Commentary

 

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

For some physicians, this is a daily reality. Whether patients in the clinic, or cases in the queue, some hematologists revisit the storm every day. Most, however, are engaged in an academic practice where at least some respite from direct patient care is offered. Whether teaching medical students, analyzing data, participating in administrative meetings, or writing manuscripts, most of us do something more beyond the clinic. We do this during our “protected time.”

But what are we protected from? Patients and their concerns? Really, this is what we want to be protected from?

“Protected” is the wrong word. The time we spend pursuing academics is really “professional” time. Some centers call it administrative time, but this also falls short. Time allotted to nonclinical activities keeps us fresh, sharpens our intellect, and ultimately helps our patients. Professional time helps prevent burnout by making us more present when we are in clinic. Professional time allows for scientific inquiry to advance treatments, and encourages continuing education to remain at the cutting edge of technology. Professional time, though, competes with patient time and that tension can drive disengagement.

Patients, and their problems, do not operate according to half-day clinic schedules. When there exists any professional time, patient time is always interfering. The interference becomes more acute as academic success increases and the allotted professional time seems inadequate. Hematologists then start to blame patients for interfering with their careers. A pernicious disdain for patient care may develop because it interrupts the academic motivations that drive many physicians once they get a taste of success. Manifestations of this attitude include dread of inpatient service, negotiations to reduce clinic time for research, and refusal to see or sometimes even talk to patients when not assigned to clinic. The more successful the academic hematologist becomes, the less he or she wants to be troubled with patients without whom professional success could not have been achieved.

The professional and patient time balance is as important to recognize as work and life balance, as one tension directly impacts the other. When nature sends a snowstorm, a warm home allows survival, but if one never ventures from home, the beauty and grandeur of nature is lost. True satisfaction comes from a balance of the two and no one person knows how best to accomplish it. I believe we can learn to manage our professional and patient time better by exchanging ideas and best practices. Please email me at [email protected] with your ideas and we will post as many as we can on the Hematology News website for all to learn from.
 

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

 

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

For some physicians, this is a daily reality. Whether patients in the clinic, or cases in the queue, some hematologists revisit the storm every day. Most, however, are engaged in an academic practice where at least some respite from direct patient care is offered. Whether teaching medical students, analyzing data, participating in administrative meetings, or writing manuscripts, most of us do something more beyond the clinic. We do this during our “protected time.”

But what are we protected from? Patients and their concerns? Really, this is what we want to be protected from?

“Protected” is the wrong word. The time we spend pursuing academics is really “professional” time. Some centers call it administrative time, but this also falls short. Time allotted to nonclinical activities keeps us fresh, sharpens our intellect, and ultimately helps our patients. Professional time helps prevent burnout by making us more present when we are in clinic. Professional time allows for scientific inquiry to advance treatments, and encourages continuing education to remain at the cutting edge of technology. Professional time, though, competes with patient time and that tension can drive disengagement.

Patients, and their problems, do not operate according to half-day clinic schedules. When there exists any professional time, patient time is always interfering. The interference becomes more acute as academic success increases and the allotted professional time seems inadequate. Hematologists then start to blame patients for interfering with their careers. A pernicious disdain for patient care may develop because it interrupts the academic motivations that drive many physicians once they get a taste of success. Manifestations of this attitude include dread of inpatient service, negotiations to reduce clinic time for research, and refusal to see or sometimes even talk to patients when not assigned to clinic. The more successful the academic hematologist becomes, the less he or she wants to be troubled with patients without whom professional success could not have been achieved.

The professional and patient time balance is as important to recognize as work and life balance, as one tension directly impacts the other. When nature sends a snowstorm, a warm home allows survival, but if one never ventures from home, the beauty and grandeur of nature is lost. True satisfaction comes from a balance of the two and no one person knows how best to accomplish it. I believe we can learn to manage our professional and patient time better by exchanging ideas and best practices. Please email me at [email protected] with your ideas and we will post as many as we can on the Hematology News website for all to learn from.
 

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

 

As I write this article, the snow is piling up outside. While Cleveland’s west side citizens are raking up the last of fallen leaves, its east siders will dig out of 2 feet of snow. The lake effect is affecting us. The snow plow trucks vainly clear a path only for it to disappear in minutes. There seems to be no end to the torrents of white flakes that are each unique and tiny, but in aggregate uniform and overwhelming.

A blizzard of patients awaits my return from the annual meeting of the American Society of Hematology in San Diego. Like snowflakes, they are each unique, but in aggregate can be overwhelming. Plowing through a clinic, we go from patient to patient knowing that we will eventually see them all, then return to our offices or home to finish the labor of charting.

For some physicians, this is a daily reality. Whether patients in the clinic, or cases in the queue, some hematologists revisit the storm every day. Most, however, are engaged in an academic practice where at least some respite from direct patient care is offered. Whether teaching medical students, analyzing data, participating in administrative meetings, or writing manuscripts, most of us do something more beyond the clinic. We do this during our “protected time.”

But what are we protected from? Patients and their concerns? Really, this is what we want to be protected from?

“Protected” is the wrong word. The time we spend pursuing academics is really “professional” time. Some centers call it administrative time, but this also falls short. Time allotted to nonclinical activities keeps us fresh, sharpens our intellect, and ultimately helps our patients. Professional time helps prevent burnout by making us more present when we are in clinic. Professional time allows for scientific inquiry to advance treatments, and encourages continuing education to remain at the cutting edge of technology. Professional time, though, competes with patient time and that tension can drive disengagement.

Patients, and their problems, do not operate according to half-day clinic schedules. When there exists any professional time, patient time is always interfering. The interference becomes more acute as academic success increases and the allotted professional time seems inadequate. Hematologists then start to blame patients for interfering with their careers. A pernicious disdain for patient care may develop because it interrupts the academic motivations that drive many physicians once they get a taste of success. Manifestations of this attitude include dread of inpatient service, negotiations to reduce clinic time for research, and refusal to see or sometimes even talk to patients when not assigned to clinic. The more successful the academic hematologist becomes, the less he or she wants to be troubled with patients without whom professional success could not have been achieved.

The professional and patient time balance is as important to recognize as work and life balance, as one tension directly impacts the other. When nature sends a snowstorm, a warm home allows survival, but if one never ventures from home, the beauty and grandeur of nature is lost. True satisfaction comes from a balance of the two and no one person knows how best to accomplish it. I believe we can learn to manage our professional and patient time better by exchanging ideas and best practices. Please email me at [email protected] with your ideas and we will post as many as we can on the Hematology News website for all to learn from.
 

Dr. Kalaycio is Editor in Chief of Hematology News. Dr. Kalaycio chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at [email protected].

 

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Recently, because of the prevalence of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) (the American Psychiatric Association’s DSM-5 version of fetal alcohol spectrum disorders) in my community, I have begun to tout this problem as a major public health issue. When we formulated the Institute of Medicine’s 2009 Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities report, we did not include the problem of fetal alcohol exposure – and this was an unfortunate oversight.

However, this area of interest had not yet fully developed, and nearly 8 years later, there have been some confluent developments regarding potential prevention of this problem. They both involve choline.

First, we know that when women drink while pregnant, the alcohol they consume rids their bodies of choline, a nutrient the fetus needs for proper cell construction, neurogenesis, and neurodevelopment. Accordingly, several scientists are exploring using choline both pre- and postnatally to see if the defects on ND-PAE can be ameliorated or prevented. All of the research in this area is new, but it looks very promising.

Recently, I had the good fortune to present an idea during the Andrea Delgado Memorial Lecture at the Black Psychiatrists of America transcultural conference in the Bahamas. I also spoke at a mini-plenary at the 32nd Annual Rosalynn Carter Mental Health Policy Symposium in Atlanta. The core of the presentations were not too deep (to paraphrase a line Morgan Freeman used on Jack Nicholson in the movie “The Bucket List” – ‘I have seen bathtubs that are deeper’), but I think it explicated an essential idea. Jessie Aujla, a 4th-year medical student, and I explored the content of choline in the 25 top prenatal vitamins and found none of them contained the 450-mg daily recommended dose of choline advised by the Institute of Medicine in 1998. In fact, only two contain 50 mg; six others contain less than 30 mg; and the other 17 have no choline whatsoever (this study is in press at the Journal of Family Medicine and Prevention). So we are advocating that the prenatal vitamin manufacturers increase the choline content of their prenatal vitamins, because although women may be getting some choline from their food diets, we found one large study illustrating that 90% of pregnant women are choline deficient.

The other area of interest regarding choline as a preventive agent for mental illness is work published by researchers at the University of Colorado Denver. This research group is proposing that choline may prevent the development of autism, attention-deficit/hyperactivity disorder, and schizophrenia by an epigenetic mechanism involving a nicotinic acetylcholine receptor. This makes perfectly good sense clinically among those of us who are treating patients with ND-PAE. Some of us are starting to think of ND-PAE as a choline deficiency disorder and see symptoms that are extremely similar to autism, ADHD, and schizophrenia in such patients. Many patients with ND-PAE are misdiagnosed with these disorders. Accordingly, there appears to be some common ground between ideas aimed at preventing fetal alcohol exposure and those aimed at preventing autism, ADHD, and schizophrenia – specifically, ensuring that pregnant women get an adequate supply of choline.

There is certainly a great need to do more research to nail down these two potential preventive actions. But until that research is done, it seems to me that the least we can do is to advocate for a position that the manufacturers of prenatal vitamins at least include the daily recommended dose of choline (450 mg/day) pregnant women need per the findings of the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline, published in 1998.
 

 

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

 

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Recently, because of the prevalence of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) (the American Psychiatric Association’s DSM-5 version of fetal alcohol spectrum disorders) in my community, I have begun to tout this problem as a major public health issue. When we formulated the Institute of Medicine’s 2009 Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities report, we did not include the problem of fetal alcohol exposure – and this was an unfortunate oversight.

However, this area of interest had not yet fully developed, and nearly 8 years later, there have been some confluent developments regarding potential prevention of this problem. They both involve choline.

First, we know that when women drink while pregnant, the alcohol they consume rids their bodies of choline, a nutrient the fetus needs for proper cell construction, neurogenesis, and neurodevelopment. Accordingly, several scientists are exploring using choline both pre- and postnatally to see if the defects on ND-PAE can be ameliorated or prevented. All of the research in this area is new, but it looks very promising.

Recently, I had the good fortune to present an idea during the Andrea Delgado Memorial Lecture at the Black Psychiatrists of America transcultural conference in the Bahamas. I also spoke at a mini-plenary at the 32nd Annual Rosalynn Carter Mental Health Policy Symposium in Atlanta. The core of the presentations were not too deep (to paraphrase a line Morgan Freeman used on Jack Nicholson in the movie “The Bucket List” – ‘I have seen bathtubs that are deeper’), but I think it explicated an essential idea. Jessie Aujla, a 4th-year medical student, and I explored the content of choline in the 25 top prenatal vitamins and found none of them contained the 450-mg daily recommended dose of choline advised by the Institute of Medicine in 1998. In fact, only two contain 50 mg; six others contain less than 30 mg; and the other 17 have no choline whatsoever (this study is in press at the Journal of Family Medicine and Prevention). So we are advocating that the prenatal vitamin manufacturers increase the choline content of their prenatal vitamins, because although women may be getting some choline from their food diets, we found one large study illustrating that 90% of pregnant women are choline deficient.

The other area of interest regarding choline as a preventive agent for mental illness is work published by researchers at the University of Colorado Denver. This research group is proposing that choline may prevent the development of autism, attention-deficit/hyperactivity disorder, and schizophrenia by an epigenetic mechanism involving a nicotinic acetylcholine receptor. This makes perfectly good sense clinically among those of us who are treating patients with ND-PAE. Some of us are starting to think of ND-PAE as a choline deficiency disorder and see symptoms that are extremely similar to autism, ADHD, and schizophrenia in such patients. Many patients with ND-PAE are misdiagnosed with these disorders. Accordingly, there appears to be some common ground between ideas aimed at preventing fetal alcohol exposure and those aimed at preventing autism, ADHD, and schizophrenia – specifically, ensuring that pregnant women get an adequate supply of choline.

There is certainly a great need to do more research to nail down these two potential preventive actions. But until that research is done, it seems to me that the least we can do is to advocate for a position that the manufacturers of prenatal vitamins at least include the daily recommended dose of choline (450 mg/day) pregnant women need per the findings of the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline, published in 1998.
 

 

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

 

Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.

I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.

Recently, because of the prevalence of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) (the American Psychiatric Association’s DSM-5 version of fetal alcohol spectrum disorders) in my community, I have begun to tout this problem as a major public health issue. When we formulated the Institute of Medicine’s 2009 Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities report, we did not include the problem of fetal alcohol exposure – and this was an unfortunate oversight.

However, this area of interest had not yet fully developed, and nearly 8 years later, there have been some confluent developments regarding potential prevention of this problem. They both involve choline.

First, we know that when women drink while pregnant, the alcohol they consume rids their bodies of choline, a nutrient the fetus needs for proper cell construction, neurogenesis, and neurodevelopment. Accordingly, several scientists are exploring using choline both pre- and postnatally to see if the defects on ND-PAE can be ameliorated or prevented. All of the research in this area is new, but it looks very promising.

Recently, I had the good fortune to present an idea during the Andrea Delgado Memorial Lecture at the Black Psychiatrists of America transcultural conference in the Bahamas. I also spoke at a mini-plenary at the 32nd Annual Rosalynn Carter Mental Health Policy Symposium in Atlanta. The core of the presentations were not too deep (to paraphrase a line Morgan Freeman used on Jack Nicholson in the movie “The Bucket List” – ‘I have seen bathtubs that are deeper’), but I think it explicated an essential idea. Jessie Aujla, a 4th-year medical student, and I explored the content of choline in the 25 top prenatal vitamins and found none of them contained the 450-mg daily recommended dose of choline advised by the Institute of Medicine in 1998. In fact, only two contain 50 mg; six others contain less than 30 mg; and the other 17 have no choline whatsoever (this study is in press at the Journal of Family Medicine and Prevention). So we are advocating that the prenatal vitamin manufacturers increase the choline content of their prenatal vitamins, because although women may be getting some choline from their food diets, we found one large study illustrating that 90% of pregnant women are choline deficient.

The other area of interest regarding choline as a preventive agent for mental illness is work published by researchers at the University of Colorado Denver. This research group is proposing that choline may prevent the development of autism, attention-deficit/hyperactivity disorder, and schizophrenia by an epigenetic mechanism involving a nicotinic acetylcholine receptor. This makes perfectly good sense clinically among those of us who are treating patients with ND-PAE. Some of us are starting to think of ND-PAE as a choline deficiency disorder and see symptoms that are extremely similar to autism, ADHD, and schizophrenia in such patients. Many patients with ND-PAE are misdiagnosed with these disorders. Accordingly, there appears to be some common ground between ideas aimed at preventing fetal alcohol exposure and those aimed at preventing autism, ADHD, and schizophrenia – specifically, ensuring that pregnant women get an adequate supply of choline.

There is certainly a great need to do more research to nail down these two potential preventive actions. But until that research is done, it seems to me that the least we can do is to advocate for a position that the manufacturers of prenatal vitamins at least include the daily recommended dose of choline (450 mg/day) pregnant women need per the findings of the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline, published in 1998.
 

 

Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

 

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

The case example above brings up a number of potential findings from the history that can help the evaluating clinician sort out the role of ADHD and/or anxiety in a child’s difficulties. Here are five specific questions to consider asking in these kinds of situations.

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

 

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

Dr. Rettew is a child and adolescent psychiatrist and assistant professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych. Email him at [email protected].

 

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

The case example above brings up a number of potential findings from the history that can help the evaluating clinician sort out the role of ADHD and/or anxiety in a child’s difficulties. Here are five specific questions to consider asking in these kinds of situations.

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

 

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

Dr. Rettew is a child and adolescent psychiatrist and assistant professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych. Email him at [email protected].

 

This month’s column comes directly by request from a pediatric colleague. She asked about a common diagnostic dilemma for pediatricians that involves what at least on the surface appears like disruptive or oppositional behavior at the home, school, or both, but is complicated by the possibility that the primary engine of this behavior is anxiety. This is an important challenge to try and get right because the treatment plan will take different paths, depending on the final call that is made.

Case summary

Devin is a 6-year-old boy who comes in with his parents for concerns about his behavior. His parents note that he has always been “high strung” but not disruptive or aggressive. When he was younger, Devin was quite sensitive to sounds, textures, and tactile sensations, but this has improved on its own. Thunderstorms continue to bother him quite a bit, though, and he often will ask his parents repeated questions when it is cloudy about the possibility of a thunderstorm. With some extra teacher and parent support, Devin made the transition to kindergarten fairly well. Now, however, he is struggling in a larger 1st grade class. His teacher states that he often seems distracted, fidgety, and easily frustrated, causing him to “shut down” and refuse to do his work. This past week, during a more challenging assignment, he crawled under his desk and would not come out. The teacher is now recommending an evaluation for attention-deficit/hyperactivity disorder (ADHD).

Discussion

The case example above brings up a number of potential findings from the history that can help the evaluating clinician sort out the role of ADHD and/or anxiety in a child’s difficulties. Here are five specific questions to consider asking in these kinds of situations.

1. Are there other times in the child’s life when clearly he is very anxious? The presence of developmentally elevated levels of anxiety in areas outside the particular situations in question can provide a clue that anxiety is contributing to what otherwise might be seen as more oppositional behavior. In this case, the high levels of anxiety about thunderstorms show that anxiety is present in the child and could be playing a role in his disruptive behavior at school.

2. When he’s not focusing on the task at hand, what is he thinking about? Nonanxious children with or without ADHD can frequently daydream and go “off task,” but the content of those thoughts frequently involves anticipation for more preferred activities, reminisces of positive events from the past, or attention to other stimuli in the environment (for example, the bird in a tree outside). More anxious children, by contrast, may have more worried and ruminating thoughts about poor performance, possible bad events that might happen in the future, or “what if?” kinds of concerns.

3. Is there a family history of anxiety? While one should not over-rely on family history, the presence of one or more family members with clinically significant anxiety does raise the possibility of anxiety in the identified patient. Research indicates that the heritability of anxiety is about 50%,^1,2 but that a significant amount of the transmission of anxiety from parent to child comes from environmental mechanisms.³

4. Is there a consistent trigger to his outbursts? For anxious children, meltdowns are frequently provoked by situations in which a child feels uncomfortable, overstimulated, or overwhelmed, and the outburst is a reflection of those intense feelings that are difficult to manage. An outburst like that above, which occurs when a child is pushed to finish difficult work, might be a good example of one that is triggered by anxiety.

5. What does the rating scale show? A broad-based rating scale that assesses multiple domains of symptoms can be a big help for diagnostic dilemmas such as this one. Our clinic uses the Child Behavior Checklist⁴ which has subscales for both anxiety and attention problems. Evidence of a spike in either of those domains, or both, really can help guide our thinking.

Of course, it is very possible that the answer to the ADHD versus anxiety question is that both are present. This is a common conclusion when it comes to mental health assessment, and it is different from the traditional “this or that” thinking present in more classic differential diagnosis decision making. Research indicates that the ADHD and anxiety disorders frequently co-occur.⁵ When that happens, concurrent evidence-based psychotherapy for anxiety in conjunction with multimodal treatment for ADHD has been recommended as a first step.⁶

Case follow-up

Based on all the information, the pediatrician judges that Devin’s disruptive behavior is in large part being driven by his level of anxiety. She makes a referral to a child psychologist to begin evidence-based psychotherapy and recommends that the school consider some modifications and accommodations that may help his behavior at school. At a follow-up appointment, Devin’s difficulties have improved, and there is little evidence of ADHD now that the anxiety has been fully addressed.

 

References

1. Genes Brain Behav. 2005;4(8):466-81.

2. J Am Acad Child Adolesc Psychiatry. 2010;49(3):248-55.

3. Am J Psychiatry. 2015;172(7):630-7.

4. Manual for the ASEBA School-Age Forms & Profiles (Burlington, Vt.: University of Vermont, Research Center for Children, Youth, and Families, 2001).

5. J Anxiety Disord. 1997;11(4):377-94.

6. J Abnorm Child Psychol. 2000;28(6):527-41.
 

Dr. Rettew is a child and adolescent psychiatrist and assistant professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych. Email him at [email protected].

 

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Although randomized data in regard to the benefit of CABG, compared with medical therapy in this high-risk population, are now available from the STICH 5-year follow-up (N Engl J Med. 2016 Apr 21;374:1511-20), information about the long-term benefit of PCI, compared with medical therapy, does not exist. SYNTAX provides us at least a reference point in regard to the relative benefit of these two interventions. The recent analysis assists the interventional cardiologist and surgeon in making the choice between these two procedures based on anatomy. The joint decision making that has evolved in the last few years in regard to valvular surgery appears to have had an impact on the decision-making process in other cardiosurgical procedures, and particularly coronary artery interventions.

One of the overriding predictors of increased mortality with PCI is the increased complexity of anatomy. The higher SYNTAX score was related to incomplete revascularization using PCI, compared with CABG. The presence of concomitant peripheral and carotid vascular disease, in addition to a left ventricular ejection fraction of less than 30%, favored the CABG group. Multiple stents and stent thrombosis were also issues leading to the increased mortality in the PCI group. The main cause of death was recurrent myocardial infarction, which occurred more frequently in the PCI patients and was associated with incomplete revascularization.

The data in the SYNTAX follow-up is not new, but do reinforce what has been reported in previous meta-analyses. This study does, however, emphasize the importance of recurrent infarction as a cause of death in these patients with complex anatomy. It is possible that new stent technology and coronary flow assessment at the time of intervention could have improved the outcome of this comparison and improved the long-term patency of the stented vessels. PCI is an evolving technology heavily affected by the experience of the operator. CABG surgery has also changed, and its associated mortality and morbidity have also changed and improved. It is clear that this population raises important questions in which the operators need to individualize their decision based on trials like SYNTAX.

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

 

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Although randomized data in regard to the benefit of CABG, compared with medical therapy in this high-risk population, are now available from the STICH 5-year follow-up (N Engl J Med. 2016 Apr 21;374:1511-20), information about the long-term benefit of PCI, compared with medical therapy, does not exist. SYNTAX provides us at least a reference point in regard to the relative benefit of these two interventions. The recent analysis assists the interventional cardiologist and surgeon in making the choice between these two procedures based on anatomy. The joint decision making that has evolved in the last few years in regard to valvular surgery appears to have had an impact on the decision-making process in other cardiosurgical procedures, and particularly coronary artery interventions.

One of the overriding predictors of increased mortality with PCI is the increased complexity of anatomy. The higher SYNTAX score was related to incomplete revascularization using PCI, compared with CABG. The presence of concomitant peripheral and carotid vascular disease, in addition to a left ventricular ejection fraction of less than 30%, favored the CABG group. Multiple stents and stent thrombosis were also issues leading to the increased mortality in the PCI group. The main cause of death was recurrent myocardial infarction, which occurred more frequently in the PCI patients and was associated with incomplete revascularization.

The data in the SYNTAX follow-up is not new, but do reinforce what has been reported in previous meta-analyses. This study does, however, emphasize the importance of recurrent infarction as a cause of death in these patients with complex anatomy. It is possible that new stent technology and coronary flow assessment at the time of intervention could have improved the outcome of this comparison and improved the long-term patency of the stented vessels. PCI is an evolving technology heavily affected by the experience of the operator. CABG surgery has also changed, and its associated mortality and morbidity have also changed and improved. It is clear that this population raises important questions in which the operators need to individualize their decision based on trials like SYNTAX.

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

 

The recent report from the SYNTAX trials should give pause to our interventionalist colleagues embarking on multiple angioplasty and stenting procedures in patients with complex coronary anatomy.

SYNTAX randomized 1,800 patients with left main or triple-vessel coronary artery disease to either percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent or coronary artery bypass grafting (CABG) after being judged by a heart team as being in equipoise in regard to the appropriateness of either procedure (Eur Heart J. 2011;32;2125-34). The findings of several previous analyses have trended toward benefit for CABG, but none as clearly as SYNTAX. The original study was reported 6 years ago (Lancet 2013 Feb;381:629-38) and indicated that CABG was superior to PCI in patients with complex lesions. The most recent 5-year data of that study (J Am Coll Cardiol. 2016 Jan:67;42-55) indicates that cardiac mortality in the CABG patients is superior to that in the PCI group (5.3% vs. 9.6%, respectively), and the follow-up data provide more in-depth analysis in addition to the mechanism of death. Most importantly, the recent 5-year data clarify the reasons PCI fails to measure up to the results of CABG in patients with complex coronary artery disease.

Although randomized data in regard to the benefit of CABG, compared with medical therapy in this high-risk population, are now available from the STICH 5-year follow-up (N Engl J Med. 2016 Apr 21;374:1511-20), information about the long-term benefit of PCI, compared with medical therapy, does not exist. SYNTAX provides us at least a reference point in regard to the relative benefit of these two interventions. The recent analysis assists the interventional cardiologist and surgeon in making the choice between these two procedures based on anatomy. The joint decision making that has evolved in the last few years in regard to valvular surgery appears to have had an impact on the decision-making process in other cardiosurgical procedures, and particularly coronary artery interventions.

One of the overriding predictors of increased mortality with PCI is the increased complexity of anatomy. The higher SYNTAX score was related to incomplete revascularization using PCI, compared with CABG. The presence of concomitant peripheral and carotid vascular disease, in addition to a left ventricular ejection fraction of less than 30%, favored the CABG group. Multiple stents and stent thrombosis were also issues leading to the increased mortality in the PCI group. The main cause of death was recurrent myocardial infarction, which occurred more frequently in the PCI patients and was associated with incomplete revascularization.

The data in the SYNTAX follow-up is not new, but do reinforce what has been reported in previous meta-analyses. This study does, however, emphasize the importance of recurrent infarction as a cause of death in these patients with complex anatomy. It is possible that new stent technology and coronary flow assessment at the time of intervention could have improved the outcome of this comparison and improved the long-term patency of the stented vessels. PCI is an evolving technology heavily affected by the experience of the operator. CABG surgery has also changed, and its associated mortality and morbidity have also changed and improved. It is clear that this population raises important questions in which the operators need to individualize their decision based on trials like SYNTAX.

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

 

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Nevertheless, they will encounter LGBT patients whether they’re comfortable with it or not. It would be a disservice to ignore the health needs of LGBT patients. To expect them to go to a clinic whose providers are more comfortable with LGBT health issues would create major barriers for this vulnerable population, as many of these clinics are in urban areas and would require extensive traveling to reach. Contact with a primary care provider may be the only time when an LGBT youth will interact with the health care system. It can be a critical time, when pediatricians may have a positive impact on the health outcomes of the LGBT patient.

Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

 

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

 

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Nevertheless, they will encounter LGBT patients whether they’re comfortable with it or not. It would be a disservice to ignore the health needs of LGBT patients. To expect them to go to a clinic whose providers are more comfortable with LGBT health issues would create major barriers for this vulnerable population, as many of these clinics are in urban areas and would require extensive traveling to reach. Contact with a primary care provider may be the only time when an LGBT youth will interact with the health care system. It can be a critical time, when pediatricians may have a positive impact on the health outcomes of the LGBT patient.

Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

 

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

 

A while ago, I gave a talk on LGBT health to a group of primary care pediatricians. Although I was glad that they invited me to speak, I also sensed some discomfort in the audience. At the end of the lecture, many pediatricians told me that they were uncomfortable with bringing up the topic of sexuality and gender identity with their patients, and others wanted guidance on how to ask questions on sexuality and gender identity.

There are many barriers for primary pediatricians in addressing sexuality and gender identity concerns in their patients. First, pediatricians often will have up to 15 minutes for a visit, so they will have little time to address a complex issue. Second, primary care pediatricians may have known many of their patients since birth, and asking questions on sexuality and gender can feel awkward. Finally, many pediatricians may be working in more conservative areas in the country where asking questions on sexuality and gender identity may be controversial.

Nevertheless, they will encounter LGBT patients whether they’re comfortable with it or not. It would be a disservice to ignore the health needs of LGBT patients. To expect them to go to a clinic whose providers are more comfortable with LGBT health issues would create major barriers for this vulnerable population, as many of these clinics are in urban areas and would require extensive traveling to reach. Contact with a primary care provider may be the only time when an LGBT youth will interact with the health care system. It can be a critical time, when pediatricians may have a positive impact on the health outcomes of the LGBT patient.

Although a very important topic, there is not much empirical evidence on how to ask questions on sexuality and gender appropriately, and most of these recommendations are based on my own experience working with LGBT youth. Regardless, I hope these pointers will help the primary care pediatrician address the needs of LGBT youth efficiently and with sensitivity.

Tip No. 1: The environment counts

I cannot overstate how important it is to make your clinic a welcoming place for LGBT youth. Having various signs and stickers – like rainbow flags or the Human Rights Campaign sticker – will signal to LGBT youth that they are safe in your clinic. Creating a safe and welcoming environment is important because many people in the LGBT community have experienced rejection and discrimination from their primary care doctors.¹ Making your clinic a safe space will make it easier and efficient for patients to ask questions about sexuality and gender identity (see Dr. Gaya Chelvakumar’s column “Creating safe spaces for LGBTQ youth, families in health care settings” at pediatricnews.com).

Tip No. 2: Consider the context

Most likely, many presenting complaints – such as colds or sports injuries – of your adolescent patients will not involve sexual orientation or gender identity. There are exceptions. If you suspect an STD, then the risk for certain infections, such as HIV² or gonorrhea of the anus or of the pharynx³ are higher in gay young men. For the latter, your screening method would be different (that is, obtaining a pharyngeal swab or an anal swab instead of a urine sample). Also, because many LGBT youth have higher rates of mental health problems compared with heterosexual youth,⁴ you may want to ask questions about sexuality or gender identity to patients complaining of depressive or anxiety symptoms. This is especially important for transgender youth, because the implementation of pubertal blockers or cross-sex hormones can be therapeutic.⁵ To prevent or reduce many of these health problems, asking about sexuality and gender identity is a good idea during the well visit, when you may have more time.

Tip No. 3: Not all developmental stages are considered equal

Adolescence is a period of rapid and phasic growth. Formation of an identity is one of the major psychosocial tasks for adolescence,⁶ and sexuality and gender are important identities. In general, in early adolescence identity becomes an issue as the teenager gains autonomy from parents. I typically start asking questions about sexuality and gender when the patient is 11 or 12, because many children may not understand sexuality and gender identity at a younger age. At these ages, I ask these questions with the parents in the room, then I ask them confidentially on subsequent well visits. This approach serves two purposes: it will prepare the adolescent for these complex and thought-provoking questions in future encounters, and it gives the parents an idea of the type of questions you will ask the children when they are old enough for the confidential visit, helping parents feel more comfortable in stepping out of the room during this time.

 

Tip No. 4: Keep it confidential

Many adolescents are reluctant to see a doctor, even if they are sick. The primary reason adolescents do not seek care is the fear that the provider will tell their parents about their illness.⁷ Although this should be applicable to all of your adolescent patients, you should make an extra effort to explicitly state to LGBT patients that the clinic visit is confidential (with the exception of risk of suicide, homicide, or child abuse). This is important for LGBT youth who are not out to their parents and may be in danger if they do come out.⁸

Tip No. 5: Normalize, normalize, normalize

Because of the stigma and discrimination surrounding sexual orientation and gender identity, many LGBT youth will be reluctant to disclose their sexual orientation or gender identity to their health care providers. At the same time, heterosexual youth may think that you’re asking them questions about sexuality or gender identity because you suspect them to be a member of the LGBT community. To avoid this awkward situation, many pediatricians do not ask these questions at all. A good remedy for this is to preface your questions about sexual orientation or gender identity by saying that you ask these questions to all your patients – that way no one feels singled out.

Tip No. 6: Ask for permission

As previously mentioned, members of the LGBT community may experience discrimination from their health care providers after disclosing to them their sexual orientation or gender identity.¹ This rejection can be traumatizing for LGBT youth, making them reluctant to discuss any issues related to sexual orientation or gender identity with any medical provider. As part of the trauma-informed approach, asking for permission before delving into issues related to sexual orientation and gender identity will give LGBT patients a sense of control, especially in an environment where there is a significant power differential.

Tip No. 7: Treat this as a skill

Despite the pressures for primary care pediatricians to maintain an efficient and effective clinical practice, many strive to learn new skills to provide the best care for their patients. Asking questions about sexuality and gender identity should be one of those skills. As with any skill, it will feel unnatural at first, and it will require practice. Mastering this skill, however, will help you address the health needs of this vulnerable population.

Asking questions about sexuality and gender identity is difficult for the primary care pediatrician. Hopefully, these tips can help you develop this important skill. It will also help you reach out to a population that is wary of the health care system.

References

1. J Am Board Fam Med. 2016;29(1):156-60.

2. https://www.cdc.gov/hiv/group/msm/index.html.

3. https://www.cdc.gov/std/tg2015/default.htm.

4. J Adolesc Health. 2011;49(2):115-23.

5. Nat Rev Endocrinol. 2011;7(8):466-72.
6. Neinstein LS. Adolescent health care: a practical guide. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.

7. J Adolesc Health. 2007;40(3):218-26.

8. Am J Orthopsychiatry. 1998;68(3):361-71.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. Email him at [email protected].

The Centers for Disease Control and Prevention just released a surveillance report describing national estimates of antimicrobial resistance among health care–associated infections (HAIs) in hospitals. The report compiles HAI data submitted to the CDC’s National Healthcare Safety Network (NHSN) from almost all short-term acute care hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals in the country.

These data highlight the broad reach and urgent nature of the drug resistance problem challenging clinicians today; resistance is occurring across different types of infections and patient populations, and dangerous resistance profiles such as carbapenem-resistant Enterobacteriaceae, or CRE, are not going away.

The report highlights the percentage of HAI organisms that were resistant to select antibiotics for 21 different bug-drug combinations from 2011 to 2014. Most noticeable across this time period was an increase in the percentage of Escherichia coli that tested resistant to extended-spectrum cephalosporins, fluoroquinolones, and were identified as multidrug resistant (Infect Control Hosp Epidemiol. 2016 Aug 30. doi: 10.1017/ice.2016.174).

In 2011, 41.1% of E. coli central line–associated bloodstream infections (CLABSIs) were resistant to fluoroquinolones; this percentage increased to 49.3% by 2014. And, among catheter-associated UTIs (CAUTIs), 8% of E. coli were identified as multidrug resistant in 2014, an increase from 5.5% in 2011.

Hospitals continue to report CRE infections, which are often untreatable and represent a serious public health threat. Across the major HAI types analyzed in this report, CRE were found in CLABSIs (7.1% of Enterobacteriaceae were resistant to carbapenems), CAUTIs (4.0% resistant), and surgical site infections (1.8% resistant). After taking a closer look at individual species of bacteria, we found that almost 11% of CLABSIs caused by Klebsiella species were resistant to carbapenems, which was the highest resistance among all Enterobacteriaceae species. Furthermore, Enterobacter species showed increasing resistance to carbapenems, as the percentage resistant in CLABSIs increased from 3.0% in 2011 to 6.6% in 2014.

These data underscore the urgent nature of CRE prevention efforts, and fighting back against these deadly bacteria will require collaborative efforts from the entire health care community including health care facility leaders, health care providers, and state and local health departments.

Antibiotic-resistant infections are an important patient safety issue and continue to pose a threat to modern medicine. There are small improvements in some phenotypes such as multidrug-resistant Acinetobacter, in which the percentage resistant in CLABSIs decreased from 60.9% in 2011 to 43.7% in 2014. Multidrug-resistant Klebsiella appears to be declining as well, from 20.9% resistant to 17.2%. Despite some improvements, the data in this report support the conclusion that much more work is needed to combat antibiotic resistance. The CDC has identified three critical efforts to slow the spread of resistant HAIs:

• Prevent infections related to devices and surgeries.

• Prevent the spread of bacteria between patients and between facilities.

• Improve antibiotic use in health care settings.

In addition to drug resistance, this report looked at the frequency of pathogens causing HAIs. The No. 1 and No. 3 most common pathogens among all HAIs were E.coli and Klebsiella, both of which are gram-negative bacteria with the propensity to develop antibiotic resistance.

The data also help identify important differences in the causes of HAIs across each of the infection types. For example, CLABSIs were more commonly due to gram positive organisms and Candida (a fungus), while surgical site infections (SSIs) were most frequently caused by Staph aureus. NHSN tracks SSIs following 39 different types of procedures, and while Staph aureus was the most common pathogen reported overall, the pathogen distributions did vary by surgery site. For example, almost 30% of SSIs following transplant procedures were caused by a species of Enterococcus.

Obviously, there’s far more data in the report than we can discuss here. Fortunately, the CDC’s new Antibiotic Resistance Patient Safety Atlas gives everyone an opportunity to explore these resistance patterns further; color-coded maps and charts included within the Atlas can help you identify common resistance phenotypes in your state and region. While these data give us a national snapshot of resistance profiles, we know there is wide variation among individual health care settings. It is important for providers to become familiar with the common pathogens and resistance profiles in their hospitals and recognize that common infecting organisms vary across different types of infections.

This report underscores the important challenges posed by resistant organisms in hospitals. Combating antibiotic resistance is a top public health priority in the United States and around the world, and having data to direct action is a key part of tackling the problem.

The CDC will continue to use and expand its efforts to monitor antibiotic resistance through surveillance systems such as NHSN, and will remain committed to providing data to support the health care community in efforts to reduce the spread of resistance and improve antibiotic use.
 

 

Lindsey Weiner, MPH, is an epidemiologist and associate service fellow in the Surveillance Branch, Division of Healthcare Quality Promotion, at the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention just released a surveillance report describing national estimates of antimicrobial resistance among health care–associated infections (HAIs) in hospitals. The report compiles HAI data submitted to the CDC’s National Healthcare Safety Network (NHSN) from almost all short-term acute care hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals in the country.

These data highlight the broad reach and urgent nature of the drug resistance problem challenging clinicians today; resistance is occurring across different types of infections and patient populations, and dangerous resistance profiles such as carbapenem-resistant Enterobacteriaceae, or CRE, are not going away.

The report highlights the percentage of HAI organisms that were resistant to select antibiotics for 21 different bug-drug combinations from 2011 to 2014. Most noticeable across this time period was an increase in the percentage of Escherichia coli that tested resistant to extended-spectrum cephalosporins, fluoroquinolones, and were identified as multidrug resistant (Infect Control Hosp Epidemiol. 2016 Aug 30. doi: 10.1017/ice.2016.174).

In 2011, 41.1% of E. coli central line–associated bloodstream infections (CLABSIs) were resistant to fluoroquinolones; this percentage increased to 49.3% by 2014. And, among catheter-associated UTIs (CAUTIs), 8% of E. coli were identified as multidrug resistant in 2014, an increase from 5.5% in 2011.

Hospitals continue to report CRE infections, which are often untreatable and represent a serious public health threat. Across the major HAI types analyzed in this report, CRE were found in CLABSIs (7.1% of Enterobacteriaceae were resistant to carbapenems), CAUTIs (4.0% resistant), and surgical site infections (1.8% resistant). After taking a closer look at individual species of bacteria, we found that almost 11% of CLABSIs caused by Klebsiella species were resistant to carbapenems, which was the highest resistance among all Enterobacteriaceae species. Furthermore, Enterobacter species showed increasing resistance to carbapenems, as the percentage resistant in CLABSIs increased from 3.0% in 2011 to 6.6% in 2014.

These data underscore the urgent nature of CRE prevention efforts, and fighting back against these deadly bacteria will require collaborative efforts from the entire health care community including health care facility leaders, health care providers, and state and local health departments.

Antibiotic-resistant infections are an important patient safety issue and continue to pose a threat to modern medicine. There are small improvements in some phenotypes such as multidrug-resistant Acinetobacter, in which the percentage resistant in CLABSIs decreased from 60.9% in 2011 to 43.7% in 2014. Multidrug-resistant Klebsiella appears to be declining as well, from 20.9% resistant to 17.2%. Despite some improvements, the data in this report support the conclusion that much more work is needed to combat antibiotic resistance. The CDC has identified three critical efforts to slow the spread of resistant HAIs:

• Prevent infections related to devices and surgeries.

• Prevent the spread of bacteria between patients and between facilities.

• Improve antibiotic use in health care settings.

In addition to drug resistance, this report looked at the frequency of pathogens causing HAIs. The No. 1 and No. 3 most common pathogens among all HAIs were E.coli and Klebsiella, both of which are gram-negative bacteria with the propensity to develop antibiotic resistance.

The data also help identify important differences in the causes of HAIs across each of the infection types. For example, CLABSIs were more commonly due to gram positive organisms and Candida (a fungus), while surgical site infections (SSIs) were most frequently caused by Staph aureus. NHSN tracks SSIs following 39 different types of procedures, and while Staph aureus was the most common pathogen reported overall, the pathogen distributions did vary by surgery site. For example, almost 30% of SSIs following transplant procedures were caused by a species of Enterococcus.

Obviously, there’s far more data in the report than we can discuss here. Fortunately, the CDC’s new Antibiotic Resistance Patient Safety Atlas gives everyone an opportunity to explore these resistance patterns further; color-coded maps and charts included within the Atlas can help you identify common resistance phenotypes in your state and region. While these data give us a national snapshot of resistance profiles, we know there is wide variation among individual health care settings. It is important for providers to become familiar with the common pathogens and resistance profiles in their hospitals and recognize that common infecting organisms vary across different types of infections.

This report underscores the important challenges posed by resistant organisms in hospitals. Combating antibiotic resistance is a top public health priority in the United States and around the world, and having data to direct action is a key part of tackling the problem.

The CDC will continue to use and expand its efforts to monitor antibiotic resistance through surveillance systems such as NHSN, and will remain committed to providing data to support the health care community in efforts to reduce the spread of resistance and improve antibiotic use.
 

 

Lindsey Weiner, MPH, is an epidemiologist and associate service fellow in the Surveillance Branch, Division of Healthcare Quality Promotion, at the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention just released a surveillance report describing national estimates of antimicrobial resistance among health care–associated infections (HAIs) in hospitals. The report compiles HAI data submitted to the CDC’s National Healthcare Safety Network (NHSN) from almost all short-term acute care hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals in the country.

These data highlight the broad reach and urgent nature of the drug resistance problem challenging clinicians today; resistance is occurring across different types of infections and patient populations, and dangerous resistance profiles such as carbapenem-resistant Enterobacteriaceae, or CRE, are not going away.

The report highlights the percentage of HAI organisms that were resistant to select antibiotics for 21 different bug-drug combinations from 2011 to 2014. Most noticeable across this time period was an increase in the percentage of Escherichia coli that tested resistant to extended-spectrum cephalosporins, fluoroquinolones, and were identified as multidrug resistant (Infect Control Hosp Epidemiol. 2016 Aug 30. doi: 10.1017/ice.2016.174).

In 2011, 41.1% of E. coli central line–associated bloodstream infections (CLABSIs) were resistant to fluoroquinolones; this percentage increased to 49.3% by 2014. And, among catheter-associated UTIs (CAUTIs), 8% of E. coli were identified as multidrug resistant in 2014, an increase from 5.5% in 2011.

Hospitals continue to report CRE infections, which are often untreatable and represent a serious public health threat. Across the major HAI types analyzed in this report, CRE were found in CLABSIs (7.1% of Enterobacteriaceae were resistant to carbapenems), CAUTIs (4.0% resistant), and surgical site infections (1.8% resistant). After taking a closer look at individual species of bacteria, we found that almost 11% of CLABSIs caused by Klebsiella species were resistant to carbapenems, which was the highest resistance among all Enterobacteriaceae species. Furthermore, Enterobacter species showed increasing resistance to carbapenems, as the percentage resistant in CLABSIs increased from 3.0% in 2011 to 6.6% in 2014.

These data underscore the urgent nature of CRE prevention efforts, and fighting back against these deadly bacteria will require collaborative efforts from the entire health care community including health care facility leaders, health care providers, and state and local health departments.

Antibiotic-resistant infections are an important patient safety issue and continue to pose a threat to modern medicine. There are small improvements in some phenotypes such as multidrug-resistant Acinetobacter, in which the percentage resistant in CLABSIs decreased from 60.9% in 2011 to 43.7% in 2014. Multidrug-resistant Klebsiella appears to be declining as well, from 20.9% resistant to 17.2%. Despite some improvements, the data in this report support the conclusion that much more work is needed to combat antibiotic resistance. The CDC has identified three critical efforts to slow the spread of resistant HAIs:

• Prevent infections related to devices and surgeries.

• Prevent the spread of bacteria between patients and between facilities.

• Improve antibiotic use in health care settings.

In addition to drug resistance, this report looked at the frequency of pathogens causing HAIs. The No. 1 and No. 3 most common pathogens among all HAIs were E.coli and Klebsiella, both of which are gram-negative bacteria with the propensity to develop antibiotic resistance.

The data also help identify important differences in the causes of HAIs across each of the infection types. For example, CLABSIs were more commonly due to gram positive organisms and Candida (a fungus), while surgical site infections (SSIs) were most frequently caused by Staph aureus. NHSN tracks SSIs following 39 different types of procedures, and while Staph aureus was the most common pathogen reported overall, the pathogen distributions did vary by surgery site. For example, almost 30% of SSIs following transplant procedures were caused by a species of Enterococcus.

Obviously, there’s far more data in the report than we can discuss here. Fortunately, the CDC’s new Antibiotic Resistance Patient Safety Atlas gives everyone an opportunity to explore these resistance patterns further; color-coded maps and charts included within the Atlas can help you identify common resistance phenotypes in your state and region. While these data give us a national snapshot of resistance profiles, we know there is wide variation among individual health care settings. It is important for providers to become familiar with the common pathogens and resistance profiles in their hospitals and recognize that common infecting organisms vary across different types of infections.

This report underscores the important challenges posed by resistant organisms in hospitals. Combating antibiotic resistance is a top public health priority in the United States and around the world, and having data to direct action is a key part of tackling the problem.

The CDC will continue to use and expand its efforts to monitor antibiotic resistance through surveillance systems such as NHSN, and will remain committed to providing data to support the health care community in efforts to reduce the spread of resistance and improve antibiotic use.
 

 

Lindsey Weiner, MPH, is an epidemiologist and associate service fellow in the Surveillance Branch, Division of Healthcare Quality Promotion, at the Centers for Disease Control and Prevention.

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

 

“Still Down: What to Do When Antidepressants Fail” by Dean F. MacKinnon, MD, is a compact little book that recently was released by Johns Hopkins University Press. The title, “Still Down,” says it all. At 152 pages, the book is short, but not because it isn’t jammed full of information, but because – like the title – the writing is succinct and straight to the point; there’s no flowery detail, and Dr. MacKinnon doesn’t parse words. He tells the reader up front what his mission is, how the book is organized, and who his audience is. He’s an organized writer who captures the reader while getting his point across.

So how organized is Dr. MacKinnon? Each chapter is a clinical vignette, and the patients and doctors are given pseudonyms in alphabetical order: Ann sees Dr. Abernathy in chapter 1; then Bob sees Dr. Beasly in chapter 2. While “Still Down” is a series of nine short stories that make for a quick and interesting read, it provides enough information for a book twice the size. And in case the reader misses the point of the story (which is hard to imagine), each chapter ends with a summary of bullet points followed by case notes to clarify and expand on the points that were made during the vignette, and to add important commentary on the variety of decisions that might have been made for that particular patient’s story. Each chapter is short – a matter of pages, and there is no opportunity for the reader to get bored or tune out.

The book is divided into three distinct parts. In chapter 1, Ann suffers from “textbook depression.” Dr. MacKinnon uses this as an opportunity to educate the reader on the signs and symptoms of major depression, and the fact that treatment takes several weeks, during which side effects may occur before the resolution of symptoms. He talks about depression as a recurring medical illness, lists the available antidepressants by their class, and mentions that depression can be a result of other medical illnesses such as thyroid disease. In chapter 2, college student Bob remains depressed until he takes the medications as prescribed at a steady dose on a daily basis. This involves some coaxing, education, and even outreach by the school nurse, all while being cognizant of things that can go wrong in a young person on antidepressants.

In chapter 3, Carla is a patient of both Dr. Cohen and Dr. Clark, and she is a sensitive soul who sees herself as beyond help. In addition, she has difficulty tolerating medications, and it is only with much support that she is able to get an antidepressant up to a therapeutic dose that gives her relief from her distress. In fact, Dr. Clark resorts to using an older tricyclic antidepressant so he can monitor levels, and he discovers that Carla’s levels run much higher than expected from the dose she’s on, explaining some of her sensitivity to medication and propensity to side effects.

Part 2 of “Still Down” takes on the sticky issue of misdiagnosis. Darius sees Dr. Dennis for treatment of depression during a distressing period of his life when treatment with another doctor had already failed. After careful assessment, Dr. Dennis concludes that while antidepressants weren’t unreasonable to try, Darius is actually suffering from demoralization from losing his business, a miserable divorce, and a child custody battle. Dr. Dennis suggests therapy instead of medications at this point. This was where I found that, I, as a clinician, swayed from Dr. MacKinnon’s treatment approach: He emphasizes an inability to function and to feel pleasure as necessary elements of major depression, and Darius could do both to some extent. But still, his sleep was poor from shift work. He’d gained 30 pounds; he had little energy for activities besides work; and he was in a rut, unhappy, and having trouble entertaining his children when they visited and feeling too lazy to make changes. I thought Darius was depressed and demoralized, and while I agreed with the author that he needed psychotherapy, I also would have continued with medication trials. Dr. MacKinnon certainly doesn’t dismiss the idea of medication, and I found it helpful to revisit demoralization as a state responsible for many psychiatric symptoms.

Moving on in the section on misdiagnoses, the author talks about Evelyn, who turns out to have bipolar versus unipolar depression, and Frances, who carries an incorrect diagnosis of bipolar disorder, and has been overmedicated into a state of delirium. They both do well with time, thoughtful assessment, and treatment. Clinical pearls are threaded through these chapters.

“Depression-plus” is the title of the final section. Gary has major depression superimposed on his dysthymia, or persistent depressive disorder, and Dr. MacKinnon notes that people with constitutionally gloomy moods may have persistent sadness even after successful treatment of major depression. Here, there is a need for accommodation to a given personality state, and therapy can be helpful. Hannah, a patient of Dr. Hernandez, has what the author calls “depressed functioning.” This part I found most interesting, because I see this often in practice – a patient with a long history of being unmotivated and underfunctioning does not get fully (or any) better with antidepressants. Here, the functioning must improve before mood and self-esteem lift, and this is not an easy task. Finally, Irma has treatment-resistant depression, and with her doctor, considers a variety of augmentation medications as well as more novel strategies.

Simply stated, this book is a gem. It’s a very understandable guide to a very complex and frustrating issue, one that needs more time-consuming and thoughtful evaluation, and more intensive resources than a simple episode of depression usually entails.

Finally, I have to admit that I enjoyed Dr. MacKinnon’s quiet jabs at electronic medical records.
 

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has known Dr. MacKinnon for many years.

Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

 

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

 

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

Intravenous catheters (ICs) are common and necessary for inpatient care. However, peripheral and especially central venous catheters (CVCs) are associated with increased risk for local and systemic complications, including bloodstream infections and endocarditis.

University of Wisconsin School of Medicine and Public Health

Prevention of these complications is important and should be a major focus of infection control and patient safety practices. There are three main points of focus on infection prevention with regard to ICs – proper insertion techniques, proper care of the catheter, and prompt removal when it is no longer necessary.

We focused our review, published in the American Journal of Infection Control (2016 Oct. doi: 10.1016/j.ajic.2016.03.073), on the final point – determining the prevalence, risk factors, and outcomes related to idle intravenous catheters. To accomplish this, we conducted an integrative review of published studies related to idle catheters, excluding reviews, abstracts, and commentaries. Thirteen studies met the inclusion criteria and four of these focused on CVCs.

Generally, an idle catheter is one that remains in place even though it is not being used for patient care. However, the definition of an “idle” catheter varied amongst the reviewed studies, as did the unit of measure, especially for peripheral catheters. Central venous catheter-focused studies were more consistent in using “idle catheter days” and “catheter days.”

Studies of peripheral catheters revealed that 16%-50% of patients had an idle catheter of some type. For the studies focused on CVCs, the percentage of patients with idle catheters ranged from 2.7% in one intensive care unit to 26.2% in a different study. Interestingly, in the study with 2.7% idle CVCs in the ICU, there was a higher percentage of idle CVCs outside of the ICU in the same hospital.

The major reasons for leaving catheters in place in studies where reasons were noted were convenience, future intention to use intravenous medication, and inappropriate use of intravenous medications when oral could be used.

Although data are scarce, complications in the reviewed studies were relatively common with idle peripheral catheters, where 9%-12% suffered thrombophlebitis. Obviously, the risk for catheter-related bloodstream infection increases as the number of catheter days increases – this is especially important with regard to idle CVCs.
 

Decreasing the prevalence of idle catheters is likely to decrease the risk for infection and improve patient safety. Based on our review of the data, a standardized definition of an “idle catheter” is needed. At the very least, a standard definition should be developed at each institution. This would allow an individual hospital the ability to identify and track the presence of these lines, and implement targeted interventions to decrease the proportion of idle lines. Ideally, a common definition would be created and validated so that data and interventions could be comparable across institutions and guidelines could be developed.

The goal of targeted interventions should be zero idle lines. Prevention of idle peripheral catheters should also be pursued, but because CVC-related complications are often more serious, these lines are often the focus of efforts. Use of peripherally inserted central catheters (PICCs) has increased and while these catheters in some settings may have decreased complication risk, compared with femoral/internal jugular/subclavian CVCs, prevention of idle catheter days is paramount for these catheters as well.

Many ICUs, including at our own institution, have instituted programs to closely monitor for ongoing need for CVCs. This increased focus on the CVC likely explains the lower rates of idle catheters in ICUs noted in the reviewed studies. This close surveillance can be done outside of the ICU as well, and could include peripheral catheters.

At our own institution, the need for catheters is reviewed on some units as part of formalized patient safety rounds. Another potential group of interventions could focus on electronic medical record (EMR)-based changes such as limits on the duration of the order, requirement for renewal of the order, or on-screen reminders of the presence of a catheter. This sort of intervention could possibly be expanded as EMR use becomes more common and robust. For instance, if intravenous medications have not been ordered or given in a certain amount of time, an alert might be triggered. Another EMR-based mechanism could be to require an indication for ongoing catheter use.

Education about the potential adverse outcomes of idle catheters is important. Promoting a team-based approach to interventions, where all involved team members can discuss patient safety issues on equal ground is paramount to successfully decreasing idle catheters and improving patient care and safety in general. As with other hospital-wide initiatives, engagement of hospital administration is important to decrease barriers to implementation.

Intravenous catheter use will remain an integral part of patient care, but efforts should be made to create standardization around the definition of an idle catheter, standardize units of measure, and institute programs to prevent idle catheters.

 

Daniel Shirley, MD, MS, is assistant professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital. Nasia Safdar, MD, PhD, is associate professor in the division of infectious disease at the University of Wisconsin–Madison School of Medicine and Public Health and the William S. Middleton Memorial Veterans Hospital.

The island of Adak is Alaska’s last frontier. There are no stores, doctors, streetlights, traffic lights, or even a need for license plates. Just the lonely cry of a bald eagle and the howl of the arctic wind accompany you along the dark streets of this ghost town on the edge of the earth, where the North Pacific and the Bering Sea collide. The frigid Arctic front travels down the west coast, while the warmer Japanese current comes up the Pacific side. The low tundra does little to block the winds generated by that confluence, which often whip at 90 mph or more for days on end. Otherwise, the weather is generally gray and misty, and temperatures range from about 20°F to 65°F.

The weather matches the ambience and surroundings—decaying shambles of a once grand Navy base with facilities designed to make life as pleasant as possible for service members. But the Navy left in the late 1990s. By the time I arrived to practice here in 2013, only a few hundred people inhabited the island. There was virtually no economy, and almost all the roads and buildings were deserted. Man’s creation had fallen victim to vandals and nature.

My practice claimed a converted high school principal’s office and a two-bed emergency department (ED) that had some nice equipment—but with no medical aid, x-ray technician, phlebotomist, or lab technician, there was only me to operate it.

One of the oddities of the Alaskan bush is that medical providers often perform as All Species Providers; my first patient, Sadie, was a very well-behaved black Labrador retriever. Unable to anesthetize her, I was thankful for her even-tempered, patient breed (and for my experience as a veterinarian). Sadie lay calmly on the ED bed, her head in her owner’s hands, while I sutured her forepaw. In hindsight, she was one of my easier cases.

Adak’s isolated location (450 miles from the nearest settled outpost), rugged terrain, and vast wildlife come with an elevated risk for injuries and no shortage of challenges in treating them. During my first week, an autistic child presented with a foot laceration. There was no electricity when he arrived, as was often the case due to the wind; the only available light came through the open door. It was dusk and snow was gently falling, but we huddled in the doorway, as the patient’s mother and my husband held the boy while I sutured him. I just managed to get the last stitch in before the child entered his incoherent world.

Credit: iStockphoto.com/mbarrettimages

Anchorage, the nearest evacuation location, was 1,200 miles away. In the absolute best case (ie, the weather conditions were suitable for planes to take off and land), it was a 3.5-hour flight—that is, it would take 3.5 hours for a plane to arrive from Anchorage (if one happened to be ready) and then another 3.5 hours to transport the patient back. This fact was always in the back of my mind, but you can imagine how nerve-wracked I was in my first week (I had quite an initiation, as you can see) when a COPD patient presented in a cyanotic, dyspneic, and agitated state (SpO₂, 80%). I immediately inserted an IV, administered oxygen, and got the nebulizer going. That was all I could do—other than pray that he would be able to breathe while we awaited transport, which was potentially days away.

 

Not surprisingly for an island, the surrounding seas brought many of my patients. Workers on commercial fishing vessels frequently sustained injuries that the conditions at sea would exacerbate. Hand injuries were common, as were slip-and-fall injuries such as dislocations and broken bones. It could take hours to get them into port. The most memorable was a fisherman who had lost the end of his thumb when it was crushed between the gunwale and a swinging, loaded crab pot being hoisted aboard. The electricity (surprise) was out, so I was forced to treat him by flashlight. He was a young man (early 30s) but especially nice. What I remember most is that he declined a digital block. I debrided the devitalized tissue via sharp dissection, but he never once cursed. So much for all those jokes about cussing like a sailor.

On a seemingly calm Saturday in my third week, one of the supervisors from the fish processing plant came in with two of his workers. One had bilateral ocular exposure to a cleaning solvent, while the other was stumbling and disoriented. My triage skills were put to the test as I anesthetized Worker 1’s eyes with proparacaine, then inserted Morgan lenses (which, thankfully, came with instructions in the packaging!). The supervisor, who was keeping Worker 2 calm simultaneously, held a basin below the patient’s eyes to catch runoff as I quickly attached a liter of saline to each lens and opened the valve full bore. With that situation under control for the moment, I switched gears to assess Worker 2, who was markedly incoherent and unable to give a history. What I did know was that he was ataxic and nauseous, with a temperature of 104°F. I flashed my penlight into his eyes, and he reacted like Dracula faced with a crucifix. In addition to his exquisite photophobia, he had marked neck stiffness. The diagnosis was my first case of human meningitis. I inserted an IV providing ceftriaxone, acyclovir, and ondansetron. He required 2.5 L of IV fluid, but he gradually recovered over the next two days.

Why, with all these challenges, did I go to Alaska? Because I felt that there I could be of most service; if ever there was an underserved community, Adak was it. Ironically, the other job offer I considered was on the Hawaiian island of Kauai. As idyllic as that might have been, it wasn’t quite the adventure that Adak turned out to be—and it wasn’t as desperately in need of a provider.

When I took the Adak post, I didn’t realize how much I would learn. Above all, I realized that a complete and meticulous physical exam is king. If I missed any life-threatening conditions, the ramifications would be extreme. There were no referrals or second opinions, just me with the patient, and I had to make the right decisions.

The bonds I formed with the people on this remote island, and the paths I trod through this unusual land, made for a unique experience. It was a thrill to look out toward the horizon and know that everything I could see had remained unchanged since the birth of these volcanic islands. In time, I came to recognize that I was not in charge. The planes carrying supplies in or patients out would come if the weather allowed. What was on the island was what I had to work with, and if I didn’t have what I wanted, it was only because I didn’t want what I had. The waves would come as they will. I could either surf them or be tossed by them. I chose to dive in.

The island of Adak is Alaska’s last frontier. There are no stores, doctors, streetlights, traffic lights, or even a need for license plates. Just the lonely cry of a bald eagle and the howl of the arctic wind accompany you along the dark streets of this ghost town on the edge of the earth, where the North Pacific and the Bering Sea collide. The frigid Arctic front travels down the west coast, while the warmer Japanese current comes up the Pacific side. The low tundra does little to block the winds generated by that confluence, which often whip at 90 mph or more for days on end. Otherwise, the weather is generally gray and misty, and temperatures range from about 20°F to 65°F.

The weather matches the ambience and surroundings—decaying shambles of a once grand Navy base with facilities designed to make life as pleasant as possible for service members. But the Navy left in the late 1990s. By the time I arrived to practice here in 2013, only a few hundred people inhabited the island. There was virtually no economy, and almost all the roads and buildings were deserted. Man’s creation had fallen victim to vandals and nature.

My practice claimed a converted high school principal’s office and a two-bed emergency department (ED) that had some nice equipment—but with no medical aid, x-ray technician, phlebotomist, or lab technician, there was only me to operate it.

One of the oddities of the Alaskan bush is that medical providers often perform as All Species Providers; my first patient, Sadie, was a very well-behaved black Labrador retriever. Unable to anesthetize her, I was thankful for her even-tempered, patient breed (and for my experience as a veterinarian). Sadie lay calmly on the ED bed, her head in her owner’s hands, while I sutured her forepaw. In hindsight, she was one of my easier cases.

Adak’s isolated location (450 miles from the nearest settled outpost), rugged terrain, and vast wildlife come with an elevated risk for injuries and no shortage of challenges in treating them. During my first week, an autistic child presented with a foot laceration. There was no electricity when he arrived, as was often the case due to the wind; the only available light came through the open door. It was dusk and snow was gently falling, but we huddled in the doorway, as the patient’s mother and my husband held the boy while I sutured him. I just managed to get the last stitch in before the child entered his incoherent world.

Credit: iStockphoto.com/mbarrettimages

Anchorage, the nearest evacuation location, was 1,200 miles away. In the absolute best case (ie, the weather conditions were suitable for planes to take off and land), it was a 3.5-hour flight—that is, it would take 3.5 hours for a plane to arrive from Anchorage (if one happened to be ready) and then another 3.5 hours to transport the patient back. This fact was always in the back of my mind, but you can imagine how nerve-wracked I was in my first week (I had quite an initiation, as you can see) when a COPD patient presented in a cyanotic, dyspneic, and agitated state (SpO₂, 80%). I immediately inserted an IV, administered oxygen, and got the nebulizer going. That was all I could do—other than pray that he would be able to breathe while we awaited transport, which was potentially days away.

 

Not surprisingly for an island, the surrounding seas brought many of my patients. Workers on commercial fishing vessels frequently sustained injuries that the conditions at sea would exacerbate. Hand injuries were common, as were slip-and-fall injuries such as dislocations and broken bones. It could take hours to get them into port. The most memorable was a fisherman who had lost the end of his thumb when it was crushed between the gunwale and a swinging, loaded crab pot being hoisted aboard. The electricity (surprise) was out, so I was forced to treat him by flashlight. He was a young man (early 30s) but especially nice. What I remember most is that he declined a digital block. I debrided the devitalized tissue via sharp dissection, but he never once cursed. So much for all those jokes about cussing like a sailor.

On a seemingly calm Saturday in my third week, one of the supervisors from the fish processing plant came in with two of his workers. One had bilateral ocular exposure to a cleaning solvent, while the other was stumbling and disoriented. My triage skills were put to the test as I anesthetized Worker 1’s eyes with proparacaine, then inserted Morgan lenses (which, thankfully, came with instructions in the packaging!). The supervisor, who was keeping Worker 2 calm simultaneously, held a basin below the patient’s eyes to catch runoff as I quickly attached a liter of saline to each lens and opened the valve full bore. With that situation under control for the moment, I switched gears to assess Worker 2, who was markedly incoherent and unable to give a history. What I did know was that he was ataxic and nauseous, with a temperature of 104°F. I flashed my penlight into his eyes, and he reacted like Dracula faced with a crucifix. In addition to his exquisite photophobia, he had marked neck stiffness. The diagnosis was my first case of human meningitis. I inserted an IV providing ceftriaxone, acyclovir, and ondansetron. He required 2.5 L of IV fluid, but he gradually recovered over the next two days.

Why, with all these challenges, did I go to Alaska? Because I felt that there I could be of most service; if ever there was an underserved community, Adak was it. Ironically, the other job offer I considered was on the Hawaiian island of Kauai. As idyllic as that might have been, it wasn’t quite the adventure that Adak turned out to be—and it wasn’t as desperately in need of a provider.

When I took the Adak post, I didn’t realize how much I would learn. Above all, I realized that a complete and meticulous physical exam is king. If I missed any life-threatening conditions, the ramifications would be extreme. There were no referrals or second opinions, just me with the patient, and I had to make the right decisions.

The bonds I formed with the people on this remote island, and the paths I trod through this unusual land, made for a unique experience. It was a thrill to look out toward the horizon and know that everything I could see had remained unchanged since the birth of these volcanic islands. In time, I came to recognize that I was not in charge. The planes carrying supplies in or patients out would come if the weather allowed. What was on the island was what I had to work with, and if I didn’t have what I wanted, it was only because I didn’t want what I had. The waves would come as they will. I could either surf them or be tossed by them. I chose to dive in.

The island of Adak is Alaska’s last frontier. There are no stores, doctors, streetlights, traffic lights, or even a need for license plates. Just the lonely cry of a bald eagle and the howl of the arctic wind accompany you along the dark streets of this ghost town on the edge of the earth, where the North Pacific and the Bering Sea collide. The frigid Arctic front travels down the west coast, while the warmer Japanese current comes up the Pacific side. The low tundra does little to block the winds generated by that confluence, which often whip at 90 mph or more for days on end. Otherwise, the weather is generally gray and misty, and temperatures range from about 20°F to 65°F.

The weather matches the ambience and surroundings—decaying shambles of a once grand Navy base with facilities designed to make life as pleasant as possible for service members. But the Navy left in the late 1990s. By the time I arrived to practice here in 2013, only a few hundred people inhabited the island. There was virtually no economy, and almost all the roads and buildings were deserted. Man’s creation had fallen victim to vandals and nature.

My practice claimed a converted high school principal’s office and a two-bed emergency department (ED) that had some nice equipment—but with no medical aid, x-ray technician, phlebotomist, or lab technician, there was only me to operate it.

One of the oddities of the Alaskan bush is that medical providers often perform as All Species Providers; my first patient, Sadie, was a very well-behaved black Labrador retriever. Unable to anesthetize her, I was thankful for her even-tempered, patient breed (and for my experience as a veterinarian). Sadie lay calmly on the ED bed, her head in her owner’s hands, while I sutured her forepaw. In hindsight, she was one of my easier cases.

Adak’s isolated location (450 miles from the nearest settled outpost), rugged terrain, and vast wildlife come with an elevated risk for injuries and no shortage of challenges in treating them. During my first week, an autistic child presented with a foot laceration. There was no electricity when he arrived, as was often the case due to the wind; the only available light came through the open door. It was dusk and snow was gently falling, but we huddled in the doorway, as the patient’s mother and my husband held the boy while I sutured him. I just managed to get the last stitch in before the child entered his incoherent world.

Credit: iStockphoto.com/mbarrettimages

Anchorage, the nearest evacuation location, was 1,200 miles away. In the absolute best case (ie, the weather conditions were suitable for planes to take off and land), it was a 3.5-hour flight—that is, it would take 3.5 hours for a plane to arrive from Anchorage (if one happened to be ready) and then another 3.5 hours to transport the patient back. This fact was always in the back of my mind, but you can imagine how nerve-wracked I was in my first week (I had quite an initiation, as you can see) when a COPD patient presented in a cyanotic, dyspneic, and agitated state (SpO₂, 80%). I immediately inserted an IV, administered oxygen, and got the nebulizer going. That was all I could do—other than pray that he would be able to breathe while we awaited transport, which was potentially days away.

 

Not surprisingly for an island, the surrounding seas brought many of my patients. Workers on commercial fishing vessels frequently sustained injuries that the conditions at sea would exacerbate. Hand injuries were common, as were slip-and-fall injuries such as dislocations and broken bones. It could take hours to get them into port. The most memorable was a fisherman who had lost the end of his thumb when it was crushed between the gunwale and a swinging, loaded crab pot being hoisted aboard. The electricity (surprise) was out, so I was forced to treat him by flashlight. He was a young man (early 30s) but especially nice. What I remember most is that he declined a digital block. I debrided the devitalized tissue via sharp dissection, but he never once cursed. So much for all those jokes about cussing like a sailor.

On a seemingly calm Saturday in my third week, one of the supervisors from the fish processing plant came in with two of his workers. One had bilateral ocular exposure to a cleaning solvent, while the other was stumbling and disoriented. My triage skills were put to the test as I anesthetized Worker 1’s eyes with proparacaine, then inserted Morgan lenses (which, thankfully, came with instructions in the packaging!). The supervisor, who was keeping Worker 2 calm simultaneously, held a basin below the patient’s eyes to catch runoff as I quickly attached a liter of saline to each lens and opened the valve full bore. With that situation under control for the moment, I switched gears to assess Worker 2, who was markedly incoherent and unable to give a history. What I did know was that he was ataxic and nauseous, with a temperature of 104°F. I flashed my penlight into his eyes, and he reacted like Dracula faced with a crucifix. In addition to his exquisite photophobia, he had marked neck stiffness. The diagnosis was my first case of human meningitis. I inserted an IV providing ceftriaxone, acyclovir, and ondansetron. He required 2.5 L of IV fluid, but he gradually recovered over the next two days.

Why, with all these challenges, did I go to Alaska? Because I felt that there I could be of most service; if ever there was an underserved community, Adak was it. Ironically, the other job offer I considered was on the Hawaiian island of Kauai. As idyllic as that might have been, it wasn’t quite the adventure that Adak turned out to be—and it wasn’t as desperately in need of a provider.

When I took the Adak post, I didn’t realize how much I would learn. Above all, I realized that a complete and meticulous physical exam is king. If I missed any life-threatening conditions, the ramifications would be extreme. There were no referrals or second opinions, just me with the patient, and I had to make the right decisions.

The bonds I formed with the people on this remote island, and the paths I trod through this unusual land, made for a unique experience. It was a thrill to look out toward the horizon and know that everything I could see had remained unchanged since the birth of these volcanic islands. In time, I came to recognize that I was not in charge. The planes carrying supplies in or patients out would come if the weather allowed. What was on the island was what I had to work with, and if I didn’t have what I wanted, it was only because I didn’t want what I had. The waves would come as they will. I could either surf them or be tossed by them. I chose to dive in.