Jenny LaChance

Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response

OBJECTIVES We analyzed differences in pediatric elevated blood lead level incidence before and after Flint, Michigan, introduced a more corrosive water source into an aging water system without adequate corrosion control. METHODS We reviewed blood lead levels for children younger than 5 years before (2013) and after (2015) water source change in Greater Flint, Michigan. We assessed the percentage of elevated blood lead levels in both time periods, and identified geographical locations through spatial analysis. RESULTS Incidence of elevated blood lead levels increased from 2.4% to 4.9% (P < .05) after water source change, and neighborhoods with the highest water lead levels experienced a 6.6% increase. No significant change was seen outside the city. Geospatial analysis identified disadvantaged neighborhoods as having the greatest elevated blood lead level increases and informed response prioritization during the now-declared public health emergency. CONCLUSIONS The percentage of children with elevated blood lead levels increased after water source change, particularly in socioeconomically disadvantaged neighborhoods. Water is a growing source of childhood lead exposure because of aging infrastructure.

The utility of PEG3350 without electrolytes for 2-day colonoscopy preparation in children.

OBJECTIVES Successful colonoscopy preparation requires a method which is easy to administer. Simplifying this technique would be useful for adult and pediatric gastroenterologists. Most cleanout agents are not well tolerated by children. Polyethylene glycol without electrolytes (PEG3350 without electrolytes) has been used for constipation and bowel cleanout, but has not been studied as 2-day preparation for colonoscopy in children. This study evaluates the dosing, effectiveness and satisfaction with PEG3350 without electrolytes as a 2-day cleanout for colonoscopy preparation in children. METHODS Parents of patients aged 5 years or older undergoing colonoscopies were approached for participation. All caretakers received standard instructions with a suggested food handout and a diary to track the doses of PEG3350 administered and to document other adjunct measures (suppository, enema). On the procedure day, parents and children completed appropriate satisfaction questionnaires. Post procedure, the physician rated the visualization of the mucosa. A pediatric gastroenterologist investigator and a second blinded pediatric gastroenterologist assessed the effectiveness using standard procedure photos. RESULTS 30 patients aged 5-16 years were recruited (15 males, 15 females). The majority of parents and children reported being “very satisfied” or “satisfied” with the preparation. The preparation was rated by the principal investigator and independent pediatric gastroenterologist as effective in all cases. The mean number of doses was 4.7 on Day 1 and 4.9 on Day 2. The average dose given was 1.90 g/kg/day. CONCLUSION PEG3350 without electrolytes appears to be safe, effective, and well tolerated as a 2-day clean out for colonoscopy preparation in children with an average dose of 1.90 g/kg/day.

Social and Built Environmental Correlates of Predicted Blood Lead Levels in the Flint Water Crisis

Objectives To highlight contextual factors tied to increased blood lead level (BLL) risk following the lead-in-water contamination in Flint, Michigan. Methods Using geocoded BLL data collected in 2013 and 2015 and areal interpolation, we predicted BLLs at every residential parcel in the city. We then spatially joined social and built environmental variables to link the parcels with neighborhood-level factors that may influence BLLs. Results When we compared levels before and during the water crisis, we saw the highest estimates of predicted BLLs during the water crisis and the greatest changes in BLLs in neighborhoods with the longest water residence time in pipes (μ = 2.30 µg/dL; Δ = 0.45 µg/dL), oldest house age (μ = 2.22 µg/dL; Δ = 0.37 µg/dL), and poorest average neighborhood housing condition (μ = 2.18 µg/dL; Δ = 0.44 µg/dL). Conclusions Key social and built environmental variables correlate with BLL; such information can continue to guide response by prioritizing older, deteriorating neighborhoods with the longest water residence time in pipes.

Surveying Resident and Faculty Physician Knowledge, Attitudes, and Experiences in Response to Public Lead Contamination.

Environmental health crises can appear anywhere and without warning. After research revealed a significant incidence of elevated pediatric blood lead levels following a water source change, Genesee County declared a public health emergency in Flint, Michigan. Hospital patients and family members began approaching Hurley Medical Centers physicians with questions regarding the health implications of the lead contamination. Many of the physicians voiced concerns about responding appropriately to patient needs and increasing demands for information. As a result, a Hurley research team decided to conduct an informal survey across training programs to determine the need for added education.Because of heightened patient anxiety, it was necessary for the timeline to progress quickly. In creating the survey, the teams objective was to assess resident and faculty physician knowledge, attitudes, and experiences concerning lead contamination. The results revealed a critical need for supplementary training. Therefore, Hurley embarked on an education campaign for its graduate medical education programs, benefiting physicians and patients alike.Patient and physician needs may change drastically following an environmental health emergency. It is the duty of medical centers to ensure their clinicians are well equipped to confront such threats. As prompt treatment is often a key to positive health outcomes, the authors stress the importance of acting quickly and suggest conducting informal surveys to identify gaps in physician knowledge. Likewise, the authors encourage medical educators nationwide to examine their environmental health curricula. It appears lead-contaminated water is not just a Flint problem but may have far-reaching implications for many cities.

Prevalence of occult celiac disease in females with iron deficiency in the United States: an NHANES analysis

ABSTRACT Aim: The prevalence of celiac disease (CD) in patients with iron deficiency (ID) is estimated at 0–6% in European countries. The prevalence of celiac disease in patients with iron deficiency in the USA is unknown. Given the treatable nature of gluten hypersensitivity, estimating the prevalence of CD in patients with ID can help to determine the need to screen these patients for occult CD. Methods: Data were obtained from the NHANES database, a nationally representative health survey conducted from 2009 to 2010. We included 2,105 females aged 6 years or older. Iron deficiency was defined as serum ferritin level <20 ng/ml and considered positive for celiac disease when subjects were tested positive for both immunoglobulin A (IgA) tissue transglutaminase antibody and IgA endomysial antibody. Subjects were divided between two groups (ID and non-ID). The association of CD and ID, which was the primary outcome, was obtained after adjusting for other covariates using logistic regression. Results: Among the sample of 2,105 subjects, 569 had ID and 1536 did not have ID. Five people were identified as having CD among the ID group, as were two people in the non-ID group. After adjusting for selected covariates, the prevalence of CD was higher in female subjects with ID with OR of 12.5 (95% CI 1.74–90). Conclusions: The overall prevalence of celiac disease in the USA’ female population is low, however, the prevalence is higher in subjects with iron deficiency. Further prospective studies are needed to validate our findings.

Feasibility and Perceptions of Cell Phone–Based, Health-Related Communication With Adolescents in an Economically Depressed Area

We examined the feasibility and perception of cell-based (texting, voicemail [VM], and email/social media), health-related communication with adolescents in Genesee County, MI, where 22% reside below the poverty level. Results of an anonymous survey found that 86% of respondents owned a cell phone, 87% had data, 96% texted, 90.5% emailed/used social media, and 68% had VM. Most adolescents were interested in cell-based communication via texting (52%), VM (37%), and email/social media (31%). Interest in types of health communication included appointment reminders (99% texting; 94% VM; 95% email/social media), shot reminders (84.5% texting; 74.5% VM; 81% email/social media), call for test results (71.5% texting; 75% VM; 65% email/social media), medication reminders (63% texting; 54% VM; 58% e-mail/social media), and health tips (36% texting; 18.5% VM; 73% email/social media). Cell-based health-related communication with adolescents is feasible even within low socioeconomic status populations, primarily via texting. Health providers should embrace cell-based patient communication.

Herpes simplex esophagitis: Report of 4 pediatric cases in immunocompetent patients

Although herpetic infection is considered in the differential diagnosis of a patient who is immunocompromised with esophagitis, it is less thought of in the immunocompetent patient. There are few reports of esophagitis caused by herpes simplex virus in immunocompetent children and adolescents. We are reporting four cases in this age group who have been identified to have herpes simplex esophagitis. The first patient was nine-year-old boy who presented with chest pain, fever, and diarrhea. The second patient was a six-year-old boy who presented severe chest pain and had a negative endoscopy four months prior. The third was an 18-year-old young man with history of vomiting, odynophagia, and recent weight loss of 25 lbs. The fourth patient was a six-year-old girl admitted for dehydration and febrile illness three days after tonsillectomy, complaining of chest pain and epigastric abdominal.Their endoscopic findings varied from punched-out ulceration only to erosive esophagitis or both. They were all diagnosed by PCR analysis and not by pathology. All had biopsies suggestive of esophagitis. They all responded well to acyclovir. Based on testing and available follow up, all patients appeared to be immunocompetent, although one case refused HIV testing. Herpes simplex esophagitis in children can have variable presentations. High level of suspicion is warranted even in the immunocompetent patient. This is especially important when the history of acute gastrointestinal symptoms includes a triad of fever, chest pain, and odynophagia, but also even if these symptoms are recurrent. Viral cultures and PCR of the esophageal biopsies should be performed in addition to pathology looking for Cowdry Type A bodies.

Pain management trend of vaso-occulsive crisis (VOC) at a community hospital emergency department (ED) for patients with sickle cell disease

Pain management at the emergency department (ED) for vaso-occulsive crisis (VOC) for patients with sickle cell disease has not been optimum, with a long delay in giving the initial analgesic. We conducted a retrospective survey over a 7-year period to determine our ED’s timing in giving pain medication to patients with VOC as a quality improvement project. We compared different periods, children vs adults, and the influence of gender in the analgesic administration timing. This is a retrospective chart review of three different periods: (1) years 2007–2008, (2) years 2011–2012, and (3) year 2013. We extracted relevant information from ED records. Data were analyzed using Student t test, chi-square analysis, and the Kruskal-Wallis test. There was a progressive improvement in the time interval to the 1st analgesic over these three periods. Children received analgesics more quickly than adults in all periods. Male adult patients received pain medication faster than female adult patients, although initial pain scores were higher in female than in male patients. Progressively fewer pediatric patients utilized ED over these three periods, but no difference for adult patients was observed. The proportion of pediatric patients admitted to the hospital increased with each period. The progressive decrease in both the number of patients and the number of visits to the ED by children suggested that the collective number of VOC in children has decreased, possibly secondary to the dissemination of hydroxyurea use. We failed to observe the same trend in adult patients. The need for IV access, and ordering laboratory tests or imaging studies tends to delay analgesic administration. Delay in administration of the first analgesic was more pronounced for female adult patients than male adult patients in spite of their higher pain score. Health care providers working in ED should make conscious efforts to respect pain in women as well as pain in men. Though not proven from this study, we believe that a significantly wider use of hydroxyurea by adult patients most likely would reduce their utilization of ED for the purpose of relief of pain, and further pediatric hematologists may be better positioned to increase hydroxyurea adherence by young adult patients, since they have had established rapport with them before transitioning to adult care.