Vol. 68 June 1, 2012 ECMO or Elmo for your child?

June 1, 2012

Nellie is a girl, a twin born 2 weeks prematurely in our pediatric practice. She weighed a beautiful 4 lbs. 10 oz at birth and was very healthly. At her two-month well baby visit she and her brother were clearly thriving in a loving, attentive family. She got her routine DTaP immunization (Diptheria/Tetanus/Pertussis) then. Thirty seven days later she came back to our office after vomiting three times the night before. Both twins were a bit fussy. We determined that the vomiting actually followed and was associated with several coughing spells. Her exam was normal, her lungs were clear, and she did not appear sick in any way.

The next day she returned to the office with difficulty breathing, had signs of pnemonia in her right lung, and was immediately admitted to our community hospital. Overnight in the hospital she developed pneumonia in the other lung and began to drop the oxygen level in her blood. She was transferred to a children’s hospital because she  now required a ventilator to be able to breathe.  The very next day she suffered almost complete cardiac-respiratory  collapse. Her lungs would not work at all. That is when they put her on the ECMO machine (Extra Corporeal Membrane Oxygenator, aka the “artificial lung”). Like a heart bypass machine the ECMO takes blood from the patient, circulates it through membranes with oxygen, and returns the oxygenated blood to the patient. Without that oxygen,of course, the brain and other vital organs begin to die. Her lungs had failed from an infection with pertussis, whooping cough.

Vaccinations nearly wiped out whooping cough more than 30 years ago, but it has made a vengeful comeback in California, Washington, and other states.

Cases of pertussis declined rapidly in the 1940s. The all-time low was in 1976, with only 75 cases reported in the United States. Since the early 1980s, there has been an increase in reported cases of whooping cough.

Why this resurgence?

Vaccination rates are decreasing as more parents refuse to have their children immunized against a number of preventable diseases.

But, that is not the whole story. Most of the new cases in California are in infants under two months of age, too young to be fully immunized (like Nellie). We also know that even with a full series of three to four pertussis immunizations only 85% of the children develop a level of immunity high enough to protect them. There is also recent speculation that the new pertussis cases are caused by a more virulent, mutant strain of the bacteria that can cause whooping cough even in those receiving our current vaccine. Studies have been launched to test that hypothesis.

One thing is clear. “Herd immunity”, protection of an individual infant by immunizing all the surrounding children in the community, is not enough for pertussis. Some states have refined the herd (community-wide) immunity  concept with a more focussed family-wide immunity concept, “cocooning”. Cocooning seeks to reimmunize for pertussis any adult caretakers of the infant, including the pregnant mother and all other adults surrounding the infant. The objective is too avoid any exposure of the infant to the pertussis germ in the first six months of life, or until the pertussis vaccination series can be completed. The easiest thing for adults to do is to get a Tdap (Tetanus/diptheria/pertussis) instead of their next regular tetanus booster—the Td shot – that is recommended for adults every 10 years.

THE OTHER EASIEST THING TO DO IS MAKE SURE YOUR CHILD OR GRANDCHILD GETS IMMUNIZED AGAINST PERTUSSIS STARTING AT TWO MONTHS OF AGE.

Currently there are 17 preventable diseases for which we give immunizations in the first two years of life. In 1980 we only had 7 vaccines. Those 7 vaccines contained over 3000 proteins (aka “foreign protein” by anti-vaccine advocates). In 2012 our more purified vaccines, including acellular pertussis vaccine (the “ap” of Tdap) with only 2 proteins, contain a total of  less than 200 proteins in all 17 vaccines.

Ellie was on ECMO for three weeks. Every attempt to remove her from the artificial lung resulted in a dramatic drop in blood oxygen and ECMO treatment was continued. Her kidneys , heart, and lungs were stressed to the failing point. Finally, her lungs began to recover from the pertussis infection. Yesterday they put her twin in the ICU bassinet with her, and her vital signs calmed right down and became even more stable. The two looked like they just “chilled out together” as twins do. Today she will have her breathing tube removed. We antiicpate that she will breathe on her own and continue to improve. We all wonder how her brain fared during all this stress. We shall see.  Some of us wonder what all this intensive care cost?

Make sure you do everything you can so your children to get to know Elmo rather than ECMO.

Let them have their immunizations!


Vol. 66 May 1, 2012 A Medical Business and Marketing Report

May 1, 2012

TOOTH FAIRY PRICE FUTURES UNCERTAIN

The price the tooth fairy pays has increased nearly 90% since 1998 to a high of $2.50 in late 2009, but after a 2010 correction in the average price Delta Dental has downgraded its future to “uncertain”. Delta has been tracking how much money kids have been getting for teeth left under pillows for their more than 100,000 subscribers. As illustrated by the graph showing the Dow Jones average and the tooth fairy average price, both took a hit in 2008. (1)

WHOOPING COUGH SURGES TO HIGHEST LEVEL SINCE WW II

There were more than 9000 whooping cough cases in California in 2010, a level unseen since 1940s. The number of cases in Vermont has gone from 18 to 102 in two years. The number of kindergartener who have been vaccinated against whooping cough (aka pertussis, or the “P” in the DPT vaccine) has dropped from 93% in 2005 to 83% in 2010. In Ashland Oregon the rate of unvaccinated children reached about 30%. Though the link between vaccinations and autism has been shown to be wrong, and it’s author a fraud, the far-fetched rumors on the internet continue to feed the unfounded fears about vaccinations held by many young parents. (2)

ROBOT’S STOCK VALUE ON “HOLD”

A survey of 600 men over the age of 65 who were operated on for prostatic surgery revealed that 27% of those undergoing open-surgery radical prostatectomy still suffered from significant urinary incontinence 14 months after surgery. But, 33% of those undergoing robotic-assisted laparoscopic radical prostatectomy reported urinary incontinence. After the usual caveats about differences between surgeons, the long learning curve for robotic surgery, and the lack of information in the survey about pre-surgical urinary incontinence, the editorial comment casually mentioned that 88% in BOTH groups had “moderate or big problems” with sexual function post-operatively.(3)

RAW MILK ADVOCATES CHEERED BY MARKET PRICE UPTICK

Between 1993 and 2006 over 4000 in the U.S. were affected in 121 infectious outbreaks from raw (unpasteurized) milk or cheese. Two-thirds of those affected were children who had more hospitalizations for these illnesses than adults. Most of these outbreaks occurred in states where the sale of raw milk and milk products is legal. (4) “Advocates of raw milk hold that pasteurization kills enzymes that make food digestible and bacteria that contribute to a healthy immune system….it tends to be richer and sweeter, and, sometimes, to retain a whiff of the farm – known to connoisseurs as ‘cow butt’.” But, raw milk is profitable. The largest raw milk diary in the world, with 430 cows in Southern California, produces 2400 gallons of milk a day which retail at $16 a gallon.(5)

SATISFIED PATIENTS PAY MORE FOR HEALTHCARE

A four-year study of over 34,000 adults interviewed about 18 variables revealed that the “most satisfied” patients had a 12% higher hospital admission rate, had 9% more drug prescriptions, and a death rate 26% higher than the “least satisfied” patients. The correlation between higher mortality and more patient satisfaction seems to contradict the adage that “more is always better.” (6)

STARBUCKS TO STOP USING MEAT BY-PRODUCTS

In response to an on-line petition with 6000 signatures Starbucks has announced it will stop using cochineal dye to color its strawberry and raspberry products. Cochineal dye is widely used in the food industry and is extracted from a tiny beetle. The petition against the bug-based dye was started by a South Carolina woman who “wanted to inform customers that the chain’s strawberry drinks weren’t vegan-friendly.” (Now THAT’S an “angry vegan”) (7)

PARTNERS HEALTH CARE VALUE HITS THE ROOF

Partners Health Care is building a new rehab hospital across the harbor from Boston on the edge of the Charlestown Navy Yard. The architects assume the building will have a 80 year life span, and that with global warming the worst storm within 80 years might cause floods up to 5.5 feet above previous flood levels. “Looking at long-term risks, benefits, and costs the Spaulding Hospital design team decided it would be a prudent investment to put the hospital generators on the roof… And 61% of Americans don’t think global warming will pose a serious threat to them or their way of life in their lifetime.” (8)

ZOCOR’S SUCCESS MAY BECOME A DIM MEMORY

In February the US Food and Drug Administration began requiring that drugs that lower cholesterol, statins like Lipitor and Zocor, carry a new warning that cognitive side effects such as memory loss and confusion can occur while taking statins. About 10% of statin takers already suffer from muscle ache side effects from the drug. People take statins to prevent heart disease, of course, but a 2011 Cochrane review of 14 trials of statins found that 1000 patients need to be treated for a whole year to prevent one death. (9)

WEIGHT LOSS SECRET OF HOLLYWOOD STARLETS NOT WORTH ITS WEIGHT

Having sex does not help you lose weight. Twenty minutes of running burns about 261 calories, swimming about 182 calories, jogging about 159 calories, while twenty minutes of vigorous sexual activity for a 150-pounder burns a paltry 35 calories. It may be aerobic, but it won’t make you lighter. (10)

DOCTORS LIST 45 UNNEEDED AND COSTLY TESTS

Nine medical specialty groups have developed a list of 45 “routine” tests  and procedures they consider unnecessary, a waste of money, and can expose patients to some risks. The list includes annual electrocardiograms for healthy people, CT scans for low back pain, chest X-rays before surgery, giving antibiotics in the first week of a cold, brain MRIs for headaches in healthy patients, and CT scans or antibiotic treatment for sinusitis . The physicians involved in the groups project (“Choose Wisely”) think that patients do play a role by asking for tests or procedures they have heard or read about, but don’t need. The groups also think that the list may help reduce the amount of “defensive medicine”, performing tests out of fear of malpractice if something is missed. (11)

MEDICAL MALPRACTICE REFORM SAVINGS MAY BE OVERSOLD

A recent Avoiding Avoidable Care Conference reported that the $10 Billion a year is paid to medically injured patients (and their lawyers, of course), and that another $46 Billion is spent on “doing more than we should because we want to reduce the threat of litigation”. The total of $56 Billion represents about 8 days or only 0.02% of our annual health care spending. “It is not clear to me that [medical malpractice reform] is really going to be the thing that changes the cost curve.”said Amitabh Chandra, an economist and Professor of Public Policy at Harvard. (12)

CURVEBALL FUTURES IS PROMISING BUT CHANCY

Pitchers elbow” in Little League pitchers used to be attributed to their throwing the curveball, and its use was severely curtailed for the youngsters, but it is now making a comeback as new studies indicate that it is total number of pitches thrown rather than the type of pitch that causes the inflammatory condition. As is common in predicting future values, the range of maximum pitches allowed per week to avoid the development of “pitchers elbow” is from 150 to 300 depending on the source. Some orthopedic surgeons still feel that the curveball should remain banned from Little League play. Dr. Lyle Micheli, director of Sports Medicine at Children’s Hospital in Boston, recommends that young pitchers learn how to throw the knuckleball instead. (13)

References:
1. Boston Globe, April 24, 2012, G 13, Rachel Zarrell
2. Boston Globe,  April 22, 2012, editorial page
3. N Engl J Med 2012 Mar 15;366 and Journal Watch General Medicine April 1, 2012;vol.32,7,p.54
4. Emerg Inf Dis 2012 March; 18:385 and Journal Watch General Medicine April 1, 2012;vol.32,7,p.56
5. New Yorker Magazine, April 30, 2012, p.32, Dana Goodyear
6. Arch Int Med 2012 Mar 12;172 and Journal Watch General Medicine, April 1, 2012;vol. 32, p.59
7. Cape Cod Times, April 20, 2012, C5
8. Boston Globe, April 20, 2012 Opinion, Joan Wickersham, A 11
9. Boston Globe, April 16, 2012, G 12, Deborah Kotz
10. Consumer Reports on Health, May 2012, p. 12, “Tip of the Month”
11. Boston Globe, April 4, 2012, B 11, Liz Kowalczyak
12. Boston Globe, April 20, 2012, B 6, Chelsea Conaboy, “White Coat Notes”
13. Boston Globe, April 1, 2012, C 2, Kevin Paul Dupont, “On Second Thought”

THIS IS NOT THE APRIL FOOLS ISSUE!  


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