaviors, including having sexual relationships and using condoms, isn’t affected by how strongly their states encourage HPV vaccines.

 

Neither of these specific studies is a slam-dunk – and that’s the way science can be. We accumulate more and more evidence as time goes by. But they add up to what we can say with confidence: HPV vaccines are safe, and HPV vaccines can help protect your children from cancer. It’s a compelling story, and something parents ought to feel good about. There is no reason to hesitate – make sure your children are protected and up to date.

 

Key studies on HPV vaccination

A huge, comprehensive review of studies from May, 2018 showed that “There is high-certainty evidence that HPV vaccines protect against cervical precancer in adolescent girls and young women aged 15 to 26.” (Earlier review here) This study from August 2018 documented dropping cancer rates after the vaccine was introduced. The vaccine is working, and it’s saving lives.

A 2010 review of post-licensure studies showing good safety profile, and another large study of 600,000 doses in 2011 didn’t find any important safety concerns. Another 2012 study found no significant problems after almost 200,000 doses. These are big, reassuring studies that all say the same thing: HPV vaccination is safe.

Studies showing HPV vaccines do not cause chronic fatigue, autoimmune diseases, complex regional pain syndrome or postural orthostatic tachycardia syndrome. These and other studies looking for specific diseases or conditions caused or worsened by HPV vaccines have all been reassuring – these vaccines aren’t associated with these or any other worrisome health conditions.

When polio was wild

September 12, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

“Polio. I’ve seen polio.”

Last night, I was speaking with one of the most experienced pediatricians I’ve ever met, Dr. Jack Burstiner. I’ve known him for 50 years. I would have known him even longer if I had been born earlier. He lived in my neighborhood, two doors down. He was my pediatrician.

Jack is almost 90 years old. But he still looks like a pediatrician. He’s got a smile a child could trust, now hidden under a white mustache. His green eyes twinkle when he talks about his patients, the kids he’s seen. There are some things about a pediatrician that never change.

Though he stopped practicing in the 1980’s, Dr. Burstiner worked for 30 years in pediatrics, at a time when pediatricians did everything. Hospitals, emergency departments, newborn deliveries, everything. And in 1955, just starting his training, Dr. Burstiner was a pediatric intern at Kings County Hospital, Brooklyn. It was a busy hospital, sure, but it was especially busy in the summer. Polio season.

“That’s where they’d all come, the kids with polio. They didn’t look right. They’d be dragging a leg, or not moving right. Sometimes an arm wouldn’t move, but usually a leg. And all night, every third night, I admitted all of them. It was just me. I’d do the spinal tap, and I’d look in the microscope, and I’d count the cells. If they had a lot of cells, that was polio. Of course we knew it anyway, but we had to tap all of them to be sure. All night long.”

Polio is caused by specific virus, an enterovirus that circulates especially in the summer and fall. It’s spread by contaminated water, sometimes in swimming pools or from unsafe taps, or from household contamination via stool. Most kids with polio develop a fever and then recover, but many develop paralysis of their skeletal muscles. It doesn’t affect their thinking, or their ability to feel sensations or pain. But it can make it impossible to walk or use other muscle groups, and can sometimes shut down the muscles that keep them breathing.

“It’s funny,” Dr. Burstiner said. “It was a big hospital, and upstairs – up above the emergency department, and the wards, the rooms the patients – upstairs were some of the smartest people in the world. They had dedicated their whole lives to fighting polio, and they knew all about it. But we still couldn’t really do anything to treat it. I was there, this intern, and I could tap them and I’d admit them, and then hopefully they’d keep breathing.”

In 1955 there were about 29,000 cases of polio in the United States. Dr. Burstiner estimates he admitted about 100 of those, ten a night, on the every third overnight he worked at the Brooklyn Hospital for one month during that hot summer.

“100 cases, I think I admitted, just in that one month. And all of those smart people upstairs, what could they do? But you know what happened next? The vaccine came out, and everyone wanted it. And in just a few years, it wasn’t 100 a month in one hospital. There wasn’t any, there was no polio anymore. I saw more polio in that one month than there was in the entire country, just a few years later.”

The first polio vaccine was introduced in 1955. By the mid-sixties, there were fewer than 100 cases of polio per year in the United States. We beat it. There have been zero cases of polio transmitted in the US since 1979; the last imported case to reach our shores from overseas was in 1993. There are still pockets of polio transmission, but it’s very possible the disease will be wiped off the earth entirely in the coming years.

Dr. Burstiner and I talked a while more, trading war stories, talking about cases. I’ve never seen polio, but I have seen children die of pneumococcal meningitis, and I’ve seen complications of chicken pox that put children in the ICU for weeks. Those are some of the diseases I may have the pleasure of never seeing anymore. Maybe someday I’ll tell the next generation of pediatricians about how we knocked out rotavirus diarrhea, and HIB septicemia, and HPV-related cancer. Measles, diphtheria, hepatitis A and B, we’ve got the tools to beat these and other diseases. We just need the will to see the fight to the end.

There’s a lot that hasn’t changed. Parents still worry about their kids, and kids still get sick. But there are many diseases that parents just don’t have to worry about anymore. That’s incredibly good news for you and your family. Protect your children, protect your communities, and help be a part of making the world healthier for the future. Vaccinate.

ADHD meds don’t help students without ADHD

September 4, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

College students work hard, and many are looking for ways to improve their studying and learn more effectively. Getting more sleep and more exercise would probably help, but up to a third are trying ADHD medications to see if pills can give them that extra boost. A small, recent study shows that they’re not getting the effect they’re looking for.

We’re not talking, here, about teens who have ADHD. There’s robust evidence that medical and non-medical therapy helps people with ADHD stay focused, and medication can help them succeed. But what about the far-larger number of college students who don’t have ADHD. Can they benefit from the same medications?

Researchers at two universities in Rhode Island – a tiny state, but they’ve got 12 colleges overall – picked 13 healthy student volunteers to take tests of their cognitive ability, memory, and other academic measures. They took these tests in a random order on 2 different days. But on one day, they also took the commonly-used ADHD medication Adderall at a nice hefty dose of 30 mg. On the other day, they received placebo. The researchers were then able to compare the differences in their performance.

Some things did change. On Adderall, blood pressure and pulse were higher, as were self-reported positive emotions and energy. However, there were very small effects on actual cognitive or thinking ability, with some small positive and some small negative effects. Working memory – the ability to recall information – was much worse with the medication. Overall, Adderall did not help these college students study better or learn more.

This was a small study, with only 13 subjects. But the results are striking. On college campuses, medications like Adderall are being used both as study aids and as a way to stay up longer and party harder. But they’re not without risks, including depression, psychosis, weight loss, and addiction. These are serious medications, and while they can have a role in helping some people, they ought to be only used when necessary, under medical supervision.  They’re not for everyone, and especially not for most college students looking for a way to improve their grades.

Urgent care centers lead the way in unneeded antibiotic prescribing

July 23, 2018

The Pediatric Insider

© 2018 Roy Benaroch, MD

Urgent care centers are way ahead in prescribing unnecessary, potentially harmful antibiotics that are doing no one any good – at least no patients any good. The owners of the urgent care centers are the ones who are benefitting. And you and your family are being bilked, misled, and harmed.

A July, 2018 study published in JAMA Internal Medicine looked at the proportion of antibiotic prescriptions that were made for viral respiratory infections – things like the common cold and bronchitis. These are viral infections, caused by viruses (sorry if I’m hammering that too much – but obviously it bears repeating.) The researchers looked at over 150 million visits to emergency departments, urgent care centers, retail pharmacy clinics, and medical office visits to compare the rates of inappropriate prescribing between these settings.

Why is this important? Because antibiotics will not help anyone who has a viral infection. But they can lead to allergic reactions and serious complications like C. difficile colitis. They also contribute to antibiotic resistance, or the emergence of so-called “superbugs” that we can’t kill with any antibiotics. This is not just a theoretical problem – it’s a huge a growing nightmare occurring in hospitals all over the world. Some bacteria have figured out how to evade all of our antibiotics, and it’s entirely our fault.

Big differences were found in the rates of inappropriate antibiotic prescriptions. In ordinary medical offices, 17% of respiratory viral infections were treated with antibiotics. That’s way too high, and we need to work on that. But even worse: emergency departments prescribed antibiotics for about 25% of these viral infections. And topping the list was urgent care centers, where 46% of viral respiratory infections were treated with antibiotics. That’s about three times as bad as regular office visits.

The best prescribing habits – and they deserve credit for this – was found at the retail pharmacy clinics, at about 14%. They often use protocol-driven clinical pathways which leave little “wiggle room” for the nurse practitioners that usually are on staff. I’ve been critical of these quick-minute-clinics before, and I still don’t think they’re a good place for children to be seen, but give them credit for not throwing around antibiotics.

But those urgent care centers – why are they so quick to write for an unneeded and potentially harmful antibiotic? Though this study didn’t look at potential reasons, one potential driver may be profit. Urgent cares may be especially quick to write antibiotics because they make more money that way.

Some urgent care centers sell the antibiotics (and other medicines) that are prescribed, so there’s a direct profit there. But more commonly, antibiotics are prescribed because it’s a quick way to give patient what they want, to get them out the door so the next patient can be seen. It takes much more time to explain why an antibiotic isn’t needed than it takes to write the prescription. And writing that prescription seems to feed a cycle of dependence – now, the patient thinks every cough needs an antibiotic. Repeat business!

It’s not just antibiotics that fly off the shelves at urgent care centers. They make money from lab tests and x-rays, too. I spoke with one urgent care center physician who had this to say:

Our pay was a small base compensation and all the rest was a percentage of our billing. The more patients you saw, and the more lab, x-ray and meds you ordered, the more you got paid. Plain and simple. So not only was prescribing an antibiotic lucrative, not wasting time explaining why was also lucrative.

Now, many urgent care physicians are good doctors who genuinely want to help people. And it’s convenient to have them nearby for quick visits. But their employees may be under financial pressure to over-prescribe and over-test – and that can affect the care that you get.

How can you protect yourself?

  • Tell the physician, plainly, that you don’t want an antibiotic if it’s not needed. The doctor may be assuming incorrectly that everyone wants a prescription. Tell her that’s not the case.
  • Have reasonable expectations about ordinary illnesses. Coughs and cold symptoms rarely need antibiotics, even when they make you feel miserable. Most sore throats are caused by viral infections. We know you want to return to work and feel better, but an antibiotic isn’t going to help.
  • Use your primary care physician’s office as your main site of care. Get to know your doctors, and let them get to know you as someone who isn’t there just to get a prescription. If your own doctor is one of those that’s quick to prescribe, think about why that might be the case, and think about getting a new doctor.
  • Prevention is key! Wash your hands, stay away from sick people, get a good night’s sleep, and get all recommended vaccines. Remember, immunizations are the real immune boosters.

Earlier:

Keeping the world safe from antibiotics

Fighting back the superbugs