Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

Discordant antibiotic therapy for urinary tract infections (UTIs) is common and associated with higher length of stay (LOS) in hospitalized children, according to a study published online last month in the Journal of Hospital Medicine. But lead author Karen Jerardi, MD, division of hospital medicine at Cincinnati Children's Hospital Medical Center says the reason might be related to physicians, not their patients.

"First, use our knowledge of local resistance patterns and patient factors to select an antibiotic likely to be concordant," she says. "The second thing is [that] we probably need to analyze our practice a little bit more and try to figure out if we are just keeping patients in the hospital because we want to see them be on the concordant antibiotic for X number of hours before we send them home. Does that benefit the patient more, or are we keeping them in the hospital longer for our own peace of mind?"

The report, "Discordant Antibiotic Therapy and Length of Stay in Children Hospitalized for Urinary Tract Infection," found that discordant therapy occurred in 10% of cases in which patients had laboratory-confirmed UTIs and, in adjusted analyses, was associated with a 1.8-day increase in LOS.

Dr. Jerardi says that future studies are needed to determine whether pediatric hospitalists are extending LOS by keeping patients longer than absolutely necessary. She cautions, though, that how long a child is kept in the hospital should be determined by case-specific circumstances.

"Hopefully, this will make people analyze how they do things," she adds, "and think to themselves, 'Would I keep that patient an extra day longer because I had to switch their antibiotic—even if their fever went away, they were drinking great, and Mom and Dad were ready to go home—just for my peace of mind?'"

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

STANFORD, CALIF. – Help girls avoid the sports injuries that are more common for them than for boys by clearly explaining energy requirements, recommending prevention training programs, and educating about concussions.

Brains and knees face extra risk from sports injuries in girls than in boys, and only girls develop the Female Athlete Triad – disordered eating, amenorrhea and osteoporosis.

Courtesy CDC/Amanda Mills

In gender-compatible sports such as soccer or basketball, girls have higher concussion rates than do boys and more postconcussion symptoms. Anterior cruciate ligament (ACL) injuries are two to eight times more common in females than in males. Approximately 1% of female high school athletes meet all three criteria of the Female Athlete Triad, 6% may meet two criteria, and approximately one in five may meet one of the criteria, Dr. Jennifer L. Carlson said at a pediatric update sponsored by Stanford University.

• Female athlete triad. The key to prevention is education. Dr. Carlson explains to patients that they should consume 2,200-2,400 kcal/day (depending on their age) if they are "active," meaning their daily activity is the equivalent of walking more than 3 miles/day at 3-4 mph. If they do more, they’re "very active" and need 2,500-4,000 kcal/day, depending on the sport and the number of hours spent training.

"Many have no idea that that’s what they need to be taking in," said Dr. Carlson of the university.

Girls also need to hear that losing one’s period is not a sign of fitness. And coaches may need to be asked to de-emphasize weight goals and abandon harmful weight-loss practices.

"I’ve had athletes in non–weight-class sports where the coach monitors weight" and even asks them to get a bone density scan, for no good reason, Dr. Carlson said.

One study of 170 female athletes in six Southern California high schools found that 1% met the three criteria for female athlete triad and 6% met two criteria. "But any one of the three criteria is pretty significant," Dr. Carlson said, and 18%-24% in the study had one of the individual criteria (Arch. Pediatr. Adolesc. Med. 2006;160:137-42).

The three criteria of disordered eating, amenorrhea, and osteoporosis that were identified in 1992 have evolved, and today would be described as low energy availability, menstrual disturbances, and low bone mineral density, she said. These can lead to fatigue, difficulty concentrating, emotional lability, impaired athletic performance, stress reactions, and fractures.

The triad is most likely in sports such as gymnastics in which the athlete is scored partly on aesthetics, endurance sports such as cross-country running that favor low body weight for better performance, sports like wrestling or crew that have different weight classes, or any sport in which clothing reveals body contours.

Physicians can find helpful resources about the syndrome from the Female Athlete Triad Coalition website, she said.

• ACL injuries. In females, ACL injuries most commonly come from noncontact maneuvers in sports involving sudden stopping and changing of direction, known as "cutting." The injuries range from small, mild tears to completely torn ligaments. Prevention focuses on awareness of risk factors and specific training programs.

Prevention training programs focus on minimizing risky positions (such as landing from a jump in an upright position instead of crouched), increasing balance and knee stiffness, and decreasing ACL strain. Training programs significantly reduced the risk for ACL injuries by 60% in a meta-analysis of six studies (Am. J. Sports Med. 2006;34:490-8).

The elite and collegiate-level sports programs incorporate prevention training programs. More and more experts advocate for them to be integrated into sports programs for prepubertal age groups, she said.

Greater friction on playing fields increases the risk of ACL injury. Generally, artificial turf is thought to be riskier, and wet surfaces may decrease risk of an ACL tear. Females may have higher risk because of neuromuscular or anatomic factors (such as wider hips) or less core stability, some think.

Biomechanical differences contribute to risk, compared with males. Hormones play a role, too. The peak time of female ACL injury is in the first phase of the menstrual cycle, and oral contraceptives seem to be protective, probably because of the action on neuromuscular junctions that hormones affect, Dr. Carlson said.

• Concussion. Higher rates of concussions in girls playing gender-comparable sports may be caused by reporting bias if boys are more reluctant than girls to report the injury, some speculate. In a recent study of 296 athletes, however, females had worse visual memory scores and more concussion symptoms than did males after a concussion, and neurocognitive impairments persisted as long as 10-21 days for high schoolers and 5-7 days for college athletes (Am. J. Sports Med. 2012;40:1303-12).

Possible reasons for these sex differences may include female sex hormones: rat studies show that estrogen has both protective and exacerbative effects, Dr. Carlson said. Cerebral blood flow and basal rate of glucose metabolism are higher in females than in males, and perhaps an increase in either of these after injury may cause concussion symptoms to persist or be more severe, she speculated.

There’s nothing gender specific about concussion-prevention efforts, except perhaps how they’re applied. Boys playing lacrosse are required to wear helmets, for example, but girls are not, she said. Concerns about universal use of headgear leading to more aggressive play and more collisions come from studies of boys, she added.

Regulations may play an increasing role in preventing concussions. A 2011 California law requires that players with suspected concussion must be pulled from school-based sports and not allowed to return without clearance from a health care profession, and they must get yearly head-trauma clearance.

Female participation in high school sports increased 900% in the past 40 years and increased 500% in collegiate sports. It’s not just the older girls who are at risk, though. Recent trends of increased participation in organized sports and greater specialization in sports at younger ages may contribute to overuse and sport-specific injuries at younger ages, Dr. Carlson said.

"My 3-year-old already gets flyers for soccer teams," she said.

Dr. Carlson reported having no financial disclosures.

STANFORD, CALIF. – Help girls avoid the sports injuries that are more common for them than for boys by clearly explaining energy requirements, recommending prevention training programs, and educating about concussions.

Brains and knees face extra risk from sports injuries in girls than in boys, and only girls develop the Female Athlete Triad – disordered eating, amenorrhea and osteoporosis.

Courtesy CDC/Amanda Mills

In gender-compatible sports such as soccer or basketball, girls have higher concussion rates than do boys and more postconcussion symptoms. Anterior cruciate ligament (ACL) injuries are two to eight times more common in females than in males. Approximately 1% of female high school athletes meet all three criteria of the Female Athlete Triad, 6% may meet two criteria, and approximately one in five may meet one of the criteria, Dr. Jennifer L. Carlson said at a pediatric update sponsored by Stanford University.

• Female athlete triad. The key to prevention is education. Dr. Carlson explains to patients that they should consume 2,200-2,400 kcal/day (depending on their age) if they are "active," meaning their daily activity is the equivalent of walking more than 3 miles/day at 3-4 mph. If they do more, they’re "very active" and need 2,500-4,000 kcal/day, depending on the sport and the number of hours spent training.

"Many have no idea that that’s what they need to be taking in," said Dr. Carlson of the university.

Girls also need to hear that losing one’s period is not a sign of fitness. And coaches may need to be asked to de-emphasize weight goals and abandon harmful weight-loss practices.

"I’ve had athletes in non–weight-class sports where the coach monitors weight" and even asks them to get a bone density scan, for no good reason, Dr. Carlson said.

One study of 170 female athletes in six Southern California high schools found that 1% met the three criteria for female athlete triad and 6% met two criteria. "But any one of the three criteria is pretty significant," Dr. Carlson said, and 18%-24% in the study had one of the individual criteria (Arch. Pediatr. Adolesc. Med. 2006;160:137-42).

The three criteria of disordered eating, amenorrhea, and osteoporosis that were identified in 1992 have evolved, and today would be described as low energy availability, menstrual disturbances, and low bone mineral density, she said. These can lead to fatigue, difficulty concentrating, emotional lability, impaired athletic performance, stress reactions, and fractures.

The triad is most likely in sports such as gymnastics in which the athlete is scored partly on aesthetics, endurance sports such as cross-country running that favor low body weight for better performance, sports like wrestling or crew that have different weight classes, or any sport in which clothing reveals body contours.

Physicians can find helpful resources about the syndrome from the Female Athlete Triad Coalition website, she said.

• ACL injuries. In females, ACL injuries most commonly come from noncontact maneuvers in sports involving sudden stopping and changing of direction, known as "cutting." The injuries range from small, mild tears to completely torn ligaments. Prevention focuses on awareness of risk factors and specific training programs.

Prevention training programs focus on minimizing risky positions (such as landing from a jump in an upright position instead of crouched), increasing balance and knee stiffness, and decreasing ACL strain. Training programs significantly reduced the risk for ACL injuries by 60% in a meta-analysis of six studies (Am. J. Sports Med. 2006;34:490-8).

The elite and collegiate-level sports programs incorporate prevention training programs. More and more experts advocate for them to be integrated into sports programs for prepubertal age groups, she said.

Greater friction on playing fields increases the risk of ACL injury. Generally, artificial turf is thought to be riskier, and wet surfaces may decrease risk of an ACL tear. Females may have higher risk because of neuromuscular or anatomic factors (such as wider hips) or less core stability, some think.

Biomechanical differences contribute to risk, compared with males. Hormones play a role, too. The peak time of female ACL injury is in the first phase of the menstrual cycle, and oral contraceptives seem to be protective, probably because of the action on neuromuscular junctions that hormones affect, Dr. Carlson said.

• Concussion. Higher rates of concussions in girls playing gender-comparable sports may be caused by reporting bias if boys are more reluctant than girls to report the injury, some speculate. In a recent study of 296 athletes, however, females had worse visual memory scores and more concussion symptoms than did males after a concussion, and neurocognitive impairments persisted as long as 10-21 days for high schoolers and 5-7 days for college athletes (Am. J. Sports Med. 2012;40:1303-12).

Possible reasons for these sex differences may include female sex hormones: rat studies show that estrogen has both protective and exacerbative effects, Dr. Carlson said. Cerebral blood flow and basal rate of glucose metabolism are higher in females than in males, and perhaps an increase in either of these after injury may cause concussion symptoms to persist or be more severe, she speculated.

There’s nothing gender specific about concussion-prevention efforts, except perhaps how they’re applied. Boys playing lacrosse are required to wear helmets, for example, but girls are not, she said. Concerns about universal use of headgear leading to more aggressive play and more collisions come from studies of boys, she added.

Regulations may play an increasing role in preventing concussions. A 2011 California law requires that players with suspected concussion must be pulled from school-based sports and not allowed to return without clearance from a health care profession, and they must get yearly head-trauma clearance.

Female participation in high school sports increased 900% in the past 40 years and increased 500% in collegiate sports. It’s not just the older girls who are at risk, though. Recent trends of increased participation in organized sports and greater specialization in sports at younger ages may contribute to overuse and sport-specific injuries at younger ages, Dr. Carlson said.

"My 3-year-old already gets flyers for soccer teams," she said.

Dr. Carlson reported having no financial disclosures.

STANFORD, CALIF. – Help girls avoid the sports injuries that are more common for them than for boys by clearly explaining energy requirements, recommending prevention training programs, and educating about concussions.

Brains and knees face extra risk from sports injuries in girls than in boys, and only girls develop the Female Athlete Triad – disordered eating, amenorrhea and osteoporosis.

Courtesy CDC/Amanda Mills

In gender-compatible sports such as soccer or basketball, girls have higher concussion rates than do boys and more postconcussion symptoms. Anterior cruciate ligament (ACL) injuries are two to eight times more common in females than in males. Approximately 1% of female high school athletes meet all three criteria of the Female Athlete Triad, 6% may meet two criteria, and approximately one in five may meet one of the criteria, Dr. Jennifer L. Carlson said at a pediatric update sponsored by Stanford University.

• Female athlete triad. The key to prevention is education. Dr. Carlson explains to patients that they should consume 2,200-2,400 kcal/day (depending on their age) if they are "active," meaning their daily activity is the equivalent of walking more than 3 miles/day at 3-4 mph. If they do more, they’re "very active" and need 2,500-4,000 kcal/day, depending on the sport and the number of hours spent training.

"Many have no idea that that’s what they need to be taking in," said Dr. Carlson of the university.

Girls also need to hear that losing one’s period is not a sign of fitness. And coaches may need to be asked to de-emphasize weight goals and abandon harmful weight-loss practices.

"I’ve had athletes in non–weight-class sports where the coach monitors weight" and even asks them to get a bone density scan, for no good reason, Dr. Carlson said.

One study of 170 female athletes in six Southern California high schools found that 1% met the three criteria for female athlete triad and 6% met two criteria. "But any one of the three criteria is pretty significant," Dr. Carlson said, and 18%-24% in the study had one of the individual criteria (Arch. Pediatr. Adolesc. Med. 2006;160:137-42).

The three criteria of disordered eating, amenorrhea, and osteoporosis that were identified in 1992 have evolved, and today would be described as low energy availability, menstrual disturbances, and low bone mineral density, she said. These can lead to fatigue, difficulty concentrating, emotional lability, impaired athletic performance, stress reactions, and fractures.

The triad is most likely in sports such as gymnastics in which the athlete is scored partly on aesthetics, endurance sports such as cross-country running that favor low body weight for better performance, sports like wrestling or crew that have different weight classes, or any sport in which clothing reveals body contours.

Physicians can find helpful resources about the syndrome from the Female Athlete Triad Coalition website, she said.

• ACL injuries. In females, ACL injuries most commonly come from noncontact maneuvers in sports involving sudden stopping and changing of direction, known as "cutting." The injuries range from small, mild tears to completely torn ligaments. Prevention focuses on awareness of risk factors and specific training programs.

Prevention training programs focus on minimizing risky positions (such as landing from a jump in an upright position instead of crouched), increasing balance and knee stiffness, and decreasing ACL strain. Training programs significantly reduced the risk for ACL injuries by 60% in a meta-analysis of six studies (Am. J. Sports Med. 2006;34:490-8).

The elite and collegiate-level sports programs incorporate prevention training programs. More and more experts advocate for them to be integrated into sports programs for prepubertal age groups, she said.

Greater friction on playing fields increases the risk of ACL injury. Generally, artificial turf is thought to be riskier, and wet surfaces may decrease risk of an ACL tear. Females may have higher risk because of neuromuscular or anatomic factors (such as wider hips) or less core stability, some think.

Biomechanical differences contribute to risk, compared with males. Hormones play a role, too. The peak time of female ACL injury is in the first phase of the menstrual cycle, and oral contraceptives seem to be protective, probably because of the action on neuromuscular junctions that hormones affect, Dr. Carlson said.

• Concussion. Higher rates of concussions in girls playing gender-comparable sports may be caused by reporting bias if boys are more reluctant than girls to report the injury, some speculate. In a recent study of 296 athletes, however, females had worse visual memory scores and more concussion symptoms than did males after a concussion, and neurocognitive impairments persisted as long as 10-21 days for high schoolers and 5-7 days for college athletes (Am. J. Sports Med. 2012;40:1303-12).

Possible reasons for these sex differences may include female sex hormones: rat studies show that estrogen has both protective and exacerbative effects, Dr. Carlson said. Cerebral blood flow and basal rate of glucose metabolism are higher in females than in males, and perhaps an increase in either of these after injury may cause concussion symptoms to persist or be more severe, she speculated.

There’s nothing gender specific about concussion-prevention efforts, except perhaps how they’re applied. Boys playing lacrosse are required to wear helmets, for example, but girls are not, she said. Concerns about universal use of headgear leading to more aggressive play and more collisions come from studies of boys, she added.

Regulations may play an increasing role in preventing concussions. A 2011 California law requires that players with suspected concussion must be pulled from school-based sports and not allowed to return without clearance from a health care profession, and they must get yearly head-trauma clearance.

Female participation in high school sports increased 900% in the past 40 years and increased 500% in collegiate sports. It’s not just the older girls who are at risk, though. Recent trends of increased participation in organized sports and greater specialization in sports at younger ages may contribute to overuse and sport-specific injuries at younger ages, Dr. Carlson said.

"My 3-year-old already gets flyers for soccer teams," she said.

Dr. Carlson reported having no financial disclosures.

Participants in randomized controlled trials of biologics for inflammatory bowel disease do not adequately represent real-world patients because of stringent inclusion criteria for the trials, reported Dr. Christina Ha and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, among 125 Crohn’s disease (CD) patients seen in routine clinical practice at a tertiary care center, only 43 – just 34% – would have qualified for enrollment in at least one of seven randomized controlled trials (RCTs) for biologics, calling into question the generalizability of these trials’ results. The corresponding percentage for ulcerative colitis (UC) patients was only 25%.

Video Source: American Gastroenterological Association

Dr. Ha, of the division of gastroenterology at Johns Hopkins University, Baltimore, and her colleagues reviewed the medical records of 206 patients with moderate to severe CD or UC presenting to the Mount Sinai Medical Center in New York for adjustment of therapy during 2008-2009.

The researchers then looked at seven randomized controlled trials of biologics in CD as well as two trials of biologics in UC, and applied their inclusion and exclusion criteria to her real-world study population (Clin. Gastroenterol. Hepatol. 2012 September [doi: 10.1016/j.cgh.2012.02.004]).

Among the Crohn’s patients, "trial eligibility for the RCTs for infliximab, adalimumab, certolizumab pegol, and natalizumab ranged from 8% for the SONIC [Study of Biologic and Immunomodulator Naïve Patients in Crohn’s Disease] trial to 27% for the CHARM [Crohn’s Trial of the Fully Human Antibody Adalimumab for Remission Maintenance] and PRECISE [Pegylated Antibody Fragment Evaluation in Crohn’s Disease] trials," wrote the investigators.

Similarly, among the 81 UC patients, only 21 (25%) would have qualified for enrollment into the ACT (Active Ulcerative Colitis Trial) 1 or 2 trials.

Among the Crohn’s patients, the most common reasons for ineligibility were symptomatic strictures or abscesses (n = 51, 62.2%), recent exposure or prior nonresponse to anti–tumor necrosis factor drugs (n = 42, 51.2%), use of high-dose steroids (n = 15, 18.3%), and comorbid cardiovascular or pulmonary disease and malignancies (n = 21, 25.6%).

"The most common reason for trial ineligibility for UC was current rectal therapy usage (n = 34, 56.7%)," wrote the authors. Other reasons included steroid naivety (n = 27, 45.0%); new diagnoses of UC (n = 10, 16.7%); or need for colectomy due to age, comorbidity, or concomitant dysplasia found during colonoscopy (n = 9, 15.0%).

Finally, the authors assessed the outcomes of patients who would not have qualified for the biologics trials but initiated biologic therapy nevertheless. In the CD cohort, "ultimately, almost 50% of these ‘trial ineligible’ patients underwent surgery, either as a primary therapy or due to inadequate response to biologics or immunomodulators," wrote the authors. In the UC group, roughly one-quarter of would-be ineligible patients underwent colectomy at 4-12 weeks.

The authors conceded that if patients had been studied longitudinally, "with the inclusion and exclusion criteria applied at the time patients were first being considered for immunomodulators or biologics or at the time of diagnosis, a larger percentage of patients may have been eligible for trial participation."

Nevertheless, Dr. Ha and her colleagues concluded, "pragmatic trials of the major IBD therapeutics would not only serve to validate RCT findings, but provide additional insight regarding medication safety across a broader patient population."

Several of the authors disclosed financial relationships with pharmaceutical companies, including the makers of biologics. The authors stated that this study received no grant support.

Participants in randomized controlled trials of biologics for inflammatory bowel disease do not adequately represent real-world patients because of stringent inclusion criteria for the trials, reported Dr. Christina Ha and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, among 125 Crohn’s disease (CD) patients seen in routine clinical practice at a tertiary care center, only 43 – just 34% – would have qualified for enrollment in at least one of seven randomized controlled trials (RCTs) for biologics, calling into question the generalizability of these trials’ results. The corresponding percentage for ulcerative colitis (UC) patients was only 25%.

Video Source: American Gastroenterological Association

Dr. Ha, of the division of gastroenterology at Johns Hopkins University, Baltimore, and her colleagues reviewed the medical records of 206 patients with moderate to severe CD or UC presenting to the Mount Sinai Medical Center in New York for adjustment of therapy during 2008-2009.

The researchers then looked at seven randomized controlled trials of biologics in CD as well as two trials of biologics in UC, and applied their inclusion and exclusion criteria to her real-world study population (Clin. Gastroenterol. Hepatol. 2012 September [doi: 10.1016/j.cgh.2012.02.004]).

Among the Crohn’s patients, "trial eligibility for the RCTs for infliximab, adalimumab, certolizumab pegol, and natalizumab ranged from 8% for the SONIC [Study of Biologic and Immunomodulator Naïve Patients in Crohn’s Disease] trial to 27% for the CHARM [Crohn’s Trial of the Fully Human Antibody Adalimumab for Remission Maintenance] and PRECISE [Pegylated Antibody Fragment Evaluation in Crohn’s Disease] trials," wrote the investigators.

Similarly, among the 81 UC patients, only 21 (25%) would have qualified for enrollment into the ACT (Active Ulcerative Colitis Trial) 1 or 2 trials.

Among the Crohn’s patients, the most common reasons for ineligibility were symptomatic strictures or abscesses (n = 51, 62.2%), recent exposure or prior nonresponse to anti–tumor necrosis factor drugs (n = 42, 51.2%), use of high-dose steroids (n = 15, 18.3%), and comorbid cardiovascular or pulmonary disease and malignancies (n = 21, 25.6%).

"The most common reason for trial ineligibility for UC was current rectal therapy usage (n = 34, 56.7%)," wrote the authors. Other reasons included steroid naivety (n = 27, 45.0%); new diagnoses of UC (n = 10, 16.7%); or need for colectomy due to age, comorbidity, or concomitant dysplasia found during colonoscopy (n = 9, 15.0%).

Finally, the authors assessed the outcomes of patients who would not have qualified for the biologics trials but initiated biologic therapy nevertheless. In the CD cohort, "ultimately, almost 50% of these ‘trial ineligible’ patients underwent surgery, either as a primary therapy or due to inadequate response to biologics or immunomodulators," wrote the authors. In the UC group, roughly one-quarter of would-be ineligible patients underwent colectomy at 4-12 weeks.

The authors conceded that if patients had been studied longitudinally, "with the inclusion and exclusion criteria applied at the time patients were first being considered for immunomodulators or biologics or at the time of diagnosis, a larger percentage of patients may have been eligible for trial participation."

Nevertheless, Dr. Ha and her colleagues concluded, "pragmatic trials of the major IBD therapeutics would not only serve to validate RCT findings, but provide additional insight regarding medication safety across a broader patient population."

Several of the authors disclosed financial relationships with pharmaceutical companies, including the makers of biologics. The authors stated that this study received no grant support.

Participants in randomized controlled trials of biologics for inflammatory bowel disease do not adequately represent real-world patients because of stringent inclusion criteria for the trials, reported Dr. Christina Ha and her colleagues in the September issue of Clinical Gastroenterology and Hepatology.

Indeed, among 125 Crohn’s disease (CD) patients seen in routine clinical practice at a tertiary care center, only 43 – just 34% – would have qualified for enrollment in at least one of seven randomized controlled trials (RCTs) for biologics, calling into question the generalizability of these trials’ results. The corresponding percentage for ulcerative colitis (UC) patients was only 25%.

Video Source: American Gastroenterological Association

Dr. Ha, of the division of gastroenterology at Johns Hopkins University, Baltimore, and her colleagues reviewed the medical records of 206 patients with moderate to severe CD or UC presenting to the Mount Sinai Medical Center in New York for adjustment of therapy during 2008-2009.

The researchers then looked at seven randomized controlled trials of biologics in CD as well as two trials of biologics in UC, and applied their inclusion and exclusion criteria to her real-world study population (Clin. Gastroenterol. Hepatol. 2012 September [doi: 10.1016/j.cgh.2012.02.004]).

Among the Crohn’s patients, "trial eligibility for the RCTs for infliximab, adalimumab, certolizumab pegol, and natalizumab ranged from 8% for the SONIC [Study of Biologic and Immunomodulator Naïve Patients in Crohn’s Disease] trial to 27% for the CHARM [Crohn’s Trial of the Fully Human Antibody Adalimumab for Remission Maintenance] and PRECISE [Pegylated Antibody Fragment Evaluation in Crohn’s Disease] trials," wrote the investigators.

Similarly, among the 81 UC patients, only 21 (25%) would have qualified for enrollment into the ACT (Active Ulcerative Colitis Trial) 1 or 2 trials.

Among the Crohn’s patients, the most common reasons for ineligibility were symptomatic strictures or abscesses (n = 51, 62.2%), recent exposure or prior nonresponse to anti–tumor necrosis factor drugs (n = 42, 51.2%), use of high-dose steroids (n = 15, 18.3%), and comorbid cardiovascular or pulmonary disease and malignancies (n = 21, 25.6%).

"The most common reason for trial ineligibility for UC was current rectal therapy usage (n = 34, 56.7%)," wrote the authors. Other reasons included steroid naivety (n = 27, 45.0%); new diagnoses of UC (n = 10, 16.7%); or need for colectomy due to age, comorbidity, or concomitant dysplasia found during colonoscopy (n = 9, 15.0%).

Finally, the authors assessed the outcomes of patients who would not have qualified for the biologics trials but initiated biologic therapy nevertheless. In the CD cohort, "ultimately, almost 50% of these ‘trial ineligible’ patients underwent surgery, either as a primary therapy or due to inadequate response to biologics or immunomodulators," wrote the authors. In the UC group, roughly one-quarter of would-be ineligible patients underwent colectomy at 4-12 weeks.

The authors conceded that if patients had been studied longitudinally, "with the inclusion and exclusion criteria applied at the time patients were first being considered for immunomodulators or biologics or at the time of diagnosis, a larger percentage of patients may have been eligible for trial participation."

Nevertheless, Dr. Ha and her colleagues concluded, "pragmatic trials of the major IBD therapeutics would not only serve to validate RCT findings, but provide additional insight regarding medication safety across a broader patient population."

Several of the authors disclosed financial relationships with pharmaceutical companies, including the makers of biologics. The authors stated that this study received no grant support.

Dr. Hale discusses how regular sunscreen use can diminish the chances of developing future skin cancers and can slow the process of premature skin aging. For more information, read Dr. Hale's article in the May 2012 issue, "Sunscreens and Photoaging: An Update."

Dr. Hale discusses how regular sunscreen use can diminish the chances of developing future skin cancers and can slow the process of premature skin aging. For more information, read Dr. Hale's article in the May 2012 issue, "Sunscreens and Photoaging: An Update."

Dr. Hale discusses how regular sunscreen use can diminish the chances of developing future skin cancers and can slow the process of premature skin aging. For more information, read Dr. Hale's article in the May 2012 issue, "Sunscreens and Photoaging: An Update."

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Many thanks for the thoughtful e-mails from many of you readers. Some express cautious hope, some skepticism, and all the curiosity and caring that reminds me of how fortunate I am to have been a physician advocate for my legal career.

Here is one reader’s concerns about patient engagement – or lack thereof – in accountable care organizations.

– Reader: "ACOs will never work because, once again, the patient has been left out of the equation."

We hear this quite often, and it is surely true in some cases – but not all. In fact, we are convinced that patient engagement is such an essential element necessary for every successful ACO, that an ACO should not be called an ACO without it.

Patient noncompliance is a problem, especially regarding chronic diseases and lifestyle management. It is difficult to accept a compensation model based on input on improved patient population health when that is dramatically affected by a variable outside of your control: patient adherence. But patient engagement is part of patient-centeredness, which is required by the Affordable Care Act for an ACO to qualify for CMS’ Shared Savings Program.

So, what can an ACO do to engage patients?

Consider the following approaches:

– The patient compact. Some ACOs, such as the Geisinger Clinic, engage the patient through a compact, or agreement. It may involve a written commitment by the patient to be responsible for his or her own wellness or chronic care management, coupled with rewards for so doing, education, tools, self-care modules, and shared decision-making empowerment. The providers will need to embrace the importance of patient involvement and hold up their end of the engagement bargain.

– Benefit differentials for lifestyle choices. The financial impact of many volitional patient lifestyle choices is actuarially measurable. A logical consequence of the patient choice could be a benefit or financial differential reflecting at least partially these avoidable health care costs.

– Stay in contact. A Kaiser Permanente study of more than 35,000 hypertensive and diabetic patients found that the blood pressure and cholesterol levels for those who engaged in secure messaging were better than for those who did not.

– More time with your patients. Develop personal relationships. One ACO saw its results jump when its primary care physicians started using Biosignia’s "Know Your Number," a computer-generated graphic depiction of a patient’s health risks based on lab results and the Framingham Study. It is used by the treating physician at the point of care.

– Patient remote access to test results. This can be achieved with tools such as a web portal with multiple functions.

– Care navigators. We predict that the demands for care navigators, or coordinators, will skyrocket as ACOs take hold. Their use will include home visits. This may be the best patient engagement method.

– Empathetic listening. In curriculum and residency programs of medical schools, the paternalistic model is yielding to empathetic listening and communication skills in physician training.

– Educational materials. This consists of patient-friendly educational material that explains the benefits of being linked to a medical home.

I agree so much with this reader’s assertion that an ACO without patient engagement will fail, that I consider it an essential, almost definitional, element of every successful ACO. It is crucial that we emphasize the role of the patient. It is truly the "other shoe" that must fall for the new outcomes-based health care to succeed.

Mr. Bobbitt is a senior partner and head of the Health Law Group at the Smith Anderson law firm in Raleigh, N.C. He has many years’ experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact Mr. Bobbit at [email protected], or at 919-821-6612.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

Just as the federal government is introducing several new programs to promote the recruitment, training, and placement of more primary-care providers, other efforts are being threatened with funding decreases or elimination.

One, the Children’s Hospitals Graduate Medical Education program, distributed $268 million in pediatric training funds to 55 freestanding children’s teaching hospitals in fiscal-year 2012. The program, however, was zeroed out in President Obama’s initial budget proposal last year, and the president’s fiscal-year 2013 budget proposal recommends slashing the program’s annual funding by two-thirds to $88 million.

Kathleen Klink, MD, director of the Division of Medicine and Dentistry in the federal Health Resources and Services Administration, also points to the Title VII Area Health Education Center program as an example of government-funded assistance. The competitive grant process supports innovation and access to care for vulnerable populations, in part by improving the primary-care workforce’s geographic and ethnic distribution. Some of the grantees introduce high school students to medical careers, while others recruit and train minorities or place providers in underserved communities, effectively targeting both ends of the pipeline.

Robert Phillips, MD, MSPH, director of the Washington, D.C.-based Robert Graham Center, a primary-care research center, has high regard for the Title VII program. But making an impact requires a long-term investment, he cautions. “In the states that do this well, like Arkansas and North Carolina, it pays off,” he says. “But they can’t prove it sufficiently to save their budget.” The federal program received $233 million in fiscal-year 2012. Under the president’s fiscal-year 2013 budget proposal, however, the funding is likewise eliminated.

Other programs have debuted in recent legislation. One program, introduced under the Affordable Care Act, provides $230 million over five years to expand residency training slots within ambulatory primary-care settings. Dr. Klink says the Teaching Health Center Graduate Medical Education program, as it is known, has so far supported 22 health centers and 150 enrolled residents. “It’s just the beginning,” she adds.

Another program, the Primary Care Residency Expansion, likewise initiated under the Affordable Care Act, will distribute $167 million to train an estimated 700 primary-care physicians (PCPs), 900 physician assistants, and 600 nurse practitioners and nurse midwives over five years. Glen Stream, president of the American Academy of Family Physicians, recently told The Washington Post, “It’s good, but it’s also a drop in the bucket.”

Bryn Nelson is a freelance medical writer in Seattle.

The permanent implantable cardiac heart pump was developed in the mid-20th century as an outgrowth of the success of heart-lung machines –which provided systemic support during cardiac arrest – required for valve replacement and later coronary bypass surgery.

The challenge to build a totally implantable heart has been the "holy grail" for almost half a century and occurred long before heart failure therapy was high on the agenda of cardiologists. It emerged as a result of the experimental perseverance and genius of Dr. Willem Kolff, who in 1957 was able to totally support dogs using an artificial heart device. Other surgeons, working in separate laboratories – including Dr. Adrian Kantrowitz, Dr. Denton Cooley, and Dr. Robert Jarvik – provided additional research support for the ultimate creation of the artificial heart. However, it wasn’t until 15 years later, in 1982, that Dr. Kolff captured the attention of the medical and lay press by supporting a Seattle dentist suffering from severe heart failure, Dr. Barney Clark, for 112 days with the heart that he and Dr. Jarvik had developed.

Since then, research on the totally implantable heart led to the approval in 2004 the SynCardia temporary Total Artificial Heart as a bridge to transplantation in patients with biventricular failure. In 2001, the first AbioCor totally implantable pump with an external power source was implanted. Initially approved by the FDA as a bridge to transplant for patients with biventricular failure, more recently it has been approved for patients with end stage heart failure as destination therapy.

As work went forward on the totally implantable heart, left ventricular assist devices (LVAD) were also being developed. The pharmacologic support of end stage left ventricular failure with vasodilators and inotropic agents has provided modest temporary benefit; but it has become obvious that we have reached a therapeutic wall with very few new medical options on the horizon. LVADs appeared to be our current best hope of providing additional short- and long-term support for the failing left ventricle.

Dr. E. Stanley Crawford and Dr. Domingo Liotta performed the first LVAD implant in 1966 in a patient who had cardiac arrest after surgery. Since then, there have been a variety of LVADs developed that were initially pulsatile, but now are more commonly continuous flow. Both types of devices are externally powered via drive lines and able to achieve flows up to 10 L/min and are interposed between a left ventricular apical conduit and an ascending aorta conduit. The initial LVADs were pulsatile devices based on the presumption that pulsatile flow was important for systemic perfusion and normal physiology. However, continuous-flow LVAD has proven to be quite compatible with normal organ function and perfusion, and shown better durability and lower mortality and morbidity compared to the pulsatile flow devices. (J. Am. Coll. Cardiol. 2011;57:1890-8).

In addition, as noted in "The Lead," LVADs have shown superiority over medical therapy in patients with advanced heart failure as destination therapy, and the 1-year mortality with continuous flow LVADs now approximates the experience with the 1-year mortality of patients receiving a heart transplant.

The expanded use of LVADs from creating a bridge for transplantation to destination therapy has opened an entirely new opportunity for the use of LVADs in the treatment of acute, but most importantly, chronic heart failure. The limitation of heart transplantation as a function of donor availability together with the limitation of medical therapy for heart failure patients has generated increased interest in LVADs for chronic therapy in patients with end-stage heart failure. The observation that in some patients, particularly those with reversible heart failure like myocarditis, the heart may actually recover during LVAD therapy and allow for its removal, provides a window into future clinical applications (N. Engl. J. Med. 2006:355;1873-84)

The potential for further miniaturization of these devices and the potential for total implantability also open new horizons for LVAD therapy. Total implantability hinges on the ability to apply technology of transcutaneous power source that is already available in a number of electronic implantable devices, including the total heart implant. The resolution of these technical issues will allow for further expansion of the clinical indications for LVAD therapy.

Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The permanent implantable cardiac heart pump was developed in the mid-20th century as an outgrowth of the success of heart-lung machines –which provided systemic support during cardiac arrest – required for valve replacement and later coronary bypass surgery.

The challenge to build a totally implantable heart has been the "holy grail" for almost half a century and occurred long before heart failure therapy was high on the agenda of cardiologists. It emerged as a result of the experimental perseverance and genius of Dr. Willem Kolff, who in 1957 was able to totally support dogs using an artificial heart device. Other surgeons, working in separate laboratories – including Dr. Adrian Kantrowitz, Dr. Denton Cooley, and Dr. Robert Jarvik – provided additional research support for the ultimate creation of the artificial heart. However, it wasn’t until 15 years later, in 1982, that Dr. Kolff captured the attention of the medical and lay press by supporting a Seattle dentist suffering from severe heart failure, Dr. Barney Clark, for 112 days with the heart that he and Dr. Jarvik had developed.

Since then, research on the totally implantable heart led to the approval in 2004 the SynCardia temporary Total Artificial Heart as a bridge to transplantation in patients with biventricular failure. In 2001, the first AbioCor totally implantable pump with an external power source was implanted. Initially approved by the FDA as a bridge to transplant for patients with biventricular failure, more recently it has been approved for patients with end stage heart failure as destination therapy.

As work went forward on the totally implantable heart, left ventricular assist devices (LVAD) were also being developed. The pharmacologic support of end stage left ventricular failure with vasodilators and inotropic agents has provided modest temporary benefit; but it has become obvious that we have reached a therapeutic wall with very few new medical options on the horizon. LVADs appeared to be our current best hope of providing additional short- and long-term support for the failing left ventricle.

Dr. E. Stanley Crawford and Dr. Domingo Liotta performed the first LVAD implant in 1966 in a patient who had cardiac arrest after surgery. Since then, there have been a variety of LVADs developed that were initially pulsatile, but now are more commonly continuous flow. Both types of devices are externally powered via drive lines and able to achieve flows up to 10 L/min and are interposed between a left ventricular apical conduit and an ascending aorta conduit. The initial LVADs were pulsatile devices based on the presumption that pulsatile flow was important for systemic perfusion and normal physiology. However, continuous-flow LVAD has proven to be quite compatible with normal organ function and perfusion, and shown better durability and lower mortality and morbidity compared to the pulsatile flow devices. (J. Am. Coll. Cardiol. 2011;57:1890-8).

In addition, as noted in "The Lead," LVADs have shown superiority over medical therapy in patients with advanced heart failure as destination therapy, and the 1-year mortality with continuous flow LVADs now approximates the experience with the 1-year mortality of patients receiving a heart transplant.

The expanded use of LVADs from creating a bridge for transplantation to destination therapy has opened an entirely new opportunity for the use of LVADs in the treatment of acute, but most importantly, chronic heart failure. The limitation of heart transplantation as a function of donor availability together with the limitation of medical therapy for heart failure patients has generated increased interest in LVADs for chronic therapy in patients with end-stage heart failure. The observation that in some patients, particularly those with reversible heart failure like myocarditis, the heart may actually recover during LVAD therapy and allow for its removal, provides a window into future clinical applications (N. Engl. J. Med. 2006:355;1873-84)

The potential for further miniaturization of these devices and the potential for total implantability also open new horizons for LVAD therapy. Total implantability hinges on the ability to apply technology of transcutaneous power source that is already available in a number of electronic implantable devices, including the total heart implant. The resolution of these technical issues will allow for further expansion of the clinical indications for LVAD therapy.

Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The permanent implantable cardiac heart pump was developed in the mid-20th century as an outgrowth of the success of heart-lung machines –which provided systemic support during cardiac arrest – required for valve replacement and later coronary bypass surgery.

The challenge to build a totally implantable heart has been the "holy grail" for almost half a century and occurred long before heart failure therapy was high on the agenda of cardiologists. It emerged as a result of the experimental perseverance and genius of Dr. Willem Kolff, who in 1957 was able to totally support dogs using an artificial heart device. Other surgeons, working in separate laboratories – including Dr. Adrian Kantrowitz, Dr. Denton Cooley, and Dr. Robert Jarvik – provided additional research support for the ultimate creation of the artificial heart. However, it wasn’t until 15 years later, in 1982, that Dr. Kolff captured the attention of the medical and lay press by supporting a Seattle dentist suffering from severe heart failure, Dr. Barney Clark, for 112 days with the heart that he and Dr. Jarvik had developed.

Since then, research on the totally implantable heart led to the approval in 2004 the SynCardia temporary Total Artificial Heart as a bridge to transplantation in patients with biventricular failure. In 2001, the first AbioCor totally implantable pump with an external power source was implanted. Initially approved by the FDA as a bridge to transplant for patients with biventricular failure, more recently it has been approved for patients with end stage heart failure as destination therapy.

As work went forward on the totally implantable heart, left ventricular assist devices (LVAD) were also being developed. The pharmacologic support of end stage left ventricular failure with vasodilators and inotropic agents has provided modest temporary benefit; but it has become obvious that we have reached a therapeutic wall with very few new medical options on the horizon. LVADs appeared to be our current best hope of providing additional short- and long-term support for the failing left ventricle.

Dr. E. Stanley Crawford and Dr. Domingo Liotta performed the first LVAD implant in 1966 in a patient who had cardiac arrest after surgery. Since then, there have been a variety of LVADs developed that were initially pulsatile, but now are more commonly continuous flow. Both types of devices are externally powered via drive lines and able to achieve flows up to 10 L/min and are interposed between a left ventricular apical conduit and an ascending aorta conduit. The initial LVADs were pulsatile devices based on the presumption that pulsatile flow was important for systemic perfusion and normal physiology. However, continuous-flow LVAD has proven to be quite compatible with normal organ function and perfusion, and shown better durability and lower mortality and morbidity compared to the pulsatile flow devices. (J. Am. Coll. Cardiol. 2011;57:1890-8).

In addition, as noted in "The Lead," LVADs have shown superiority over medical therapy in patients with advanced heart failure as destination therapy, and the 1-year mortality with continuous flow LVADs now approximates the experience with the 1-year mortality of patients receiving a heart transplant.

The expanded use of LVADs from creating a bridge for transplantation to destination therapy has opened an entirely new opportunity for the use of LVADs in the treatment of acute, but most importantly, chronic heart failure. The limitation of heart transplantation as a function of donor availability together with the limitation of medical therapy for heart failure patients has generated increased interest in LVADs for chronic therapy in patients with end-stage heart failure. The observation that in some patients, particularly those with reversible heart failure like myocarditis, the heart may actually recover during LVAD therapy and allow for its removal, provides a window into future clinical applications (N. Engl. J. Med. 2006:355;1873-84)

The potential for further miniaturization of these devices and the potential for total implantability also open new horizons for LVAD therapy. Total implantability hinges on the ability to apply technology of transcutaneous power source that is already available in a number of electronic implantable devices, including the total heart implant. The resolution of these technical issues will allow for further expansion of the clinical indications for LVAD therapy.

Dr. Goldstein, medical editor of Cardiology News, is a professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

The recent International AIDS Conference held in Washington highlighted new paradigms in HIV prevention. The biennial meeting brought more than 20,000 attendees together to focus on the political and social – as well as the clinical – aspects of the HIV/AIDS epidemic.

A major discussion topic was the new approach to HIV prevention. Back in the early 1980s, "safe sex" via condoms and abstinence was the focus of prevention strategies. In 2006, the Centers for Disease Control and Prevention recommended routine testing for everyone, in order to broaden the potential for both treatment and prevention (MMWR 2006;55(RR-14);1-17). But in the past 3-4 years, we’ve expanded the concept of prevention in the following three ways:

• Verbal consent. In July, Massachusetts became the 49th state to stop requiring written consent for HIV testing. Other states have done the same over the last 18-24 months. Now the test is explained to the patient, and the patient can simply agree verbally to be tested for HIV, without having to sign a form. We believe that’s a significant step forward, because the requirement for a signature made HIV testing different from any other medical test, which often scared patients and resulted in their reluctance to be tested.

• Treatment as prevention. In August 2011, the landmark HIV Prevention Trial 052 (HPTN 052) showed that early antiviral therapy in HIV-infected individuals who were in serodiscordant sexual relationships reduced transmission to their uninfected partners by 96% (N. Engl. J. Med. 2011;365:493-505). This means that now, part of the clinical decision about starting treatment involves consideration of the patient’s sexual contacts and their protection as well.

There is still concern about the side effects (such as insomnia, gastrointestinal problems, and bone demineralization) of antiretrovirals, as well as uncertainty about long-term adherence when treatment is started early. However, the new data on transmission have shifted the risk/benefit equation in favor of treating more people. In HPTN 052, treatment was started at CD4 counts of 350-550 cells per mcL. Now, many experts advocate starting HIV-infected individuals at T cell counts of 500 or greater, for both improved outcome in the individual and reduction in the risk of HIV transmission.

• Prophylaxis as prevention. With the approval of the combination emtricitabine and tenofovir disoproxil fumarate (Truvada) for pre-exposure prophylaxis, we now have the option of not only treating the HIV-infected partner in serodiscordant couples, but also prophylaxing the uninfected partner in order to prevent transmission.

To do this, the individual must be tested and prove to be HIV negative prior to starting on pre-exposure prophylaxis. Regular testing must also be done every 3-6 months thereafter for as long as the person is taking Truvada. Such testing is necessary because Truvada (which comprises two reverse transcriptase inhibitors) does not sufficiently suppress viral replication by itself, and must be used in combination with antiretrovirals of other classes in the treatment of HIV-infected individuals. If a person were to become HIV infected while taking only Truvada without other classes of antiretrovirals, there is a high risk for the development of resistance as a result of mutations in the replicating virus.

Of course, it could be argued that it is more ethical to treat the person who actually has the disease than to subject an uninfected person to potential antiretroviral toxicity. However, consider the following case I saw recently: A pregnant woman said that her HIV-infected partner was taking his medication, but the partner’s physician said he hadn\'t seen the patient in many months and didn’t know if he was still taking the antiretrovirals. The woman was in labor, and said she’d had sex with the man recently. If there had been time, we would have started her on nevirapine and AZT (zidovudine) prior to delivery. But in this case, she delivered too quickly. So we put the infant on antiretrovirals and tested the mother a month later. She was negative, so we were able to take the infant off the drugs.

There are many examples like this, in which the real world doesn’t quite line up with what we try to achieve through research and guidelines.

Of course, cost is a consideration as well. Insurance will typically cover some or all of the cost ($800-$1,000 per month) for antiretroviral treatment, but it’s too early to know whether that coverage will extend to prophylaxis. I think the cost will limit its use in that capacity, at least until reasonable clinical guidelines are developed to determine which patients would be best targeted with this approach. And just to note: Although Truvada is approved for treating those as young as age 12 years, thus far its use as prophylaxis is restricted to adults aged 18 years and older.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures.

The recent International AIDS Conference held in Washington highlighted new paradigms in HIV prevention. The biennial meeting brought more than 20,000 attendees together to focus on the political and social – as well as the clinical – aspects of the HIV/AIDS epidemic.

A major discussion topic was the new approach to HIV prevention. Back in the early 1980s, "safe sex" via condoms and abstinence was the focus of prevention strategies. In 2006, the Centers for Disease Control and Prevention recommended routine testing for everyone, in order to broaden the potential for both treatment and prevention (MMWR 2006;55(RR-14);1-17). But in the past 3-4 years, we’ve expanded the concept of prevention in the following three ways:

• Verbal consent. In July, Massachusetts became the 49th state to stop requiring written consent for HIV testing. Other states have done the same over the last 18-24 months. Now the test is explained to the patient, and the patient can simply agree verbally to be tested for HIV, without having to sign a form. We believe that’s a significant step forward, because the requirement for a signature made HIV testing different from any other medical test, which often scared patients and resulted in their reluctance to be tested.

• Treatment as prevention. In August 2011, the landmark HIV Prevention Trial 052 (HPTN 052) showed that early antiviral therapy in HIV-infected individuals who were in serodiscordant sexual relationships reduced transmission to their uninfected partners by 96% (N. Engl. J. Med. 2011;365:493-505). This means that now, part of the clinical decision about starting treatment involves consideration of the patient’s sexual contacts and their protection as well.

There is still concern about the side effects (such as insomnia, gastrointestinal problems, and bone demineralization) of antiretrovirals, as well as uncertainty about long-term adherence when treatment is started early. However, the new data on transmission have shifted the risk/benefit equation in favor of treating more people. In HPTN 052, treatment was started at CD4 counts of 350-550 cells per mcL. Now, many experts advocate starting HIV-infected individuals at T cell counts of 500 or greater, for both improved outcome in the individual and reduction in the risk of HIV transmission.

• Prophylaxis as prevention. With the approval of the combination emtricitabine and tenofovir disoproxil fumarate (Truvada) for pre-exposure prophylaxis, we now have the option of not only treating the HIV-infected partner in serodiscordant couples, but also prophylaxing the uninfected partner in order to prevent transmission.

To do this, the individual must be tested and prove to be HIV negative prior to starting on pre-exposure prophylaxis. Regular testing must also be done every 3-6 months thereafter for as long as the person is taking Truvada. Such testing is necessary because Truvada (which comprises two reverse transcriptase inhibitors) does not sufficiently suppress viral replication by itself, and must be used in combination with antiretrovirals of other classes in the treatment of HIV-infected individuals. If a person were to become HIV infected while taking only Truvada without other classes of antiretrovirals, there is a high risk for the development of resistance as a result of mutations in the replicating virus.

Of course, it could be argued that it is more ethical to treat the person who actually has the disease than to subject an uninfected person to potential antiretroviral toxicity. However, consider the following case I saw recently: A pregnant woman said that her HIV-infected partner was taking his medication, but the partner’s physician said he hadn\'t seen the patient in many months and didn’t know if he was still taking the antiretrovirals. The woman was in labor, and said she’d had sex with the man recently. If there had been time, we would have started her on nevirapine and AZT (zidovudine) prior to delivery. But in this case, she delivered too quickly. So we put the infant on antiretrovirals and tested the mother a month later. She was negative, so we were able to take the infant off the drugs.

There are many examples like this, in which the real world doesn’t quite line up with what we try to achieve through research and guidelines.

Of course, cost is a consideration as well. Insurance will typically cover some or all of the cost ($800-$1,000 per month) for antiretroviral treatment, but it’s too early to know whether that coverage will extend to prophylaxis. I think the cost will limit its use in that capacity, at least until reasonable clinical guidelines are developed to determine which patients would be best targeted with this approach. And just to note: Although Truvada is approved for treating those as young as age 12 years, thus far its use as prophylaxis is restricted to adults aged 18 years and older.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures.

The recent International AIDS Conference held in Washington highlighted new paradigms in HIV prevention. The biennial meeting brought more than 20,000 attendees together to focus on the political and social – as well as the clinical – aspects of the HIV/AIDS epidemic.

A major discussion topic was the new approach to HIV prevention. Back in the early 1980s, "safe sex" via condoms and abstinence was the focus of prevention strategies. In 2006, the Centers for Disease Control and Prevention recommended routine testing for everyone, in order to broaden the potential for both treatment and prevention (MMWR 2006;55(RR-14);1-17). But in the past 3-4 years, we’ve expanded the concept of prevention in the following three ways:

• Verbal consent. In July, Massachusetts became the 49th state to stop requiring written consent for HIV testing. Other states have done the same over the last 18-24 months. Now the test is explained to the patient, and the patient can simply agree verbally to be tested for HIV, without having to sign a form. We believe that’s a significant step forward, because the requirement for a signature made HIV testing different from any other medical test, which often scared patients and resulted in their reluctance to be tested.

• Treatment as prevention. In August 2011, the landmark HIV Prevention Trial 052 (HPTN 052) showed that early antiviral therapy in HIV-infected individuals who were in serodiscordant sexual relationships reduced transmission to their uninfected partners by 96% (N. Engl. J. Med. 2011;365:493-505). This means that now, part of the clinical decision about starting treatment involves consideration of the patient’s sexual contacts and their protection as well.

There is still concern about the side effects (such as insomnia, gastrointestinal problems, and bone demineralization) of antiretrovirals, as well as uncertainty about long-term adherence when treatment is started early. However, the new data on transmission have shifted the risk/benefit equation in favor of treating more people. In HPTN 052, treatment was started at CD4 counts of 350-550 cells per mcL. Now, many experts advocate starting HIV-infected individuals at T cell counts of 500 or greater, for both improved outcome in the individual and reduction in the risk of HIV transmission.

• Prophylaxis as prevention. With the approval of the combination emtricitabine and tenofovir disoproxil fumarate (Truvada) for pre-exposure prophylaxis, we now have the option of not only treating the HIV-infected partner in serodiscordant couples, but also prophylaxing the uninfected partner in order to prevent transmission.

To do this, the individual must be tested and prove to be HIV negative prior to starting on pre-exposure prophylaxis. Regular testing must also be done every 3-6 months thereafter for as long as the person is taking Truvada. Such testing is necessary because Truvada (which comprises two reverse transcriptase inhibitors) does not sufficiently suppress viral replication by itself, and must be used in combination with antiretrovirals of other classes in the treatment of HIV-infected individuals. If a person were to become HIV infected while taking only Truvada without other classes of antiretrovirals, there is a high risk for the development of resistance as a result of mutations in the replicating virus.

Of course, it could be argued that it is more ethical to treat the person who actually has the disease than to subject an uninfected person to potential antiretroviral toxicity. However, consider the following case I saw recently: A pregnant woman said that her HIV-infected partner was taking his medication, but the partner’s physician said he hadn\'t seen the patient in many months and didn’t know if he was still taking the antiretrovirals. The woman was in labor, and said she’d had sex with the man recently. If there had been time, we would have started her on nevirapine and AZT (zidovudine) prior to delivery. But in this case, she delivered too quickly. So we put the infant on antiretrovirals and tested the mother a month later. She was negative, so we were able to take the infant off the drugs.

There are many examples like this, in which the real world doesn’t quite line up with what we try to achieve through research and guidelines.

Of course, cost is a consideration as well. Insurance will typically cover some or all of the cost ($800-$1,000 per month) for antiretroviral treatment, but it’s too early to know whether that coverage will extend to prophylaxis. I think the cost will limit its use in that capacity, at least until reasonable clinical guidelines are developed to determine which patients would be best targeted with this approach. And just to note: Although Truvada is approved for treating those as young as age 12 years, thus far its use as prophylaxis is restricted to adults aged 18 years and older.

Dr. Pelton is chief of pediatric infectious disease and coordinator of the maternal-child HIV program at Boston Medical Center. He said he had no relevant financial disclosures.

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

Dr. Chan practices rheumatology in Pawtucket, R.I.

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

Dr. Chan practices rheumatology in Pawtucket, R.I.

The Olympic Games have dominated the news in the past week. Part of the appeal is that the athletes seem so normal. They have parents. They go to school. They eat. In fact, there is now a Facebook page called "My Name Is Usain Bolt And I Love Chicken Nuggets."

When we listen to their stories, transfixed as we are by the minutiae of their lives, it is as if, in their "normalcy," we can almost see ourselves; as if by achieving the same degree of masochistic discipline, we might also turn ourselves into the better versions of ourselves that we know are hiding somewhere.

But I think another reason the athletes fascinate us is that there is a meditative, almost spiritual quality to them. It seems to permeate everything, from their training regimens to their very demeanor on that nerve-wracking world stage of Olympic sports.

I ran my first half marathon in March of this year, a few months before my 37th birthday.

There are no elaborate explanations for how I started running. I used to run in college, until I didn’t want to anymore. For a long time, I maintained a sedentary lifestyle. Medical school, marriage, residency, and fellowship provided convenient excuses.

But 3 years ago, a friend was diagnosed with cancer, and soon after that she started running. She started off with just 2 miles every day, and I thought to myself that if she, with her new life-altering reality, can run, shouldn’t I, too, be challenging myself to do something good for myself?

I couldn’t even run 2 miles. I started with half a mile and was done.

Three years later I finally ran a half-marathon. Three years. There are books out there that promise you can go from "couch to [insert whatever goal you want]" in 13 weeks or 26 weeks. It took me 3 years.

The reality is, if you keep at something consistently, you’ll get comfortable with it, and it may take 13 weeks, but it may not. When I encourage patients to exercise, I don’t frame it in terms of achieving a goal in a given time period. Consistency is very frequently just as important as goal setting; there is no need to torture yourself by setting expectations too high.

I don’t particularly enjoy running, but I don’t mind it either. It is inexpensive, does not require a lot of training, and your only competitor is yourself. You decide when you’re done. You can run and chat with friends or listen to music or podcasts. Or you can run with only your internal monologue for company. You can run at the gym and watch your favorite reality show (anyone with a guilty pleasure out there?), or run in your neighborhood and make friends with neighborhood pets.

Another added advantage, for those who might have some expendable income, is that you can run for a cause. The Arthritis Foundation, for example, is a great cause we can all get behind.

And then there’s the proverbial "runner’s high." If this is real (and there is not much evidence that it is), I didn’t get it. Or at least I did not experience what I expected it to feel like. However, I did feel an overwhelming sense of having accomplished something when I ran the half marathon. The last 2 miles of the race course were lined with spectators cheering us on, reaching out to slap hands with us, and holding up signs of people running for various causes. This was an extremely emotional moment for reasons I cannot explain scientifically, but I cried seeing those placards.

After that first half-marathon, I did not run as consistently as I should have, for various reasons (a family emergency; a subsequent soleus injury from, perhaps, stretching too enthusiastically after a run). But I signed up for another half marathon, coming up in 2 weeks, thereby forcing myself to get back to my regimen. And I discovered a wonderful thing when I started up again: My mood improved greatly. I did not even know that I was dysthymic until I started running again.

Haruki Murakami, famous writer of (really strange) Japanese fiction, is also an avid runner and has several marathons under his belt. Not only has he run the Boston Marathon, one of the hardest marathon courses, he has also run the real Marathon, from the site of the battle of Marathon to Athens (which thankfully survived, in contrast to Pheidippides’s unfortunate outcome). Murakami started running later in life as well, and documents this in his book "What I Talk About When I Talk About Running" (New York: Alfred A. Knopf, 2008).

Perhaps my favorite line in the book, and my ultimate reason for running: "Somerset Maugham once said that in each shave lies a philosophy. ... No matter how mundane some action might appear, keep at it long enough and it becomes a contemplative, even meditative act."

And, in fact, that previously mentioned Facebook page, the one called "My Name Is Usain Bolt And I Love Chicken Nuggets," its page description says "like if you love Usain Bolt’s calm relaxed personality."

Dr. Chan practices rheumatology in Pawtucket, R.I.