Child Psychiatry Consult

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

An estimated 42 million (18.1%) of the U.S. adult population continues to smoke cigarettes. Effective treatments exist for patients who are willing to avail themselves of such assistance. Varenicline is one of the most effective medications that we have to combat tobacco dependence. However, it doesn’t work for everybody, and questions have remained about how safe and effective it is to combine varenicline with other smoking cessation therapies such as nicotine replacement therapy.

Varenicline binds to a specific nicotine receptor, thereby partially agonizing and blocking it. The result is decreased cravings for tobacco and increased smoking quit rates. Data from early studies conducted by our group suggested that nicotine replacement therapy (NRT) combined with varenicline was safe, but questions remained about its efficacy.

One group of researchers conducted a multicenter clinical trial evaluating the efficacy of combining varenicline and the nicotine patch for increasing smoking cessation rates. Smokers were eligible if they smoked at least 10 cigarettes per day, reported F.N. Coenraad, from the Stellenbosch University, Cape Town, South Africa, and associates. Participants were randomized to active 15-mg nicotine patches or placebo patches started 2 weeks before the target quit date. All participants received varenicline for a total of 14 weeks with a 1-week ramp-up and a 1-week taper. Use of the varenicline in combination with the nicotine patch resulted in increased rates of continuous abstinence from smoking at 12 weeks (no smoking from weeks 9 to 12: 55.4% vs. 40.9%; odds ratio, 1.85; 95% confidence interval, 1.19-2.89; P = .007) and at 24 weeks (no smoking from weeks 9 to 24: 49% vs. 32.6%; OR, 1.98; 95% CI, 1.25-3.14; P = .004) (JAMA 2014;312:155-61).

This is a fantastic study answering a lingering question in tobacco control. But what is the theoretical underpinning by which this combination works? Isn’t the NRT blocked by the varenicline? It is possible that the varenicline incompletely saturates the nicotine receptors, which are additionally saturated by the supplemented nicotine. The varenicline effect is mediated through the alpha-4 beta-2 nicotinic receptor, and it is also possible that nicotine binds to nicotine receptor types that varenicline does not bind to, which decreases withdrawal symptoms.

We aren’t exactly sure how this might be working, but a near doubling of the odds of quitting is not to be disregarded. We are also not sure whether the effect holds when one uses other types of NRT such as the nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine gum. In practice, I tend to lean toward a combination of varenicline with the nicotine inhaler since the inhaler can help with some of the behavioral aspects of smoking while the varenicline does its heavy lifting.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert reports receiving research support from Pfizer, manufacturer of varenicline and the nicotine inhaler, and consulting fees from GlaxoSmithKline, manufacturer of the nicotine patch. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Maintaining close collaborative relationships with my dental colleagues is one of the many benefits of my primary care practice. I never cease to be amazed by how much my dental colleagues know about medicine and how little I know about dentistry. But I do ask my patients how frequently they see a dentist because it is a powerful marker for what I am going to find during the oral examination.

Many of my patients seem to have trouble maintaining their native teeth. This is surprising to me given the abundance of options for dental care; and yet, not surprising when I remember that caries is the most prevalent disease worldwide. Oral health has a huge potential impact on overall health, and the control of dental plaque is the key to oral health. I typically do not recommend toothbrushes to my patients who have identified dental disease, but I may start doing this now that I understand more about toothbrushes.

Powered toothbrushes clean teeth through a variety of mechanisms: side-to-side action, counter oscillation, rotation oscillation, circular, ultrasonic, and ionic, just to name a few. They are more expensive than regular toothbrushes, but are they better for removing plaque?

An updated systematic review of the literature has been published comparing powered versus manual toothbrushing for the maintenance of oral health. Trials were selected if they evaluated at least 4 weeks of unsupervised toothbrushing. Fifty-one trials involving 4,624 participants provided data for the meta-analysis (Cochrane Database Syst. Rev. 2014;6:CD002281 [doi:10.1002/14651858.CD002281.pub3]).

Powered toothbrushes provide a statistically significant benefit, compared with manual toothbrushes, for the reduction of plaque in both the short (1-3 months; 11% reduction) and long term (longer than 3 months; 21% reduction) over manual toothbrushes. Powered toothbrushes also provide a statistically significant benefit in the short and long term for reduction in gingivitis. Most of the evidence is for rotation oscillation brushes.

So now I can give my patients a useful tip for maintaining oral health. Does improved plaque removal translate into general health benefits? We are uncertain, but it will certainly make for more enjoyable oral examinations.

Dr. Ebbert is a professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. Dr. Ebbert reports no disclosures. The opinions expressed are his alone and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Back pain is a primary complaint of many of the patients we see and, seemingly, a secondary complaint of almost all. Exercise training to strengthen spine muscles is effective, but patients either do not attend referrals to therapy or are not compliant with prescribed regimens. An ideal treatment would be involuntary therapy occurring at all times of the day. But does such a magical therapy exist?

Indeed, it does. They are called unstable shoes or, perhaps less disconcertingly, rocker bottom shoes. They are also referred to as round bottom shoes, rounded shoes, or toning shoes.

Unstable shoes incorporate a rounded sole to increase anterior-posterior instability. Masai Barefoot Technology (MBT) has been advocating their use since the 1990s to reduce low back pain. The owners of MBT went out of business, and the future of this particular brand is uncertain, but many other brands offer this design. Studies have shown that they increase activity of ankle muscles and low back muscles and modify posture during standing and walking.

In a recently published clinical trial evaluating the effectiveness of unstable shoes, 40 hospital workers with chronic low back pain were randomized to unstable shoes or conventional sports shoes. Participants were instructed to start using the shoes 2 hours per day and increasing use by 1 hour every day. After 1 week, participants were asked to wear the shoes for a minimum of 6 hours a day during their time spent at work.

Unstable shoes were associated with a significant reduction in pain during walking. Satisfaction with pain management and the number of responders was greater in the unstable shoe group. However, the intervention had no effect on functional disability or quality of life.

This was a short trial (6 weeks). But this information will inform the discussion about the efficacy of these shoes, which are neither uniformly embraced nor recommended. Some discretionary caution should be exercised when considering these shoes for patients with hip or knee instability, Achilles tendon or heel problems, and gait unsteadiness as they might increase the risk for falls. But it is yet another arrow in the quiver to help combat chronic low back pain.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

As obesity continues to ravage the health of the United States, bariatric surgery offers an effective strategy for individual patients suffering from medical complications.

When performed in adults with a body mass index of at least 30 kg/m², bariatric surgery is associated with a mean weight loss of 20%-35% of baseline weight at 2-3 years. Bariatric surgery is associated with greater reductions in obesity comorbidities, compared with lifestyle intervention and supervised weight loss. Contemporary bariatric surgeries include Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion with duodenal switch, sleeve gastrectomy, and mini–gastric bypass.

Bariatric surgical procedures affect weight loss through two mechanisms: malabsorption and restriction. Such alterations in human physiology can change the absorption of common drugs of addiction, such as alcohol. This can increase the risk for problem drinking behaviors.

Wendy C. King, Ph.D., of the department of epidemiology at the University of Pittsburgh and her colleagues conducted an analysis of data from 1,945 patients in a cohort who underwent bariatric surgery in 10 U.S. hospitals. Symptoms of alcohol use disorder (AUD) were assessed pre- and postoperatively (JAMA 2012;307:2516-25).

The prevalence of AUD was significantly higher at 2 years postoperatively (9.6%), compared with the preoperative period (7.6%; P less than .01). Factors associated with a higher risk of postoperative AUD included male gender, younger age, smoking, regular alcohol consumption, a history of AUD, recreational drug use, low social support, and receiving Roux-en-Y gastric bypass.

AUD can disqualify patients from bariatric surgery – but 7.6% of patients in this survey (taken independently of clinical care) reported it. The authors noted that a 2% increase in AUD associated with bariatric surgery translates into 2,000 additional people with AUD each year.

This is particularly problematic for this population, because a large number of calories are associated with alcohol intake, and alcohol intake can lower inhibitions for other types of eating behaviors – all of which can lead to weight regain.

So, what do we do?

I think it may be helpful to take alcohol use histories in the patients we are seeing in bariatric surgery follow-up, especially those who appear to be regaining weight. Some patients may not be aware of this connection. For the patients who I have told about this relationship, they recognize it, which may be the first step toward dealing with it.

Dr. Ebbert is a professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Now that we have made the most likely diagnosis of a kidney stone, we can potentially avoid a urologic procedure if we expel it. Of the 22% of kidney stones that wind up in the ureter, two-thirds will be lodged in the distal ureter.

Tamsulosin works, and prednisolone may also be helpful. Anything else?

Dr. Kumar Jayant of Sudha Hospital and Medical Research Center, Kota, India, and associates investigated the efficacy of a phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) to facilitate kidney stone expulsion. PDE5 inhibitors increase levels of cyclic guanosine monophosphate and cause ureteric relaxation (Int. J. Urol. 2014 June 3 [doi:10.1111/iju.12496]).

In this study, 244 patients with distal ureteral stones between 5 and 10 mm (about a 50% chance of passing) quantitated with noncontrast CT were randomized to two groups: tamsulosin (0.4 mg daily) or tamsulosin (0.4 mg daily) plus tadalafil (10 mg daily). Medications were given for 4 weeks.

The average patient age was about 37 years, and the mean stone size was 7 mm. Participants were included only if their pain was relieved within a day by diclofenac injection. Potential participants were excluded if they had fever, hydronephrosis, multiple kidney stones, a history of surgery or endoscopic procedures, or diabetes; were taking calcium channel blockers or nitrates; were pregnant or lactating; or required immediate treatment. If stones were not passed in 4 weeks, ureterorenoscopy was used to remove them.

The tamsulosin/tadalafil combination was associated with a statistically significantly higher rate of expulsion (83.6% vs. 65.5%; P = .031) and a shorter time to expulsion (14.9 days vs. 16.7 days; P =.003). Tamsulosin/tadalafil was associated with significantly fewer hospital visits and less need for pain medications. Not surprisingly, tamsulosin/tadalafil improved erectile function. However, patients taking the tamsulosin/tadalafil combination also had more headaches, dizziness, orthostatic hypotension, and backaches.

In certain patients, hypotension may be a concern with this combination. However, the researchers highlighted a study whose authors concluded, "in subjects on tamsulosin, tadalafil 10 and 20 mg produced mean maximal decreases in standing [systolic blood pressure] that were similar to placebo" (J. Urol. 2004;172(5, pt. 1):1935-40).

Out-of-pocket cost may be a barrier for some patients. But given the significance of these findings (an almost 20% difference in expulsion rate), total cost of care may be significantly reduced for these patients.

Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.

Introduction

All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.

Case summary

A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.

Discussion

Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.

There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.

When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role

In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.

These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.

It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.

How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.

Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Nephrolithiasis affects 1 in 11 people in the United States resulting in several million emergency department visits annually. The prevalence of nephrolithiasis is higher among men, obese individuals, and white non-Hispanics. The prevalence of kidney stones also appears to be increasing.

Our patients tell us that few things hurt worse than kidney stones. We may feel especially compelled to make a diagnosis given pain severity in otherwise healthy adults who have "never experienced this kind of pain before." Perhaps because of this, lots of patients are undergoing CT imaging for kidney stones ... in the United States. Interestingly, the European Urology Association recommends ultrasonography as the first-line test for urolithiasis.

Can we predict who has a kidney stone?

Moore and colleagues derived and validated a clinical prediction rule for uncomplicated ureteral stone. The derivation cohort was 1,040 patients undergoing noncontrast CT for suspected uncomplicated kidney stone. The validation cohort was 491 consecutively enrolled patients.

Data analysis revealed five factors that were significantly associated with the presence of a ureteral stone: male sex (2 points), duration of pain to presentation (greater than 24 hours: 0 points; 6-24 hours: 1 point; less than 6 hours: 3 points), nonblack race (3 points), presence of nausea or vomiting (nausea alone: 1 point; vomiting alone: 2 points), and microscopic hematuria (3 points). The points add up to low probability (0-5 points = 10% chance of stone), moderate probability (6-9 points = about 50% chance of stone), and high probability (10-13 points = about 90% chance of stone). Acutely important alternative causes were found in 1.6% of the high-probability group in the validation set. These causes were diverticulitis, appendicitis, mass, pyelonephritis, cholecystitis, pneumonia, bowel obstruction, colitis, aortic aneurysm, and pancreatitis.

This algorithm was derived and validated in the emergency setting so it will have different performance characteristics in the outpatient, ambulatory, phone-triage world. However, as the authors discuss, this algorithm could be used to help institutions make decisions about lowering radiation doses for "stone protocol" scans. Scales such as these should be incorporated into electronic medical record systems to improve care delivery.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no disclosures.

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

Data from the Centers for Disease Control and Prevention’s National Ambulatory Medical Center Survey reveal benzodiazepine prescriptions grew by 12.5% per year between 2002 and 2009. Data from the National Health and Nutrition Examination Survey suggest that prescriptions for sleep aids (sedatives and hypnotics) tripled between 1998 and 2006. Four percent of U.S. adults age 20 years or older and 7% of adults age 80 years or older report using a prescription sleep aid in the past month.

Aside from the addictive potential and their limited long-term effectiveness, they may be associated with an increased risk of death.

Dr. Scott Weich and his colleagues at University of Warwick, Coventry, England, analyzed data from a retrospective matched cohort study involving 34,727 patients aged at least 16 years who received prescriptions for anxiolytics or hypnotics and 69,418 patients who did not (BMJ 2014;348:g1996). To reduce the likelihood that patients received a prescription that they did not fill, only patients receiving at least two prescriptions were included. The average follow-up period was 7.6 years. The most commonly prescribed drugs were diazepam (48%), temazepam (35%), zopiclone (34%), and zolpidem (8%).

Significantly higher ratios for mortality were observed with the use of these drugs. Adjusting for potential confounders, the hazard ratio for mortality during the whole follow-up period was significantly elevated for the group receiving any sedative or hypnotic in the first year of recruitment (hazard ratio, 3.32; 95% confidence interval: 3.19-3.45).

Dose responses were observed for study drugs. For example, the HR for patients receiving more than 90 doses during the first year was 4.51 (95% CI: 4.22-4.82). Patients who did not receive study drugs beyond 1 year were less likely to die than those who continued to take them. The authors point out that these data translate into four excess deaths linked to use of these drugs per 100 people over 7.6 years after the initial prescription.

The biggest challenge will be to figure out how best to incorporate this information into our counseling of patients without sounding like we are "fear-mongering." Fear-mongering doesn’t work – it just makes our patients more anxious, when what we really need to do is calm them down.

Cognitive-behavioral therapy works for insomnia, but patients report not having the time. I always start the discussion by telling patients to read the book "No More Sleepless Nights" and to start a sleep log. Amazing what we can learn from this. This as least gets the ball rolling.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. Dr. Ebbert does not receive royalties from the sale of "No More Sleepless Nights."

Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
 

Case summary

A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."

Discussion

Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.

We will start with simpler problems and work our way toward more challenging reasons.

• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.

• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.

• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.

• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.

• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.

• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.

• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.

• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.

• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.

• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.

Of course, sometimes the medication truly is not working, and it is time to try something else.

Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.

Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
 

Case summary

A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."

Discussion

Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.

We will start with simpler problems and work our way toward more challenging reasons.

• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.

• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.

• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.

• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.

• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.

• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.

• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.

• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.

• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.

• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.

Of course, sometimes the medication truly is not working, and it is time to try something else.

Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.

Welcome to a new column designed to provide practical advice regarding issues related to child mental health. It will be a joint effort, featuring contributions from several child psychiatrists working at the University of Vermont and the Vermont Center for Children, Youth, and Families. While psychopharmacology will certainly be a part of many of the columns, all of us here feel strongly that medications should be only one part of a comprehensive family-oriented plan. We encourage you to submit questions that you would like us address in future issues to [email protected].
 

Case summary

A 10-year-old boy presents for a follow-up appointment. He was diagnosed by another pediatrician in the practice 2 months ago with attention-deficit/hyperactivity disorder (ADHD) and now returns to the office with continued symptoms and a complaint from the mother that medication "isn’t working." The boy was started on an extended-release preparation of methylphenidate at 18 mg to take each morning. The child is in the fifth grade and weighs 80 lb (36 kg). He lives with his mother and 8-year-old brother. The father is no longer involved in the patient’s life, which puts added stress on the mother. The diagnosis of ADHD was made by the pediatrician based upon the history, the child’s hyperactive and intrusive behavior in the office, and the results of a standardized rating scale that was completed by the mother, who now requests that the pediatrician "try something different."

Discussion

Many children and adolescents respond extremely well to ADHD medications. Some, however, do not, and the parental complaint that the "medication isn’t working" is a frequent expression heard in pediatrician offices across the country. It is also one of the primary reasons a family is referred to a child psychiatrist. In the course of performing hundreds of these consultations, I have found that there are several possibilities to consider before assuming the medication simply isn’t effective.

We will start with simpler problems and work our way toward more challenging reasons.

• The dose is too low. Methylphenidate often needs to be dosed over 1 mg/kg/day to be effective. If the patient reports minimal response to the medication while experiencing no side effects, an increase may certainly be reasonable.

• The medication is working but wearing off. Despite the advertisements of long-acting stimulants continuing their therapeutic effect for 10-12 hours, many children seem to lose the benefit of the medication much faster. Gathering some data from the school or asking the mother about weekend mornings compared with evenings can be useful. If indeed such a wear-off is found, adding a dose of an immediate-release stimulant in the early afternoon may help.

• Symptoms are being caused by something other than ADHD. Hyperactivity due to exposures such as lead may not change your management of the symptoms, but certainly could necessitate other types of intervention. Chronic sleep problems and inadequate nutrition, especially when it comes to breakfast, also should be queried and can lead to problems with concentration.

• There is psychiatric comorbidity. Unlike many differentials in other specialties, psychiatric differential diagnosis is often a matter of "and" rather than "or." Anxiety disorders, for example, can frequently masquerade as ADHD or be present in addition to ADHD. Oppositional behavior is also very commonly present with ADHD and suggests additional types of treatment.

• There is noncompliance. This problem can surface frequently in two ways. Older children may be responsible at home for taking their medications and forget or refuse to do so. I often ask, "Are you taking the medication every single day?" Diversion is also a potential problem from the parents or for an adolescent. Checking if the refills are occurring on time can provide a clue here, and some states have systems to check for duplicate prescriptions from multiple clinicians.

• Side effects are appearing as untreated ADHD. Sometimes medications are the problem, not the solution, and a failure to recognize this phenomenon can lead to unnecessary and sometimes harmful polypharmacy. Stimulants in some children can lead to increased agitation, anger outbursts, and impulsivity. Trying a medication holiday for several days can sometimes reveal the need to back off rather than add medications.

• Family is expecting improvement for non-ADHD symptoms. Asking what particular behaviors the family is hoping to improve can sometimes expose a situation in which parents expect change in non-ADHD domains. Unfortunately, there is no pill to make kids respect their parents more or want to do their homework. Being clear from the outset about what behaviors are and are not medication responsive can sometimes prevent this problem.

• There is substance abuse. In addition to the potential problem of abuse of the stimulants described previously, other substances such as cannabis can sabotage the benefits of medications.

• There is over-reliance on medications as the sole modality of treatment. ADHD is best treated using a wide range of strategies. Nonpharmacological interventions such as exercise, good nutrition and sleep, parent behavioral training, organizational help, regular reading, screen time reduction, and school supports are critical components of a comprehensive treatment approach.

• There is parental psychopathology. In our opinion, this area is one of the most frequently neglected aspects of child mental health treatment and can have huge implications. ADHD in particular is known to have very high heritability (similar to height). If a mother or father shares the condition, their struggles can frequently contribute to an environment that can exacerbate the child’s symptoms. A pattern in which the ADHD symptoms are more prominent at home compared with school is one clue to look in this direction. When addressing parental psychopathology, it can be important not to come off as blaming the parents for their child’s problems, but rather to convey how challenging dealing with ADHD can be as a parent and how they need to be functioning at their highest mental level as well.

Of course, sometimes the medication truly is not working, and it is time to try something else.

Dr. David C. Rettew is associate professor of psychiatry and pediatrics, director of the child and adolescent psychiatry fellowship, and director of the pediatric psychiatry clinic at the University of Vermont, Burlington.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

While not a new phenomenon, antimicrobial resistance is an alarming and, arguably, still underappreciated public health problem. A mere 70 years after the introduction of antibiotics, we face the distinct possibility of a future without effective antibiotics for some infections. Such a reality will render select surgical operations, cancer chemotherapy, and organ transplants exceedingly dangerous.

The scarcity of new antimicrobial agents and the paucity of new agents in the drug development pipeline limit treatment options, particularly for patients with infections caused by multidrug-resistant organisms. Annually, multidrug resistant organisms cause an estimated 25,000 deaths in Europe and 12,000 deaths in the United States. In response to this threat, the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) was established and published their report with 17 recommendations.

Respiratory tract infections are one of the most common symptoms presenting to primary care. Overprescribing in this setting is rampant, driven largely by patient expectations and clinician need for expediency and desire to receive "high marks" for satisfaction. Available evidence has suggested that delayed antibiotic prescribing is effective. But what is the best method to delay antibiotic prescribing?

Researchers in the United Kingdom evaluated the comparative effectiveness of four different strategies of delayed antibiotic prescribing for patients not needing antibiotics right away:

• Recontact: Patients were asked to contact the office and leave a message for a clinician to prescribe an antibiotic.

• Postdated prescription: The prescription could be filled only after a certain date.

• Wait/Request: Patients were instructed to wait but could request an antibiotic from the front office.

• Delayed use: Patients received antibiotics but were asked to wait to use them.

A "no prescription" arm was added later in the trial. The primary outcome was symptom severity measured at the end of each day during days 2-4 of a two-week symptom diary. Secondary outcomes included antibiotic use and side effects.

No differences were observed between the four strategies with respect to symptom control. Antibiotic use did not differ significantly between strategies and the lowest use was reported in the no prescription arm. No significant differences were observed between groups in patient satisfaction. Complications were slightly higher in the no antibiotic group (2.5%), compared with the delayed groups (1.4%).

Delayed prescribing is associated with less than 40% of patients using an antibiotic. Given the current crisis with multidrug resistance, we should feel obligated to try one of the proposed strategies for delayed antibiotic prescription if patients do not need one right away.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.