Images Only: EoE, Measles Outbreak, and Obesity Rate Disparities


This Makes Me Mad…Immigration Policy

When our government takes actions on behalf of our country, this reflects on all of our values.  So, earlier this year I was disgusted and angry when I learned that as part of a ‘zero tolerance’ rule, young children were separated from their parents and placed in something akin to cages.  For me, this is a stain on our country’s history that could be compared to other atrocities like the Tuskegee experiments and Japanese internment during WWII.  While this policy was more short-lived, there are still children separated from their parents and for the children involved the consequences could be life-long.  Sadly, our entire country is responsible because we elected this administration which adopted these policies.

Now, this administration which seems incapable of any shame, is planning more steps that should make decent persons upset. Additional threats to lawful immigrants are being devised (KM Perreira et al. NEJM 2018; 379: 901-3).

“Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States” and in some cases deported.  Public-charge guidelines aim to keep immigrants from relying on public charges (eg. cash-assistance programs like welfare) for the first 5 years after admission to the U.S.

“The Trump administration is proposing sweeping changes to these [public-charge] guidelines.”  One of these proposed expansions of public-charge determination is including enrollment for Obamacare, which is legally mandated and which can include subsidies.  Another target is the Children’s Health Insurance Program.  As a consequence of these guideline changes, instead of ~3% of lawful immigrants being considered as receiving a public charge, if adopted, this would increase to a range from 32% to 47%.

If these policies are adopted, this is likely to have a lot of adverse health consequences.  Immigrants, including U.S.-born children, will be less likely to receive health care and more likely to be food insecure; 25% of U.S.-born children of immigrants currently receive SNAP (supplemental nutrition assistance program) benefits. Health consequences will affect millions and include an increase in low birth infants, increased infant mortality, and increased maternal morbidity.

For health care providers and institutions, implementation of these policies is likely to result in higher costs from uncompensated care.

In related commentaries (BL Grace et al. NEJM 2018; 379: 904-5, M Martin. NEJM 2018; 379: 906-7), the authors note the following points:

  • “Current immigration policies are undermining trust in U.S institutions…and changing the way immigrants and refugees seek health care.”  Many are worried that seeking health care could lead directly or indirectly (after providing information) to deportation
  • “Even naturalized citizens fear that their status is no longer secure.”
  • “I feel sad that my colleague’s 6-year-old patient has nightmares and urinary incontinence because she is terrified her parents will be deported.  Sad that my patients fear coming to the hospital despite grave illness out of panic that someone will ask about their immigration status.”

My take: We are all accomplices (many unwitting) in the roll out of these detrimental policies that are now affecting lawful immigrants..

Related blog posts:

Pain in Children with Severe Neurologic Impairment

A recent commentary (JM Hauer JAMA Pediatrics; 2018. doi: 10.1001/jamapediatrics.2018.1531) addresses a common misconception regarding children with severe neurologic impairment (SNI):

“we don’t think she experiences pain”

She notes that literature since 2002 has challenged this assumption and that this is addressed in a new AAP clinical report as well (Hauer J, Houtrow AJ. Pediatrics 2017; 139: e20171002).

Key points:

  • Children with SNI may have moaning, grimacing, changes in tone/body position in reaction to pain and treatment can make them comfortable.
  • “We can never prove that such a child does not feel pain…When parents of children with hydranencephaly were asked whether their child felt pain, 96% indicated yes.”
  • Pain can trigger changes in catecholamines, cortisol and stress hormones.  “These considerations suggest that untreated chronic pain is more harmful to the well-being of children with SNI than is treatment used for pain.”
  • Sometimes no source for pain is identified.  This may be related to a CNS etiology (alteration of CNS) and may benefit from treatment.
  • “It is time to do away with the question of whether these children feel pain and focus on how we as individuals” identify/consider pain

My take: Reframing this issue is important; pain can occur in children with SNI.  At the same time, we have to be careful that some “palliative” measures could paradoxically prolong suffering in some children.

Related blog post: Suffering


Sitting Better (like a dog) to Fix Back Problems

On the way to work, I heard this NPR story:  To Fix That Pain In Your Back, You Might Have To Change The Way You Sit

An excerpt:

“Most of us do not sit well, and we’ve certainly been putting a lot more stress on our spines,” says Khan, who operates on spines at Sutters Health’s Palo Alto Medical Foundation.

If we change the way we sit, Khan says, it will help to decrease back problems.

“We should sit less, and we should sit better,” he says.

Over the past century or so, many Americans have lost the art of sitting, he says. Most people in the U.S. — even children — are sitting in one particular way that’s stressing their backs. You might not realize you’re doing it. But it’s super easy to see in other people.

Here’s how: Take a look at people who are sitting down – not face-on but rather from the side, in profile, so you can see the shape of their spine.

There’s a high probability their back is curving like the letter C — or some version of C. Or it might make you think of a cashew nut, sitting in the chair. There are two telltale signs: Their shoulders curve over and their butts curve under. That posture is hurting their backs, Khan says…

To figure out how to shift your pelvis into a healthier position, Sherer says to imagine for a minute you have a tail. If we were designed like dogs, the tail would be right at the base of your spine…

To straighten out the C shape, Sherer says, “we need to position the pelvis in a way that this tail could wag.”

My take -disclosure: I am not a back expert –so I am not sure about the expertise of some of this advice.  Also, this article is in sync with a previous NPR segment —Back Pain May Be the Result of Bending Over at the Waist (Lost Art of Bending Over: How Other Cultures Spare Their Spines)

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Exercise and Income/Race/Gender in U.S.

Thanks again to Ben Gold for another good read: S Armstrong et al. JAMA Pediatr 2018; 172(8): 732-40.

This study provides a great deal of information on the physical activity of adolescents and young adults (age group 12-29) from 2007-2016 using NHANES data from 9472 participants.  The relationship of physical activity compared with income, race and gender is explored.


  • The current recommendation is for adolescents to engage in a minimum of 60 minutes of moderate to vigorous activity per day.  At age 20, adult guidelines recommend 150 minutes of moderate activity, 75 minutes of vigorous activity  or an equivalent combination of moderate and vigorous activity per week.
  • In previous studies, one-third of adults do not meet the recommended amount of physical activity

Key findings:

  • Percentage of individuals reporting any moderate or vigorous activity: 87.9% for age 12-17 y, 72.6% for age 18-24 y, and 70.7% for age 25-29 y.
  • Mean time for moderate or vigorous activity: For males: 71.1 min or age 12-17 y, 64.3 min for age 18-24 y, and 50.3 min for age 25-29 y. For females: 56.0 min or age 12-17 y, 44.9 min for age 18-24 y, and 39.2 min for age 25-29 y.
  • Younger age, white race, and higher income were associated with greater physical activity.  The breakdown on the specifics are listed in the five Tables.

The limitations of this study include that the data are cross-sectional and do not prove causality.  In addition, the data are self-reported and some groups may over- or under-report activity.

My take: This study shows that a lot of young individuals are not physically-active whihc increases the risk of some chronic diseases.  Examining the groups that have higher and lower physical activity may help understand ways towards improvement.

During a recent trip to Charlottesville, I came across this article. Someone is identifying dog poops with Nicholas Cage’s face –to highlight the problem?  Funny stuff.