Commentary

A good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

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 good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

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 good way to survive an acute myocardial infarction is to go to the best hospital.

Some patients seem to have found out where those are. For those of us who want to know where to go and what to look for, a recent analysis of 800,000 Medicare patients admitted with acute myocardial infarction (AMI) and heart failure in 10,000 hospitals between 2008 and 2009 provides some reassuring news (National Bureau of Economic Research Working Paper 21603). Its findings indicated that in an era when health care choice is seemingly influenced by testimonial TV ads and the creation of hospitals that look like hotels, technical medical quality outranks all the glitz and bricks. Quality was measured by hospital mortality, 30-day readmissions, adherence to well-established guidelines, and patient satisfaction questionnaires. The investigators measured the effect that medical quality and the “comfort quotient” had on the growth of hospital patient volume through the emergency departments and interhospital referrals.

Hospital admissions increased in hospitals with the highest-quality performance. Over the 2-year period, the hospitals with the highest-quality performance had increases in hospital volume. Hospitals with a 1% improvement in the adjusted AMI mortality had a 17% increase in market share and a 1.5 % growth rate.

The authors estimated that patients with an AMI (or their family) were willing to travel an additional 1.8 miles for an ED admission to a hospital with a higher survival rate, and 34 miles further for a transfer to a hospital with a higher survival rate. When patients had the option to choose a hospital to be transferred to for further care, quality of care measures had an even greater impact on choice. Postdischarge evaluation of patient satisfaction had little or no effect on growth.

Patients admitted through the ED have the least chance for hospital choice, but even in these patients knowledge about quality influenced the choice of the hospital and the long-term hospital growth rate. Considering the fact that there is scant information available either to patients or even doctors about quality measures, there appears to be a choice process either by patient family, doctor, or ambulance driver to direct patients to the hospital with the best survival rate.

How they made those decisions is not clear. Comparative hospital survival data are rarely transmitted to staff physicians and are not widely available to the public. I have never seen any data like these in the multitude of hospital TV ads, yet somehow those numbers, real or perceived, affected admission and transfer. Maybe it’s just reputation; we all know about that. If you are really interested, you can find hospital medical quality and patient experience data at Medicare’s Hospital Compare site.

All this is good. Medical quality wins. Other studies, however, suggest that usually the “comfort quotient” and measures of medical quality are more closely linked. It has also been suggested that volume is the driving force for the improvement in both quality measures by providing the resources and logistics for better care. Whatever the mechanism, it seems that high-quality medical care is not a bad way to choose which neighborhood hospital to go to in order to survive an AMI.

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.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Editor’s note: For the last five presidential elections, this news organization has offered the Republican and Democrat presidential candidate the opportunity to present their ideas directly to U.S. physicians via side-by-side Guest Editorials. The candidates – or their proxies – have used these pages to reach out to you, our readers, with their views on medicine, health care, and other issues. We have taken pride in the ability to offer you a balanced view in the weeks leading up to the general election. This year, we cannot provide you with that balanced view. Despite repeated efforts via every medium at our disposal – telephone calls, emails, Twitter, LinkedIn, and more – the Donald J. Trump for President organization has not responded to our request for a contribution. Here we present the contribution from Secretary Hillary Clinton’s proxy.

Guest Editorial

As physicians, we have the unique privilege of serving patients, often at their most vulnerable moments. We also bear witness to how our health care system works – and too often, where it falls short – through our patients’ eyes.

That view could change dramatically depending on the outcome of this year’s presidential election. Hillary Clinton has a long track record of expanding affordable health care, and wants to accelerate the march toward universal access to high-quality care. Her opponent, Donald Trump, wants to roll back the progress we’ve made, with a plan that takes health insurance away from more than 20 million Americans.

Secretary Clinton’s career demonstrates her commitment to the ideal of health care as a human right. For example, she was instrumental in the bipartisan effort to pass the Children’s Health Insurance Program. Despite recent gains in health coverage, too many Americans still struggle to access the care they need – where and when they need it. Secretary Clinton’s plan for health care would expand access to care by building on the Affordable Care Act – with more relief for high premiums and out-of-pocket costs, particularly for prescription drugs; by working with states to expand Medicaid and give people the choice of a “public option” health plan. She also worked with Sen. Bernie Sanders (I-Vt.) on a plan to double funding for community health centers and substantially expand our commitment to the National Health Service Corps – so that millions more Americans have access to primary care, especially in rural and medically underserved urban areas, and so that we can offer more loan repayment and scholarships to early-career physicians.

Anyone taking care of patients today knows that improving access to care is only the first step. We must improve the way we deliver care, refocusing around the patient-doctor relationship. Too often there are barriers – regulations, paperwork, or insurance restrictions – to taking care of patients in the way that they deserve. Secretary Clinton wants to ensure an advanced and coordinated health care system that supports patient-doctor relationships instead of getting in the way. She wants to spur delivery system reform to reward value and quality. She was one of the first elected officials to call for modernizing health information technology, reaching across the aisle to work with physician and then-Sen. Bill Frist (R-Tenn.). And she’s offered plans to address major contemporary challenges, such as preventing and better treating Alzheimer’s disease, destigmatizing mental illness, and improving care for substance use disorders.

In addition to improving our health care system, Secretary Clinton believes we must take a number of proactive steps so that all Americans – regardless of location, income, or history – have the opportunity to live full, healthy lives. She believes we must invest in our public health infrastructure to ensure preparedness for emerging threats like Zika at home and abroad; to prevent illness and injury in communities; and to promote health equity. Of course, some of the most important determinants of well-being lie outside the walls of our clinics and hospitals. Secretary Clinton also will move us forward on these fundamental issues, such as women’s rights, criminal justice reform, and climate change.

Meanwhile, Donald Trump offers a very different vision for health care in the United States. His proposals would repeal the Affordable Care Act, instantly stripping millions of people of lifesaving health insurance. He would cut Medicaid through block grants, leaving millions of the poorest Americans without a safety net. And he would once again allow insurers to discriminate, based on preexisting conditions.

The choice in November could not be more important, for our patients and for the practice of medicine. Secretary Clinton’s long track record of fighting for universal, high-quality, affordable health care speaks for itself. With so much more left to do to improve health in our country, she brings the thoughtful leadership and steely determination needed to get the job done.

Dr. Chokshi practices internal medicine at Bellevue Hospital in New York and is a health policy adviser to Hillary for America.

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

Thanksgiving is at least one time when families sit down and focus on the meal. While the turkey may be the centerpiece, at least in our family we are presented with a variety of vegetables, salads, baked goods, and desserts. Some of the dishes remain on the traditional menu because “Aunt Martha always brings her molded salad,” although if the truth be known, she had fallen out of love with making it years ago. Other selections survive as memorials to long-departed family members: “Remember how much Grampy Stevens loved that pickled watermelon rind” that no one has touched since he died 10 years ago?

And although Thanksgiving may be all about the food, it’s really about sitting down together and celebrating each other over a meal. It should really be a happy meal but not one that comes in a box with a plastic toy. But for the parents of a picky eater, Thanksgiving is often destined to be another stressful dining experience. They know that despite the bountiful spread of food, there isn’t going to be anything on the table their child is going to eat.

They can cope with the situation in one of two ways. They can bring something they know he will eat, such as a can of corn or a microwaveable macaroni and cheese so he won’t “starve.” Or they can cast a pall on the festivities by attempting to badger, coax, and coerce him to eat something, as they do every night at home.

Parents may be assisted in their efforts by other family members who will bring something from the picky eater’s “might eat list.” Or, more likely, they will join in a chorus of old favorites such as “Don’t you want to grow up to be big and strong?” Or “You won’t be able to have any of Grandma’s cookies if you don’t eat some dinner.”

Either approach will be another step toward solidifying the child’s reputation in the family as a picky eater. Rachel is the cousin who plays the piano, and everyone knows that Brandon is going to be a great soccer player. Bobby is the one who won’t eat anything but mac and cheese.

A few years ago I had the thought that instead of allowing Thanksgiving to become an event that highlights and perpetuates the picky eater’s unfortunate habits, why not use the holiday as an opportunity to turn the page and begin a more sensible approach to selective eating?

So for some parents of picky eaters, I have begun to recommend the following: Tell everyone who will be coming to Thanksgiving that the pediatrician says everyone should agree that the event will be all about having a good time and not about who eats or doesn’t eat what’s on the table. And there will be no discussion about the picky eater’s habits – positive or negative.

It might be nice to include on the menu a dish or dessert that the picky eater has eaten in the past. But this is done without ceremony, comment, or preconditions such as “You have to eat some of this to get that.” This silent gesture of kindness also may reassure nervous grandparents who are worried that the child will starve if he doesn’t eat anything for a day despite your reassurance to them that the pediatrician said it was okay.

While I admit that one Thanksgiving with these new rules is unlikely to convert a 6-year-old picky eater into a voracious omnivore, it can be a first step toward helping a family adopt a sensible approach to the child’s eating habits. At least it won’t make things worse and is likely to turn unhappy meals at home into mini feasts that celebrate togetherness.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.”

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“2016 UPDATE ON MENOPAUSE”

ANDREW M. KAUNITZ, MD (JULY 2016)

Menopause and hormone therapy

As a long-term believer (proven!) of the value of the old comment, “estrogen forever,” I was pleased to see all the positive comments about estrogen in Dr. Kaunitz’s article. I was disappointed, however, in the comments in the box (page 39), “What this evidence means for practice.”

While my prejudice, statistically supported, is old fashioned, omission of the newer and marvelous way to counteract the only bad effects of estrogen (endometrial stimulation leading to endometrial adenocarcinoma) seems to be a major oversight. The new and least (if any) side-effect method means a levonorgestrel-releasing intrauterine device (LNG-IUD) yielding local progesterone counteraction to this major side effect of estrogen therapy.

Arthur A. Fleisher II, MD
Northridge, California

Dr. Kaunitz responds

I thank Dr. Fleisher for his interest in my 2016 Update on Menopause. I agree that off-label use of the LNG-IUD represents an appropriate alternative to systemic progestin when using estrogen to treat menopausal symptoms in women with an intact uterus.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.

VIDEO: “LAPAROSCOPIC SALPINGECTOMY AND CORNUAL RESECTION REPURPOSED: A NOVEL APPROACH TO TUBAL OCCLUSION DEVICE REMOVAL”

MICHELLE PACIS, MD, MPH (JULY 2016)

Easier technique for removing tubal occlusion devices?

My patient’s rheumatologist recently asked me to remove the tubal occlusion device (Essure) inserts that I had placed approximately 5 years ago. I think the technique I used was a little easier than the one shown in the video by Dr. Pacis and featured by Dr. Advincula in his video series. I started with a standard salpingectomy from the fimbriated end, as did the technique in the video. Then I made a circumferential incision of the tubal serosa at the junction of the tube as it enters the cornua, taking care to not cut the device insert, which could be visualized and felt with cold shears. The proximal end of the device insert, including the post and coil, then easily pulled out with some elongation of the coil. Since I did not need to resect the cornua, I was able to easily seal off the small defect without need to suture.

Alexander Lin, MD
Chicago, Illinois

Dr. Pacis responds

Thank you for sharing your method for tubal occlusion device removal. Your technique would certainly work for devices that reside predominantly in the tube. We have found that many of the devices become quite anchored and adherent to the tubal mucosa. While there are many surgical approaches to device removal, our preference is to perform salpingectomy with cornual resection, so as to avoid traction on the microinsert, and remove the device intact. We are then able to give the specimen, which contains the insert, to pathology so they can comment on the status of the device.

“PROTECTING THE NEWBORN BRAIN—THE FINAL FRONTIER IN OBSTETRIC AND NEONATAL CARE”

ROBERT L. BARBIERI, MD (AUGUST 2016)

Therapeutic hypothermia

I practice in a small community hospital without a neonatal intensive care unit (NICU). We have always paid attention to warming neonates. Although we cannot start neonatal therapeutic hypothermia, as Dr. Barbieri discusses in his August Editorial, would there be any benefit to avoiding purposefully warming infants who are depressed at birth? NICU care requires a pediatric transport team, which takes at least an hour to arrive.

Jane Dawson, MD
Maryville, Missouri

Dr. Barbieri responds

I thank Dr. Dawson for her observations and query. I agree that at a hospital without a NICU, pending the arrival of a pediatric transport team, clinicians should strive to prevent hyperthermia in a newborn with encephalopathy because hyperthermia might exacerbate the ischemic injury. It may make sense to avoid aggressive warming of the newborn to permit the core temperature to decrease in order to begin the hypothermia process.

“PROTECTING THE NEWBORN BRAIN—THE FINAL FRONTIER IN OBSTETRIC AND NEONATAL CARE”

ROBERT L. BARBIERI, MD (AUGUST 2016)

Therapeutic hypothermia

I practice in a small community hospital without a neonatal intensive care unit (NICU). We have always paid attention to warming neonates. Although we cannot start neonatal therapeutic hypothermia, as Dr. Barbieri discusses in his August Editorial, would there be any benefit to avoiding purposefully warming infants who are depressed at birth? NICU care requires a pediatric transport team, which takes at least an hour to arrive.

Jane Dawson, MD
Maryville, Missouri

Dr. Barbieri responds

I thank Dr. Dawson for her observations and query. I agree that at a hospital without a NICU, pending the arrival of a pediatric transport team, clinicians should strive to prevent hyperthermia in a newborn with encephalopathy because hyperthermia might exacerbate the ischemic injury. It may make sense to avoid aggressive warming of the newborn to permit the core temperature to decrease in order to begin the hypothermia process.

“PROTECTING THE NEWBORN BRAIN—THE FINAL FRONTIER IN OBSTETRIC AND NEONATAL CARE”

ROBERT L. BARBIERI, MD (AUGUST 2016)

Therapeutic hypothermia

I practice in a small community hospital without a neonatal intensive care unit (NICU). We have always paid attention to warming neonates. Although we cannot start neonatal therapeutic hypothermia, as Dr. Barbieri discusses in his August Editorial, would there be any benefit to avoiding purposefully warming infants who are depressed at birth? NICU care requires a pediatric transport team, which takes at least an hour to arrive.

Jane Dawson, MD
Maryville, Missouri

Dr. Barbieri responds

I thank Dr. Dawson for her observations and query. I agree that at a hospital without a NICU, pending the arrival of a pediatric transport team, clinicians should strive to prevent hyperthermia in a newborn with encephalopathy because hyperthermia might exacerbate the ischemic injury. It may make sense to avoid aggressive warming of the newborn to permit the core temperature to decrease in order to begin the hypothermia process.

“STOP USING INSTRUMENTS TO ASSIST WITH DELIVERY OF THE HEAD AT CESAREAN; START DISENGAGING THE HEAD PRIOR TO SURGERY”

ERROL R. NORWITZ, MD, PHD, MBA (AUGUST 2016)

Patient positioning helps in managing impacted fetal head

As a general practice ObGyn, I have seen an increasing incidence of difficult cesareans as a result of prolonged second stage of labor. Dr. Norwitz cites this increase in his article. I have found that trying to elevate the fetal head prior to the start of surgery has been remarkably ineffective. In my practice, I place all my patients with second-stage arrest in low lithotomy stirrups (“blue fins”); this allows the nurses easier access to the vagina to elevate the head at surgery while I am reaching down from above. Usually, this facilitates delivery. It also allows better assessment of blood loss through the vagina as the cesarean progresses, and it makes placement of a Bakri balloon easier if necessary. If stirrups are not available, the patient can be placed in frog leg positioning so that my assistant can reach down and elevate the head if necessary. I find that in a patient with a very small pelvis, it is hard to get my hand down to the baby’s head. I have not yet done a breech extraction, but I know it is possible. I would probably try nitroglycerin first.

I think that difficult cesarean delivery is much more common than difficult shoulder dystocia, and we should develop standard procedures for addressing the issue and use simulation models to practice. In my time-out prior to surgery, I discuss my concerns so that everyone is ready for it, including the anesthesiologist/CRNA, and we have nitroglycerin available to relax the uterus if necessary. I hope that the American College of Obstetricians and Gynecologists (ACOG) will develop a committee opinion about this very important issue.

Marguerite P. Cohen, MD
Portland, Oregon

Assistant is key in disengaging fetal head

Disengaging the head by an assistant during a cesarean delivery is probably the most successful and useful method for managing an impacted fetal head at cesarean. The disengagement of the head prior to cesarean is practiced routinely in Europe, where forceps delivery is frequently performed. However, the disengagement should be done in the operating room (OR) just prior to or during the cesarean. To perform this in the delivery room, as suggested in Dr. Norwitz’s article, risks the associated fetal bradycardia due to head compression that might compromise an already compromised fetus. In addition, there is a risk of cord prolapse or release of excessive amniotic fluid resulting in cord compression. Also, in many hospitals in the United States, there is some delay to perform the cesarean because the OR is on a different floor from the labor and delivery room and the OR staff come from home.

Vacuum extraction can be safely used for the extraction of the head if it is not possible to deliver it manually. However, the head should be manually disimpacted and rotated to occiput anterior prior to application of the vacuum. But the presence of caput might pose some difficulty with proper application and traction.

It is important to remember that the risk factors for an impacted fetal head are also risk factors for postoperative infection. Therefore, vaginal preparation with antiseptic solution should be considered prior to cesarean delivery for all patients in labor.¹

Raymond Michael, MD
Marshall, Minnesota

Reference

1. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2010;3:CD007892.

“STOP USING INSTRUMENTS TO ASSIST WITH DELIVERY OF THE HEAD AT CESAREAN; START DISENGAGING THE HEAD PRIOR TO SURGERY”

ERROL R. NORWITZ, MD, PHD, MBA (AUGUST 2016)

Patient positioning helps in managing impacted fetal head

As a general practice ObGyn, I have seen an increasing incidence of difficult cesareans as a result of prolonged second stage of labor. Dr. Norwitz cites this increase in his article. I have found that trying to elevate the fetal head prior to the start of surgery has been remarkably ineffective. In my practice, I place all my patients with second-stage arrest in low lithotomy stirrups (“blue fins”); this allows the nurses easier access to the vagina to elevate the head at surgery while I am reaching down from above. Usually, this facilitates delivery. It also allows better assessment of blood loss through the vagina as the cesarean progresses, and it makes placement of a Bakri balloon easier if necessary. If stirrups are not available, the patient can be placed in frog leg positioning so that my assistant can reach down and elevate the head if necessary. I find that in a patient with a very small pelvis, it is hard to get my hand down to the baby’s head. I have not yet done a breech extraction, but I know it is possible. I would probably try nitroglycerin first.

I think that difficult cesarean delivery is much more common than difficult shoulder dystocia, and we should develop standard procedures for addressing the issue and use simulation models to practice. In my time-out prior to surgery, I discuss my concerns so that everyone is ready for it, including the anesthesiologist/CRNA, and we have nitroglycerin available to relax the uterus if necessary. I hope that the American College of Obstetricians and Gynecologists (ACOG) will develop a committee opinion about this very important issue.

Marguerite P. Cohen, MD
Portland, Oregon

Assistant is key in disengaging fetal head

Disengaging the head by an assistant during a cesarean delivery is probably the most successful and useful method for managing an impacted fetal head at cesarean. The disengagement of the head prior to cesarean is practiced routinely in Europe, where forceps delivery is frequently performed. However, the disengagement should be done in the operating room (OR) just prior to or during the cesarean. To perform this in the delivery room, as suggested in Dr. Norwitz’s article, risks the associated fetal bradycardia due to head compression that might compromise an already compromised fetus. In addition, there is a risk of cord prolapse or release of excessive amniotic fluid resulting in cord compression. Also, in many hospitals in the United States, there is some delay to perform the cesarean because the OR is on a different floor from the labor and delivery room and the OR staff come from home.

Vacuum extraction can be safely used for the extraction of the head if it is not possible to deliver it manually. However, the head should be manually disimpacted and rotated to occiput anterior prior to application of the vacuum. But the presence of caput might pose some difficulty with proper application and traction.

It is important to remember that the risk factors for an impacted fetal head are also risk factors for postoperative infection. Therefore, vaginal preparation with antiseptic solution should be considered prior to cesarean delivery for all patients in labor.¹

Raymond Michael, MD
Marshall, Minnesota

Reference

1. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2010;3:CD007892.

“STOP USING INSTRUMENTS TO ASSIST WITH DELIVERY OF THE HEAD AT CESAREAN; START DISENGAGING THE HEAD PRIOR TO SURGERY”

ERROL R. NORWITZ, MD, PHD, MBA (AUGUST 2016)

Patient positioning helps in managing impacted fetal head

As a general practice ObGyn, I have seen an increasing incidence of difficult cesareans as a result of prolonged second stage of labor. Dr. Norwitz cites this increase in his article. I have found that trying to elevate the fetal head prior to the start of surgery has been remarkably ineffective. In my practice, I place all my patients with second-stage arrest in low lithotomy stirrups (“blue fins”); this allows the nurses easier access to the vagina to elevate the head at surgery while I am reaching down from above. Usually, this facilitates delivery. It also allows better assessment of blood loss through the vagina as the cesarean progresses, and it makes placement of a Bakri balloon easier if necessary. If stirrups are not available, the patient can be placed in frog leg positioning so that my assistant can reach down and elevate the head if necessary. I find that in a patient with a very small pelvis, it is hard to get my hand down to the baby’s head. I have not yet done a breech extraction, but I know it is possible. I would probably try nitroglycerin first.

I think that difficult cesarean delivery is much more common than difficult shoulder dystocia, and we should develop standard procedures for addressing the issue and use simulation models to practice. In my time-out prior to surgery, I discuss my concerns so that everyone is ready for it, including the anesthesiologist/CRNA, and we have nitroglycerin available to relax the uterus if necessary. I hope that the American College of Obstetricians and Gynecologists (ACOG) will develop a committee opinion about this very important issue.

Marguerite P. Cohen, MD
Portland, Oregon

Assistant is key in disengaging fetal head

Disengaging the head by an assistant during a cesarean delivery is probably the most successful and useful method for managing an impacted fetal head at cesarean. The disengagement of the head prior to cesarean is practiced routinely in Europe, where forceps delivery is frequently performed. However, the disengagement should be done in the operating room (OR) just prior to or during the cesarean. To perform this in the delivery room, as suggested in Dr. Norwitz’s article, risks the associated fetal bradycardia due to head compression that might compromise an already compromised fetus. In addition, there is a risk of cord prolapse or release of excessive amniotic fluid resulting in cord compression. Also, in many hospitals in the United States, there is some delay to perform the cesarean because the OR is on a different floor from the labor and delivery room and the OR staff come from home.

Vacuum extraction can be safely used for the extraction of the head if it is not possible to deliver it manually. However, the head should be manually disimpacted and rotated to occiput anterior prior to application of the vacuum. But the presence of caput might pose some difficulty with proper application and traction.

It is important to remember that the risk factors for an impacted fetal head are also risk factors for postoperative infection. Therefore, vaginal preparation with antiseptic solution should be considered prior to cesarean delivery for all patients in labor.¹

Raymond Michael, MD
Marshall, Minnesota

Reference

1. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2010;3:CD007892.

The National Ambulatory Medical Care Survey^1,2 (NAMCS) indicates that less than 1 out of 4 (23%) psychiatrists provide smoking cessation counseling to their patients, and even fewer prescribe medications.

What gives? How is it that so many psychiatrists endorse having recently helped a patient quit smoking when the data from large-scale surveys^1,2 indicate they do not?

From the “glass is half-full” perspective, the discrepancy might indicate that psychiatrists finally have bought into the message put forth 20 years ago when the American Psychiatric Association first published its clinical practice guidelines for treating nicotine dependence.³ Because the figures I cited from NAMCS reflect data from 2006 to 2010, it is possible that in the last 5 years more psychiatrists have started to help their patients quit smoking. Such an hypothesis is further supported by the increasing number of research papers on smoking cessation in individuals with mental illness published over the past 8 years—a period that coincides with the release of the second edition of the Treating tobacco use and dependence clinical practice guideline from the U.S. Agency for Healthcare Research and Quality, which highlighted the need for more research in this population of smokers.⁴

Regardless of the reason, the fact that my informal surveys indicate a likely uptick in activity among psychiatrists to help their patients quit smoking is welcome news. With nearly 1 out of 2 cigarettes sold in the United States being smoked by individuals with psychiatric and substance use disorders,⁵ psychiatrists and other mental health professionals play a vital role in addressing this epidemic. That our patients smoke at rates 2- to 4-times that of the general population and die decades earlier than their non-smoking, non-mentally ill counterparts⁶ are compelling reasons urging us to end our complacency and help our patients quit smoking.

EAGLES trial results help debunk the latest myth about smoking cessation

In an article that I wrote for Current Psychiatry 11 years ago,⁷ I attempted to debunk 3 myths that might have influenced some psychiatrists’ approach and motivation to intervene in tobacco dependence. Since that article appeared, a fourth myth has been promulgated—that the non-nicotine smoking cessation medications, bupropion and varenicline, are unsafe to use in patients with stable psychiatric disorders and cause serious neuropsychiatric adverse events (AEs) including suicide. Indeed, that is one implication of the “black-box” warning both of these medications received in July 2009, which caution that, “the risks of Zyban^®/Chantix^® should be weighed against the benefits of [their] use.”^8,9 For an illness that causes 480,000 deaths each year in the United States,¹⁰ and nearly 6 million across the globe,¹¹ tobacco treatment specialists find themselves in a quandary when 2 of the only 3 approved medications available—nicotine replacement therapy being the third—carry such a stern warning.

In addition to applying the “black-box” warning, the FDA issued a post-marketing requirement to the manufacturers of bupropion and varenicline to conduct a large randomized controlled trial—Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES)—the top-line results of which were published in The Lancet this spring.¹²

The researchers found no significant increase in serious neuropsychiatric AEs—a composite measure assessing depression, anxiety, suicidality, and 13 other symptom clusters—attributable to varenicline or bupropion compared with placebo or the nicotine patch in smokers with or without psychiatric disorders. The study did detect a significant difference—approximately 4% (2% in non-psychiatric cohort vs 6% in psychiatric cohort)—in the rate of serious neuropsychiatric AEs regardless of treatment condition. In both cohorts, varenicline was more effective than bupropion, which had similar efficacy to the nicotine patch; all interventions were superior to placebo. Importantly, all 3 medications significantly improved quit rates in smokers with and without psychiatric disorders. Although the efficacy of medications in smokers with or without psychiatric disorders was similar in terms of odds ratios, overall, those with psychiatric disorders had 20% to 30% lower quit rates compared with non-psychiatrically ill smokers.

The EAGLES study results, when viewed in the context of findings from other clinical trials and large-scale observational studies, provide further evidence that smokers with stable mental illness can use bupropion and varenicline safely. It also demonstrates that moderate to severe neuropsychiatric AEs occur during a smoking cessation attempt regardless of the medication used, therefore, monitoring smokers—especially those with psychiatric disorders—is important, a role that psychiatrists are uniquely poised to play.

That all 3 smoking cessation medications are effective in patients with mood, anxiety, and psychotic disorders is good news for our patients. Combined with the EAGLES safety findings, there is no better time to intervene in tobacco dependence

The National Ambulatory Medical Care Survey^1,2 (NAMCS) indicates that less than 1 out of 4 (23%) psychiatrists provide smoking cessation counseling to their patients, and even fewer prescribe medications.

What gives? How is it that so many psychiatrists endorse having recently helped a patient quit smoking when the data from large-scale surveys^1,2 indicate they do not?

From the “glass is half-full” perspective, the discrepancy might indicate that psychiatrists finally have bought into the message put forth 20 years ago when the American Psychiatric Association first published its clinical practice guidelines for treating nicotine dependence.³ Because the figures I cited from NAMCS reflect data from 2006 to 2010, it is possible that in the last 5 years more psychiatrists have started to help their patients quit smoking. Such an hypothesis is further supported by the increasing number of research papers on smoking cessation in individuals with mental illness published over the past 8 years—a period that coincides with the release of the second edition of the Treating tobacco use and dependence clinical practice guideline from the U.S. Agency for Healthcare Research and Quality, which highlighted the need for more research in this population of smokers.⁴

Regardless of the reason, the fact that my informal surveys indicate a likely uptick in activity among psychiatrists to help their patients quit smoking is welcome news. With nearly 1 out of 2 cigarettes sold in the United States being smoked by individuals with psychiatric and substance use disorders,⁵ psychiatrists and other mental health professionals play a vital role in addressing this epidemic. That our patients smoke at rates 2- to 4-times that of the general population and die decades earlier than their non-smoking, non-mentally ill counterparts⁶ are compelling reasons urging us to end our complacency and help our patients quit smoking.

EAGLES trial results help debunk the latest myth about smoking cessation

In an article that I wrote for Current Psychiatry 11 years ago,⁷ I attempted to debunk 3 myths that might have influenced some psychiatrists’ approach and motivation to intervene in tobacco dependence. Since that article appeared, a fourth myth has been promulgated—that the non-nicotine smoking cessation medications, bupropion and varenicline, are unsafe to use in patients with stable psychiatric disorders and cause serious neuropsychiatric adverse events (AEs) including suicide. Indeed, that is one implication of the “black-box” warning both of these medications received in July 2009, which caution that, “the risks of Zyban^®/Chantix^® should be weighed against the benefits of [their] use.”^8,9 For an illness that causes 480,000 deaths each year in the United States,¹⁰ and nearly 6 million across the globe,¹¹ tobacco treatment specialists find themselves in a quandary when 2 of the only 3 approved medications available—nicotine replacement therapy being the third—carry such a stern warning.

In addition to applying the “black-box” warning, the FDA issued a post-marketing requirement to the manufacturers of bupropion and varenicline to conduct a large randomized controlled trial—Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES)—the top-line results of which were published in The Lancet this spring.¹²

The researchers found no significant increase in serious neuropsychiatric AEs—a composite measure assessing depression, anxiety, suicidality, and 13 other symptom clusters—attributable to varenicline or bupropion compared with placebo or the nicotine patch in smokers with or without psychiatric disorders. The study did detect a significant difference—approximately 4% (2% in non-psychiatric cohort vs 6% in psychiatric cohort)—in the rate of serious neuropsychiatric AEs regardless of treatment condition. In both cohorts, varenicline was more effective than bupropion, which had similar efficacy to the nicotine patch; all interventions were superior to placebo. Importantly, all 3 medications significantly improved quit rates in smokers with and without psychiatric disorders. Although the efficacy of medications in smokers with or without psychiatric disorders was similar in terms of odds ratios, overall, those with psychiatric disorders had 20% to 30% lower quit rates compared with non-psychiatrically ill smokers.

The EAGLES study results, when viewed in the context of findings from other clinical trials and large-scale observational studies, provide further evidence that smokers with stable mental illness can use bupropion and varenicline safely. It also demonstrates that moderate to severe neuropsychiatric AEs occur during a smoking cessation attempt regardless of the medication used, therefore, monitoring smokers—especially those with psychiatric disorders—is important, a role that psychiatrists are uniquely poised to play.

That all 3 smoking cessation medications are effective in patients with mood, anxiety, and psychotic disorders is good news for our patients. Combined with the EAGLES safety findings, there is no better time to intervene in tobacco dependence

The National Ambulatory Medical Care Survey^1,2 (NAMCS) indicates that less than 1 out of 4 (23%) psychiatrists provide smoking cessation counseling to their patients, and even fewer prescribe medications.

What gives? How is it that so many psychiatrists endorse having recently helped a patient quit smoking when the data from large-scale surveys^1,2 indicate they do not?

From the “glass is half-full” perspective, the discrepancy might indicate that psychiatrists finally have bought into the message put forth 20 years ago when the American Psychiatric Association first published its clinical practice guidelines for treating nicotine dependence.³ Because the figures I cited from NAMCS reflect data from 2006 to 2010, it is possible that in the last 5 years more psychiatrists have started to help their patients quit smoking. Such an hypothesis is further supported by the increasing number of research papers on smoking cessation in individuals with mental illness published over the past 8 years—a period that coincides with the release of the second edition of the Treating tobacco use and dependence clinical practice guideline from the U.S. Agency for Healthcare Research and Quality, which highlighted the need for more research in this population of smokers.⁴

Regardless of the reason, the fact that my informal surveys indicate a likely uptick in activity among psychiatrists to help their patients quit smoking is welcome news. With nearly 1 out of 2 cigarettes sold in the United States being smoked by individuals with psychiatric and substance use disorders,⁵ psychiatrists and other mental health professionals play a vital role in addressing this epidemic. That our patients smoke at rates 2- to 4-times that of the general population and die decades earlier than their non-smoking, non-mentally ill counterparts⁶ are compelling reasons urging us to end our complacency and help our patients quit smoking.

EAGLES trial results help debunk the latest myth about smoking cessation

In an article that I wrote for Current Psychiatry 11 years ago,⁷ I attempted to debunk 3 myths that might have influenced some psychiatrists’ approach and motivation to intervene in tobacco dependence. Since that article appeared, a fourth myth has been promulgated—that the non-nicotine smoking cessation medications, bupropion and varenicline, are unsafe to use in patients with stable psychiatric disorders and cause serious neuropsychiatric adverse events (AEs) including suicide. Indeed, that is one implication of the “black-box” warning both of these medications received in July 2009, which caution that, “the risks of Zyban^®/Chantix^® should be weighed against the benefits of [their] use.”^8,9 For an illness that causes 480,000 deaths each year in the United States,¹⁰ and nearly 6 million across the globe,¹¹ tobacco treatment specialists find themselves in a quandary when 2 of the only 3 approved medications available—nicotine replacement therapy being the third—carry such a stern warning.

In addition to applying the “black-box” warning, the FDA issued a post-marketing requirement to the manufacturers of bupropion and varenicline to conduct a large randomized controlled trial—Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES)—the top-line results of which were published in The Lancet this spring.¹²

The researchers found no significant increase in serious neuropsychiatric AEs—a composite measure assessing depression, anxiety, suicidality, and 13 other symptom clusters—attributable to varenicline or bupropion compared with placebo or the nicotine patch in smokers with or without psychiatric disorders. The study did detect a significant difference—approximately 4% (2% in non-psychiatric cohort vs 6% in psychiatric cohort)—in the rate of serious neuropsychiatric AEs regardless of treatment condition. In both cohorts, varenicline was more effective than bupropion, which had similar efficacy to the nicotine patch; all interventions were superior to placebo. Importantly, all 3 medications significantly improved quit rates in smokers with and without psychiatric disorders. Although the efficacy of medications in smokers with or without psychiatric disorders was similar in terms of odds ratios, overall, those with psychiatric disorders had 20% to 30% lower quit rates compared with non-psychiatrically ill smokers.

The EAGLES study results, when viewed in the context of findings from other clinical trials and large-scale observational studies, provide further evidence that smokers with stable mental illness can use bupropion and varenicline safely. It also demonstrates that moderate to severe neuropsychiatric AEs occur during a smoking cessation attempt regardless of the medication used, therefore, monitoring smokers—especially those with psychiatric disorders—is important, a role that psychiatrists are uniquely poised to play.

That all 3 smoking cessation medications are effective in patients with mood, anxiety, and psychotic disorders is good news for our patients. Combined with the EAGLES safety findings, there is no better time to intervene in tobacco dependence

It has been almost 10 years since the Advisory Committee on Immunization Practices (ACIP) recommended administration of human papillomavirus (HPV) vaccine for 11- to 12-year-old girls and young women up to 26 years of age. Routine administration in preteen boys and young adult males up to 21 years of age was recommended in 2011. An HPV series should be completed by 13 years. So how well are we protecting our patients?

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually among adolescents 13-17 years. Data are obtained from individuals from the 50 states, the District of Columbia, the U.S. Virgin Islands, and six major urban areas (MMWR. 2016 Aug 26;65[33]:850-8).

HPV vaccination continues to lag behind Tdap and the meningococcal conjugate vaccine (MCV), although each one is recommended to be administered at the 11- to 12-year visit. In 2015, coverage for receiving at least one dose of HPV vaccine among females was almost 62.8 % and for at least three doses was 41.9%; among males, coverage with at least one dose was 49.8% and for at least three doses was 28.1%. Compared with 2014, coverage for at least one dose of HPV vaccine increased 2.8% in females and 8.1% in males. Males also had a 7.6% for receipt of at least two doses of HPV vaccine, compared with 2014. HPV vaccine coverage in females aged 13 and younger also was lower than for those aged 15 and older. Coverage did not differ for males based on age.

HPV vaccination coverage also differed by state. In 2015, 28 states reported increased coverage in males, but only 7 states had increased coverage in females. Among all adolescents, coverage with at least one dose of HPV vaccine was 56.1%, at least two doses was 45.4%, and at least three doses was 34.9%. In contrast, 86.4% of all adolescents received at least one dose of Tdap, and 81.3% received at least one dose of MCV.

HPV-associated cancers

HPV is the most common sexually transmitted infection in both men and women. It is estimated that 79 million Americans are infected and 14 million new infections occur annually, usually in teens and young adults. Although most infections are asymptomatic and clear spontaneously, persistent infection with oncogenic types can progress to cancer. Cervical and oropharyngeal cancer were the most common HPV-associated cancers in women and men, respectively, in 2008-2012 (MMWR 2016;65:661-6).

All three HPV vaccines protect against HPV types 16 and 18. These types are estimated to account for the majority of cervical and oropharyngeal cancers, 66% and 62%, respectively. The additional types in the 9-valent HPV will protect against HPV types that cause approximately 15% of cervical cancers.

The association between HPV and cancer is clear. So why isn’t this vaccine being embraced? HPV vaccine is all about cancer prevention. Isn’t it? What are the barriers to HPV vaccination? Are parental concerns the only barrier? Are we recommending this vaccine as strongly as others?

Vaccine safety and efficacy

Safety has been a concern voiced by some parents. Collectively, HPV vaccines were studied in more than 95,000 individuals prior to licensure. Almost 90 million doses of vaccine have been distributed in the United States and more than 183 million, worldwide. The federal government utilizes three systems to monitor vaccine safety once a vaccine is licensed: The Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink (VSD), and the Clinical Immunization Safety Assessment (CISA) Network. Ongoing safety studies also are conducted by vaccine manufacturers. Since licensure, no serious safety concerns have been identified. Postvaccination syncope, first identified in the VAERS database in 2006, has declined since observation post injection was recommended by ACIP. Multiple studies in the United States and abroad have not demonstrated a causal association with HPV vaccine and any autoimmune and/or neurologic condition or increased risk for thromboembolism.

Mélanie Drolet, PhD, and her colleagues reviewed 20 studies in nine countries with at least 50% coverage in female adolescents aged 13-19 years. There was a 68% reduction in the prevalence of HPV types 16 and 18 and a 61% reduction in anal warts in the postvaccine era (Lancet Infect Dis. 2015 May;15[5]:565-80). Studies also indicate there is no indication of waning immunity.

Parental perceptions

Some parents feel the vaccine is not necessary because their child is not sexually active and/or is not at risk for acquiring a sexually transmitted infection. Others opt to delay initiation. NHANES (National Health and Nutrition Examination Survey) data from 2011 to 2014 revealed that among females aged 14-26 years whose age was known at the time of their first dose of HPV vaccine, 43% had reported having sex before or in the same year that they received their first dose.

One consistent reason parents indicate for not vaccinating is the lack of recommendation from their child’s health provider. Differences in age and sex recommendations also are reported. NIS-Teen 2013 demonstrated that parents of girls were more likely than parents of boys to receive a provider recommendation (65% vs.42%.) Only 29% of female parents indicated they’d received a provider recommendation to have their child vaccinated with HPV by ages 11-12 years.

Mandy A. Allison, MD, and her colleagues reviewed primary care physician perspectives about HPV vaccine in a national survey among 364 pediatricians and 218 family physicians (FPs). Although 84% of pediatricians and 75% of FPs indicated they always discuss HPV vaccination, only 60% of pediatricians and 59% of FPs strongly recommend HPV vaccine for 11- to 12-year-old girls; for boys it was 52% and 41%. More than half reported parental deferral. For pediatricians who almost never discussed the topic, the reasons included that the patient was not sexually active (54%), the child was young (38%), and the patient was already receiving other vaccines (35%) (Pediatrics. 2016 Feb;137[2]:e20152488).

Providers can be influenced by their perceptions of what value parents place on vaccines. In one study, parents were asked to put a value on specific vaccines. Providers were then asked to estimate how parents ranked the vaccines on a scale of 0-10. Providers underestimated the value placed on HPV vaccine (9.3 vs 5.2) (Vaccine 2014;32:579-84).

Improving HPV coverage: Preventing future HPV-related cancers

HPV vaccine should be recommended with as much conviction as Tdap and MCV at the 11- to 12-year visit for both girls and boys. Administration of all three should occur on the same day. Clinician recommendation is the No. 1 reason parents decide to vaccinate. The mantra “same way, same day” should become synonymous with the 11- to 12-year visit. All who have contact with the patient, beginning with the front desk staff, should know the importance of HPV vaccine, and when and why it is recommended. Often, families spend more time with support staff and have discussions prior to interacting with you.

Anticipate questions about HPV. Why give the vaccine when the child is so young and not sexually active? Is my child really at risk? Is it safe? I read on the Internet. … Questions should be interpreted as a need for additional information and reassurance from you.

Remember to emphasize that HPV vaccine is important because it prevents cancer and it is most effective prior to exposure to HPV.

Additional resources to facilitate your discussions about HPV can be found at www.cdc.gov/hpv.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

It has been almost 10 years since the Advisory Committee on Immunization Practices (ACIP) recommended administration of human papillomavirus (HPV) vaccine for 11- to 12-year-old girls and young women up to 26 years of age. Routine administration in preteen boys and young adult males up to 21 years of age was recommended in 2011. An HPV series should be completed by 13 years. So how well are we protecting our patients?

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually among adolescents 13-17 years. Data are obtained from individuals from the 50 states, the District of Columbia, the U.S. Virgin Islands, and six major urban areas (MMWR. 2016 Aug 26;65[33]:850-8).

HPV vaccination continues to lag behind Tdap and the meningococcal conjugate vaccine (MCV), although each one is recommended to be administered at the 11- to 12-year visit. In 2015, coverage for receiving at least one dose of HPV vaccine among females was almost 62.8 % and for at least three doses was 41.9%; among males, coverage with at least one dose was 49.8% and for at least three doses was 28.1%. Compared with 2014, coverage for at least one dose of HPV vaccine increased 2.8% in females and 8.1% in males. Males also had a 7.6% for receipt of at least two doses of HPV vaccine, compared with 2014. HPV vaccine coverage in females aged 13 and younger also was lower than for those aged 15 and older. Coverage did not differ for males based on age.

HPV vaccination coverage also differed by state. In 2015, 28 states reported increased coverage in males, but only 7 states had increased coverage in females. Among all adolescents, coverage with at least one dose of HPV vaccine was 56.1%, at least two doses was 45.4%, and at least three doses was 34.9%. In contrast, 86.4% of all adolescents received at least one dose of Tdap, and 81.3% received at least one dose of MCV.

HPV-associated cancers

HPV is the most common sexually transmitted infection in both men and women. It is estimated that 79 million Americans are infected and 14 million new infections occur annually, usually in teens and young adults. Although most infections are asymptomatic and clear spontaneously, persistent infection with oncogenic types can progress to cancer. Cervical and oropharyngeal cancer were the most common HPV-associated cancers in women and men, respectively, in 2008-2012 (MMWR 2016;65:661-6).

All three HPV vaccines protect against HPV types 16 and 18. These types are estimated to account for the majority of cervical and oropharyngeal cancers, 66% and 62%, respectively. The additional types in the 9-valent HPV will protect against HPV types that cause approximately 15% of cervical cancers.

The association between HPV and cancer is clear. So why isn’t this vaccine being embraced? HPV vaccine is all about cancer prevention. Isn’t it? What are the barriers to HPV vaccination? Are parental concerns the only barrier? Are we recommending this vaccine as strongly as others?

Vaccine safety and efficacy

Safety has been a concern voiced by some parents. Collectively, HPV vaccines were studied in more than 95,000 individuals prior to licensure. Almost 90 million doses of vaccine have been distributed in the United States and more than 183 million, worldwide. The federal government utilizes three systems to monitor vaccine safety once a vaccine is licensed: The Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink (VSD), and the Clinical Immunization Safety Assessment (CISA) Network. Ongoing safety studies also are conducted by vaccine manufacturers. Since licensure, no serious safety concerns have been identified. Postvaccination syncope, first identified in the VAERS database in 2006, has declined since observation post injection was recommended by ACIP. Multiple studies in the United States and abroad have not demonstrated a causal association with HPV vaccine and any autoimmune and/or neurologic condition or increased risk for thromboembolism.

Mélanie Drolet, PhD, and her colleagues reviewed 20 studies in nine countries with at least 50% coverage in female adolescents aged 13-19 years. There was a 68% reduction in the prevalence of HPV types 16 and 18 and a 61% reduction in anal warts in the postvaccine era (Lancet Infect Dis. 2015 May;15[5]:565-80). Studies also indicate there is no indication of waning immunity.

Parental perceptions

Some parents feel the vaccine is not necessary because their child is not sexually active and/or is not at risk for acquiring a sexually transmitted infection. Others opt to delay initiation. NHANES (National Health and Nutrition Examination Survey) data from 2011 to 2014 revealed that among females aged 14-26 years whose age was known at the time of their first dose of HPV vaccine, 43% had reported having sex before or in the same year that they received their first dose.

One consistent reason parents indicate for not vaccinating is the lack of recommendation from their child’s health provider. Differences in age and sex recommendations also are reported. NIS-Teen 2013 demonstrated that parents of girls were more likely than parents of boys to receive a provider recommendation (65% vs.42%.) Only 29% of female parents indicated they’d received a provider recommendation to have their child vaccinated with HPV by ages 11-12 years.

Mandy A. Allison, MD, and her colleagues reviewed primary care physician perspectives about HPV vaccine in a national survey among 364 pediatricians and 218 family physicians (FPs). Although 84% of pediatricians and 75% of FPs indicated they always discuss HPV vaccination, only 60% of pediatricians and 59% of FPs strongly recommend HPV vaccine for 11- to 12-year-old girls; for boys it was 52% and 41%. More than half reported parental deferral. For pediatricians who almost never discussed the topic, the reasons included that the patient was not sexually active (54%), the child was young (38%), and the patient was already receiving other vaccines (35%) (Pediatrics. 2016 Feb;137[2]:e20152488).

Providers can be influenced by their perceptions of what value parents place on vaccines. In one study, parents were asked to put a value on specific vaccines. Providers were then asked to estimate how parents ranked the vaccines on a scale of 0-10. Providers underestimated the value placed on HPV vaccine (9.3 vs 5.2) (Vaccine 2014;32:579-84).

Improving HPV coverage: Preventing future HPV-related cancers

HPV vaccine should be recommended with as much conviction as Tdap and MCV at the 11- to 12-year visit for both girls and boys. Administration of all three should occur on the same day. Clinician recommendation is the No. 1 reason parents decide to vaccinate. The mantra “same way, same day” should become synonymous with the 11- to 12-year visit. All who have contact with the patient, beginning with the front desk staff, should know the importance of HPV vaccine, and when and why it is recommended. Often, families spend more time with support staff and have discussions prior to interacting with you.

Anticipate questions about HPV. Why give the vaccine when the child is so young and not sexually active? Is my child really at risk? Is it safe? I read on the Internet. … Questions should be interpreted as a need for additional information and reassurance from you.

Remember to emphasize that HPV vaccine is important because it prevents cancer and it is most effective prior to exposure to HPV.

Additional resources to facilitate your discussions about HPV can be found at www.cdc.gov/hpv.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

It has been almost 10 years since the Advisory Committee on Immunization Practices (ACIP) recommended administration of human papillomavirus (HPV) vaccine for 11- to 12-year-old girls and young women up to 26 years of age. Routine administration in preteen boys and young adult males up to 21 years of age was recommended in 2011. An HPV series should be completed by 13 years. So how well are we protecting our patients?

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually among adolescents 13-17 years. Data are obtained from individuals from the 50 states, the District of Columbia, the U.S. Virgin Islands, and six major urban areas (MMWR. 2016 Aug 26;65[33]:850-8).

HPV vaccination continues to lag behind Tdap and the meningococcal conjugate vaccine (MCV), although each one is recommended to be administered at the 11- to 12-year visit. In 2015, coverage for receiving at least one dose of HPV vaccine among females was almost 62.8 % and for at least three doses was 41.9%; among males, coverage with at least one dose was 49.8% and for at least three doses was 28.1%. Compared with 2014, coverage for at least one dose of HPV vaccine increased 2.8% in females and 8.1% in males. Males also had a 7.6% for receipt of at least two doses of HPV vaccine, compared with 2014. HPV vaccine coverage in females aged 13 and younger also was lower than for those aged 15 and older. Coverage did not differ for males based on age.

HPV vaccination coverage also differed by state. In 2015, 28 states reported increased coverage in males, but only 7 states had increased coverage in females. Among all adolescents, coverage with at least one dose of HPV vaccine was 56.1%, at least two doses was 45.4%, and at least three doses was 34.9%. In contrast, 86.4% of all adolescents received at least one dose of Tdap, and 81.3% received at least one dose of MCV.

HPV-associated cancers

HPV is the most common sexually transmitted infection in both men and women. It is estimated that 79 million Americans are infected and 14 million new infections occur annually, usually in teens and young adults. Although most infections are asymptomatic and clear spontaneously, persistent infection with oncogenic types can progress to cancer. Cervical and oropharyngeal cancer were the most common HPV-associated cancers in women and men, respectively, in 2008-2012 (MMWR 2016;65:661-6).

All three HPV vaccines protect against HPV types 16 and 18. These types are estimated to account for the majority of cervical and oropharyngeal cancers, 66% and 62%, respectively. The additional types in the 9-valent HPV will protect against HPV types that cause approximately 15% of cervical cancers.

The association between HPV and cancer is clear. So why isn’t this vaccine being embraced? HPV vaccine is all about cancer prevention. Isn’t it? What are the barriers to HPV vaccination? Are parental concerns the only barrier? Are we recommending this vaccine as strongly as others?

Vaccine safety and efficacy

Safety has been a concern voiced by some parents. Collectively, HPV vaccines were studied in more than 95,000 individuals prior to licensure. Almost 90 million doses of vaccine have been distributed in the United States and more than 183 million, worldwide. The federal government utilizes three systems to monitor vaccine safety once a vaccine is licensed: The Vaccine Adverse Event Reporting System (VAERS), the Vaccine Safety Datalink (VSD), and the Clinical Immunization Safety Assessment (CISA) Network. Ongoing safety studies also are conducted by vaccine manufacturers. Since licensure, no serious safety concerns have been identified. Postvaccination syncope, first identified in the VAERS database in 2006, has declined since observation post injection was recommended by ACIP. Multiple studies in the United States and abroad have not demonstrated a causal association with HPV vaccine and any autoimmune and/or neurologic condition or increased risk for thromboembolism.

Mélanie Drolet, PhD, and her colleagues reviewed 20 studies in nine countries with at least 50% coverage in female adolescents aged 13-19 years. There was a 68% reduction in the prevalence of HPV types 16 and 18 and a 61% reduction in anal warts in the postvaccine era (Lancet Infect Dis. 2015 May;15[5]:565-80). Studies also indicate there is no indication of waning immunity.

Parental perceptions

Some parents feel the vaccine is not necessary because their child is not sexually active and/or is not at risk for acquiring a sexually transmitted infection. Others opt to delay initiation. NHANES (National Health and Nutrition Examination Survey) data from 2011 to 2014 revealed that among females aged 14-26 years whose age was known at the time of their first dose of HPV vaccine, 43% had reported having sex before or in the same year that they received their first dose.

One consistent reason parents indicate for not vaccinating is the lack of recommendation from their child’s health provider. Differences in age and sex recommendations also are reported. NIS-Teen 2013 demonstrated that parents of girls were more likely than parents of boys to receive a provider recommendation (65% vs.42%.) Only 29% of female parents indicated they’d received a provider recommendation to have their child vaccinated with HPV by ages 11-12 years.

Mandy A. Allison, MD, and her colleagues reviewed primary care physician perspectives about HPV vaccine in a national survey among 364 pediatricians and 218 family physicians (FPs). Although 84% of pediatricians and 75% of FPs indicated they always discuss HPV vaccination, only 60% of pediatricians and 59% of FPs strongly recommend HPV vaccine for 11- to 12-year-old girls; for boys it was 52% and 41%. More than half reported parental deferral. For pediatricians who almost never discussed the topic, the reasons included that the patient was not sexually active (54%), the child was young (38%), and the patient was already receiving other vaccines (35%) (Pediatrics. 2016 Feb;137[2]:e20152488).

Providers can be influenced by their perceptions of what value parents place on vaccines. In one study, parents were asked to put a value on specific vaccines. Providers were then asked to estimate how parents ranked the vaccines on a scale of 0-10. Providers underestimated the value placed on HPV vaccine (9.3 vs 5.2) (Vaccine 2014;32:579-84).

Improving HPV coverage: Preventing future HPV-related cancers

HPV vaccine should be recommended with as much conviction as Tdap and MCV at the 11- to 12-year visit for both girls and boys. Administration of all three should occur on the same day. Clinician recommendation is the No. 1 reason parents decide to vaccinate. The mantra “same way, same day” should become synonymous with the 11- to 12-year visit. All who have contact with the patient, beginning with the front desk staff, should know the importance of HPV vaccine, and when and why it is recommended. Often, families spend more time with support staff and have discussions prior to interacting with you.

Anticipate questions about HPV. Why give the vaccine when the child is so young and not sexually active? Is my child really at risk? Is it safe? I read on the Internet. … Questions should be interpreted as a need for additional information and reassurance from you.

Remember to emphasize that HPV vaccine is important because it prevents cancer and it is most effective prior to exposure to HPV.

Additional resources to facilitate your discussions about HPV can be found at www.cdc.gov/hpv.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:

Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”

Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...

You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”

“Where do you buy an analyst couch?” I asked.

“Analyticcouch.com,” she explained. “Available in a variety of colors.”

What a country!

No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”

The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.

“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”

That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.

“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”

There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.

Then the other day Marcy surprised me with this:

“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”

A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...

You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.

My jaw dropped, but no words came out.

“It’s that sign you put up,” he said, “right on the exam room door.”

As I don’t usually read my own signs, I turned to look. The sign read:

“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”

“It says, ‘No-Showed,” I said. Not ‘No Showers.”

I resisted the urge to refer him to an optometrist.

This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”

“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”

“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.

“Upstairs,” I said. “Seventh floor.”

Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”

“But it has to be a whole day ...”

“Fifteen hours,” he said. “I’ll give you 15 hours.”

“But we need ...”

“Eighteen hours. OK?”

“Well, not really. You see, the test has to be a whole day ...”

“All right, 21 hours. That’s my best offer.”

Maybe if I could get him to spend the day in that Egyptian bathroom ...

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].

Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:

Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”

Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...

You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”

“Where do you buy an analyst couch?” I asked.

“Analyticcouch.com,” she explained. “Available in a variety of colors.”

What a country!

No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”

The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.

“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”

That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.

“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”

There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.

Then the other day Marcy surprised me with this:

“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”

A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...

You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.

My jaw dropped, but no words came out.

“It’s that sign you put up,” he said, “right on the exam room door.”

As I don’t usually read my own signs, I turned to look. The sign read:

“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”

“It says, ‘No-Showed,” I said. Not ‘No Showers.”

I resisted the urge to refer him to an optometrist.

This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”

“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”

“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.

“Upstairs,” I said. “Seventh floor.”

Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”

“But it has to be a whole day ...”

“Fifteen hours,” he said. “I’ll give you 15 hours.”

“But we need ...”

“Eighteen hours. OK?”

“Well, not really. You see, the test has to be a whole day ...”

“All right, 21 hours. That’s my best offer.”

Maybe if I could get him to spend the day in that Egyptian bathroom ...

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].

Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:

Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”

Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...

You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”

“Where do you buy an analyst couch?” I asked.

“Analyticcouch.com,” she explained. “Available in a variety of colors.”

What a country!

No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”

The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.

“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”

That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.

“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”

There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.

Then the other day Marcy surprised me with this:

“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”

A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...

You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.

My jaw dropped, but no words came out.

“It’s that sign you put up,” he said, “right on the exam room door.”

As I don’t usually read my own signs, I turned to look. The sign read:

“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”

“It says, ‘No-Showed,” I said. Not ‘No Showers.”

I resisted the urge to refer him to an optometrist.

This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”

“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”

“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.

“Upstairs,” I said. “Seventh floor.”

Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”

“But it has to be a whole day ...”

“Fifteen hours,” he said. “I’ll give you 15 hours.”

“But we need ...”

“Eighteen hours. OK?”

“Well, not really. You see, the test has to be a whole day ...”

“All right, 21 hours. That’s my best offer.”

Maybe if I could get him to spend the day in that Egyptian bathroom ...

Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].