Commentary

Sometimes in life you just have to do something you’ve always wanted to do. I’ve always wanted to go to the grocery store at 1:00 a.m. in my bathrobe, drink a carton of half-and-half, and pay for it with a check, but after discussing the plan with my wife, I’m instead learning French. Online. For free. I’m sorry, my sweet crème moitié-moitié, maybe next year.

stanciuc

Bank shot

For those of us who, for whatever reason, don’t like children to get preventable deadly diseases, it’s been a depressing year. First came the news that a whooping cough outbreak in Washington state had no effect on pertussis vaccination rates there, then we learned that correcting vaccine misinformation actually makes parents less likely to protect their children than saying nothing. Finally, however, we get a ray of hope, and, like everything else in the vaccine debate, it’s confusing. Like French.

A group of researchers from Indiana appear to have cracked the code to vaccine acceptance, at least for the measles, mumps, rubella (MMR) vaccine: tell parents how the vaccine will help their children. See how simple that was, people? Any questions?

I have one: What did y’all say that we weren’t already saying?! In their Internet-based survey of 802 parents of infants, the investigators gave subjects four different messages about vaccines, all including the standard Centers for Disease Control and Prevention Vaccine Information Statement (VIS). One group got only the VIS. Another group also heard about the vaccine’s benefits to their children; a third group heard about how vaccination protects the community at large, and a fourth group heard about vaccination’s benefits both to children and to the community.

Two of those groups saw increased vaccine acceptance: the two who heard that MMR vaccines would benefit their children. In my own practice, I tend to emphasize how the MMR vaccine helps children avoid some of the common side effects of measles infection, like severe brain damage, or death, but perhaps there are some benefits I’ve been missing. Does the MMR vaccine, say, improve your complexion, burn fat without diet or exercise, or make it easier to learn a foreign language? If so, then I may be due for a booster. 

Take a hike 

There is good news from the world of summer camp, and it has nothing to do with a decrease in the number of campers infected with Lyme disease since July. No, thanks to a report from a team of psychologists in Los Angeles, we now know that summer camp is where kids learn all sorts of long-forgotten skills, like how to paddle a canoe, how to start a fire, and how to read human facial expressions.

According to well-validated tests of emotional perception, kids aged 11-13 years who spent just 5 days at a summer camp without electronics saw a dramatic leap in their perception of nonverbal communications, compared with kids who did not have to trade in their iPhones for cans of concentrated DEET. A subgroup analysis that has rocked the middle school literature also demonstrated that despite being without their electronics for 5 days, none of the 51 subjects died.

Children in both groups observed photos and short videos demonstrating emotional facial expressions and body language and were then asked to describe the emotions being demonstrated. The kids who had been to camp did remarkably well on the tests. The kids who kept their electronic devices over the same time period found the images perplexing until they were replaced with the following:  at which point they started texting each other the answers. The camp kids then stole the control group’s cell phones and paddled them across a river in a bark canoe, where they added them to a bonfire and made s’mores. The control group appeared to be both sad and angry, but having no way to communicate these feelings, they just went home.

Charlatan’s Web

How do I know I’m a pediatrician and not a businessperson? Because when I hear that parents, kids, and coaches are more aware of sports-related concussion, I think “good news,” not, “Hmm, I wonder if I can use this trend to sell someone some useless garbage in a bottle?” Not everyone, however, is a pediatrician, and the U.S. Food and Drug Administration (FDA) has taken notice.

In an announcement last week, the FDA warned the public about unscrupulous dietary supplement companies peddling products that claim to prevent, treat, or cure concussions and traumatic brain injuries because, you know, there’s stuff that can do that. The FDA’s greatest concern is not that athletes and their families may waste money on this snake oil (Was there every a time when rusty snakes were a common problem?) but that young athletes will put themselves at risk by returning to play before they’re fully recovered, believing that they are actually protected from further brain injury. The companies, of course, have found the perfect market, since the more injured someone’s brain is, the more likely that person is to believe their claims.

I certainly hope the FDA is serious when they say they plan to take enforcement actions against these mountebanks. Or, as I say in my online French lessons, “The cow in a hat gives the monkey with a book an apple and an orange.”

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

Sometimes in life you just have to do something you’ve always wanted to do. I’ve always wanted to go to the grocery store at 1:00 a.m. in my bathrobe, drink a carton of half-and-half, and pay for it with a check, but after discussing the plan with my wife, I’m instead learning French. Online. For free. I’m sorry, my sweet crème moitié-moitié, maybe next year.

stanciuc

Bank shot

For those of us who, for whatever reason, don’t like children to get preventable deadly diseases, it’s been a depressing year. First came the news that a whooping cough outbreak in Washington state had no effect on pertussis vaccination rates there, then we learned that correcting vaccine misinformation actually makes parents less likely to protect their children than saying nothing. Finally, however, we get a ray of hope, and, like everything else in the vaccine debate, it’s confusing. Like French.

A group of researchers from Indiana appear to have cracked the code to vaccine acceptance, at least for the measles, mumps, rubella (MMR) vaccine: tell parents how the vaccine will help their children. See how simple that was, people? Any questions?

I have one: What did y’all say that we weren’t already saying?! In their Internet-based survey of 802 parents of infants, the investigators gave subjects four different messages about vaccines, all including the standard Centers for Disease Control and Prevention Vaccine Information Statement (VIS). One group got only the VIS. Another group also heard about the vaccine’s benefits to their children; a third group heard about how vaccination protects the community at large, and a fourth group heard about vaccination’s benefits both to children and to the community.

Two of those groups saw increased vaccine acceptance: the two who heard that MMR vaccines would benefit their children. In my own practice, I tend to emphasize how the MMR vaccine helps children avoid some of the common side effects of measles infection, like severe brain damage, or death, but perhaps there are some benefits I’ve been missing. Does the MMR vaccine, say, improve your complexion, burn fat without diet or exercise, or make it easier to learn a foreign language? If so, then I may be due for a booster. 

Take a hike 

There is good news from the world of summer camp, and it has nothing to do with a decrease in the number of campers infected with Lyme disease since July. No, thanks to a report from a team of psychologists in Los Angeles, we now know that summer camp is where kids learn all sorts of long-forgotten skills, like how to paddle a canoe, how to start a fire, and how to read human facial expressions.

According to well-validated tests of emotional perception, kids aged 11-13 years who spent just 5 days at a summer camp without electronics saw a dramatic leap in their perception of nonverbal communications, compared with kids who did not have to trade in their iPhones for cans of concentrated DEET. A subgroup analysis that has rocked the middle school literature also demonstrated that despite being without their electronics for 5 days, none of the 51 subjects died.

Children in both groups observed photos and short videos demonstrating emotional facial expressions and body language and were then asked to describe the emotions being demonstrated. The kids who had been to camp did remarkably well on the tests. The kids who kept their electronic devices over the same time period found the images perplexing until they were replaced with the following:  at which point they started texting each other the answers. The camp kids then stole the control group’s cell phones and paddled them across a river in a bark canoe, where they added them to a bonfire and made s’mores. The control group appeared to be both sad and angry, but having no way to communicate these feelings, they just went home.

Charlatan’s Web

How do I know I’m a pediatrician and not a businessperson? Because when I hear that parents, kids, and coaches are more aware of sports-related concussion, I think “good news,” not, “Hmm, I wonder if I can use this trend to sell someone some useless garbage in a bottle?” Not everyone, however, is a pediatrician, and the U.S. Food and Drug Administration (FDA) has taken notice.

In an announcement last week, the FDA warned the public about unscrupulous dietary supplement companies peddling products that claim to prevent, treat, or cure concussions and traumatic brain injuries because, you know, there’s stuff that can do that. The FDA’s greatest concern is not that athletes and their families may waste money on this snake oil (Was there every a time when rusty snakes were a common problem?) but that young athletes will put themselves at risk by returning to play before they’re fully recovered, believing that they are actually protected from further brain injury. The companies, of course, have found the perfect market, since the more injured someone’s brain is, the more likely that person is to believe their claims.

I certainly hope the FDA is serious when they say they plan to take enforcement actions against these mountebanks. Or, as I say in my online French lessons, “The cow in a hat gives the monkey with a book an apple and an orange.”

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

Sometimes in life you just have to do something you’ve always wanted to do. I’ve always wanted to go to the grocery store at 1:00 a.m. in my bathrobe, drink a carton of half-and-half, and pay for it with a check, but after discussing the plan with my wife, I’m instead learning French. Online. For free. I’m sorry, my sweet crème moitié-moitié, maybe next year.

stanciuc

Bank shot

For those of us who, for whatever reason, don’t like children to get preventable deadly diseases, it’s been a depressing year. First came the news that a whooping cough outbreak in Washington state had no effect on pertussis vaccination rates there, then we learned that correcting vaccine misinformation actually makes parents less likely to protect their children than saying nothing. Finally, however, we get a ray of hope, and, like everything else in the vaccine debate, it’s confusing. Like French.

A group of researchers from Indiana appear to have cracked the code to vaccine acceptance, at least for the measles, mumps, rubella (MMR) vaccine: tell parents how the vaccine will help their children. See how simple that was, people? Any questions?

I have one: What did y’all say that we weren’t already saying?! In their Internet-based survey of 802 parents of infants, the investigators gave subjects four different messages about vaccines, all including the standard Centers for Disease Control and Prevention Vaccine Information Statement (VIS). One group got only the VIS. Another group also heard about the vaccine’s benefits to their children; a third group heard about how vaccination protects the community at large, and a fourth group heard about vaccination’s benefits both to children and to the community.

Two of those groups saw increased vaccine acceptance: the two who heard that MMR vaccines would benefit their children. In my own practice, I tend to emphasize how the MMR vaccine helps children avoid some of the common side effects of measles infection, like severe brain damage, or death, but perhaps there are some benefits I’ve been missing. Does the MMR vaccine, say, improve your complexion, burn fat without diet or exercise, or make it easier to learn a foreign language? If so, then I may be due for a booster. 

Take a hike 

There is good news from the world of summer camp, and it has nothing to do with a decrease in the number of campers infected with Lyme disease since July. No, thanks to a report from a team of psychologists in Los Angeles, we now know that summer camp is where kids learn all sorts of long-forgotten skills, like how to paddle a canoe, how to start a fire, and how to read human facial expressions.

According to well-validated tests of emotional perception, kids aged 11-13 years who spent just 5 days at a summer camp without electronics saw a dramatic leap in their perception of nonverbal communications, compared with kids who did not have to trade in their iPhones for cans of concentrated DEET. A subgroup analysis that has rocked the middle school literature also demonstrated that despite being without their electronics for 5 days, none of the 51 subjects died.

Children in both groups observed photos and short videos demonstrating emotional facial expressions and body language and were then asked to describe the emotions being demonstrated. The kids who had been to camp did remarkably well on the tests. The kids who kept their electronic devices over the same time period found the images perplexing until they were replaced with the following:  at which point they started texting each other the answers. The camp kids then stole the control group’s cell phones and paddled them across a river in a bark canoe, where they added them to a bonfire and made s’mores. The control group appeared to be both sad and angry, but having no way to communicate these feelings, they just went home.

Charlatan’s Web

How do I know I’m a pediatrician and not a businessperson? Because when I hear that parents, kids, and coaches are more aware of sports-related concussion, I think “good news,” not, “Hmm, I wonder if I can use this trend to sell someone some useless garbage in a bottle?” Not everyone, however, is a pediatrician, and the U.S. Food and Drug Administration (FDA) has taken notice.

In an announcement last week, the FDA warned the public about unscrupulous dietary supplement companies peddling products that claim to prevent, treat, or cure concussions and traumatic brain injuries because, you know, there’s stuff that can do that. The FDA’s greatest concern is not that athletes and their families may waste money on this snake oil (Was there every a time when rusty snakes were a common problem?) but that young athletes will put themselves at risk by returning to play before they’re fully recovered, believing that they are actually protected from further brain injury. The companies, of course, have found the perfect market, since the more injured someone’s brain is, the more likely that person is to believe their claims.

I certainly hope the FDA is serious when they say they plan to take enforcement actions against these mountebanks. Or, as I say in my online French lessons, “The cow in a hat gives the monkey with a book an apple and an orange.”

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

The words "meaningful use" have been making providers cringe for more than 2 years now. Those clinicians who worked hard to demonstrate meaningful use under the stage 1 requirements now must go on to demonstrate meaningful use under the stage 2 requirements. We recently heard one of our colleagues describe stage 2 of meaningful use as reminiscent of the 1978 movie "Jaws 2," the ads for which ran with the tagline: "Just when you thought it was safe to go back in the water..."

As you may be aware, on August 29^th the Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2.  This only applies to those who have been unable to obtain the 2014-certified software in time due to vendor delays.  Unfortunately, this flexibility does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new workflows (we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility).  Regardless of stage or year, everyone is on a 90-day reporting period for 2014, but remember that 2015 will require a full year of reporting (January through December).  So even if you qualify for the flexibility and opt to stick with the Stage 1 measures, you’ll need to be ready to hit the ground running with Stage 2 as soon as the ball drops on January 1^st, 2015.

The government’s intent with the EHR incentive program is to ensure that practitioners use an EHR to do more than what could otherwise be done on a paper note. As we review the criteria that must be met for stage 2 of meaningful use, we will see the inclusion of menu items and quality measures that are aimed at enhancing actionable decision support to improve the quality of medical care, population management (even for patients who might not come in to the office), and physician-patient communication. By articulating these goals we can see that they are very different from what most practitioners perceive to be the main outcome of the meaningful use rules: the creation of a lot of unnecessary busywork in the office that yields very little benefit for practitioners or patients.

The EHR incentive program consists of three stages.

• Stage 1, which many practitioners have already accomplished and received incentive dollars for completing, focused on basic data capture.

• Stage 2, which focuses on more advanced processes including additional requirements for e-prescribing, incorporating lab results into the record, electronic transmission of patient summaries across systems, and increased patient engagement.

• Stage 3, which will utilize the processes put in place in the first two stages and focus on improved patient outcomes.

For stage 2 of meaningful use, clinicians must meet or exceed the thresholds for the 17 core objectives and 3 menu objectives, as well as report on defined Clinical Quality Measures (CQMs). Many of the objectives in stage 2 are the same as those from stage 1. Some objectives that were in the set of choices in stage 1 are now part of the mandatory core set for stage 2, required for all providers. Some objectives that were in the core set in stage 1 now have higher thresholds or percentages of patients that must meet the criteria in order to qualify for meaningful use in stage 2. The data reported to the Centers for Medicare & Medicaid Services for CQMs must originate from an EHR that has been certified for 2014 standards. This rule requires that clinicians upgrade their EHR to current technology standards, a rule that is good for EHR vendors, makes sense when we look at the system as a whole, but may be very expensive for many practitioners.

In addition to the 17 core objectives, and 3 out of 6 menu objectives, clinicians will need to report on nine CQMs. We will review the details of reporting on CQMs in next month in part 2 of our overview of Meaningful Use Stage 2.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The words "meaningful use" have been making providers cringe for more than 2 years now. Those clinicians who worked hard to demonstrate meaningful use under the stage 1 requirements now must go on to demonstrate meaningful use under the stage 2 requirements. We recently heard one of our colleagues describe stage 2 of meaningful use as reminiscent of the 1978 movie "Jaws 2," the ads for which ran with the tagline: "Just when you thought it was safe to go back in the water..."

As you may be aware, on August 29^th the Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2.  This only applies to those who have been unable to obtain the 2014-certified software in time due to vendor delays.  Unfortunately, this flexibility does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new workflows (we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility).  Regardless of stage or year, everyone is on a 90-day reporting period for 2014, but remember that 2015 will require a full year of reporting (January through December).  So even if you qualify for the flexibility and opt to stick with the Stage 1 measures, you’ll need to be ready to hit the ground running with Stage 2 as soon as the ball drops on January 1^st, 2015.

The government’s intent with the EHR incentive program is to ensure that practitioners use an EHR to do more than what could otherwise be done on a paper note. As we review the criteria that must be met for stage 2 of meaningful use, we will see the inclusion of menu items and quality measures that are aimed at enhancing actionable decision support to improve the quality of medical care, population management (even for patients who might not come in to the office), and physician-patient communication. By articulating these goals we can see that they are very different from what most practitioners perceive to be the main outcome of the meaningful use rules: the creation of a lot of unnecessary busywork in the office that yields very little benefit for practitioners or patients.

The EHR incentive program consists of three stages.

• Stage 1, which many practitioners have already accomplished and received incentive dollars for completing, focused on basic data capture.

• Stage 2, which focuses on more advanced processes including additional requirements for e-prescribing, incorporating lab results into the record, electronic transmission of patient summaries across systems, and increased patient engagement.

• Stage 3, which will utilize the processes put in place in the first two stages and focus on improved patient outcomes.

For stage 2 of meaningful use, clinicians must meet or exceed the thresholds for the 17 core objectives and 3 menu objectives, as well as report on defined Clinical Quality Measures (CQMs). Many of the objectives in stage 2 are the same as those from stage 1. Some objectives that were in the set of choices in stage 1 are now part of the mandatory core set for stage 2, required for all providers. Some objectives that were in the core set in stage 1 now have higher thresholds or percentages of patients that must meet the criteria in order to qualify for meaningful use in stage 2. The data reported to the Centers for Medicare & Medicaid Services for CQMs must originate from an EHR that has been certified for 2014 standards. This rule requires that clinicians upgrade their EHR to current technology standards, a rule that is good for EHR vendors, makes sense when we look at the system as a whole, but may be very expensive for many practitioners.

In addition to the 17 core objectives, and 3 out of 6 menu objectives, clinicians will need to report on nine CQMs. We will review the details of reporting on CQMs in next month in part 2 of our overview of Meaningful Use Stage 2.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The words "meaningful use" have been making providers cringe for more than 2 years now. Those clinicians who worked hard to demonstrate meaningful use under the stage 1 requirements now must go on to demonstrate meaningful use under the stage 2 requirements. We recently heard one of our colleagues describe stage 2 of meaningful use as reminiscent of the 1978 movie "Jaws 2," the ads for which ran with the tagline: "Just when you thought it was safe to go back in the water..."

As you may be aware, on August 29^th the Department of Health and Human Services published a final rule allowing certain eligible providers the flexibility to continue using the Stage 1 criteria for the 2014 attestation year, even if they were due to start Stage 2.  This only applies to those who have been unable to obtain the 2014-certified software in time due to vendor delays.  Unfortunately, this flexibility does not extend to those who can’t meet Stage 2 due to measure difficulty or procrastination in purchasing software or adopting new workflows (we recommend speaking with a meaningful use expert or consultant before attempting to take advantage of this flexibility).  Regardless of stage or year, everyone is on a 90-day reporting period for 2014, but remember that 2015 will require a full year of reporting (January through December).  So even if you qualify for the flexibility and opt to stick with the Stage 1 measures, you’ll need to be ready to hit the ground running with Stage 2 as soon as the ball drops on January 1^st, 2015.

The government’s intent with the EHR incentive program is to ensure that practitioners use an EHR to do more than what could otherwise be done on a paper note. As we review the criteria that must be met for stage 2 of meaningful use, we will see the inclusion of menu items and quality measures that are aimed at enhancing actionable decision support to improve the quality of medical care, population management (even for patients who might not come in to the office), and physician-patient communication. By articulating these goals we can see that they are very different from what most practitioners perceive to be the main outcome of the meaningful use rules: the creation of a lot of unnecessary busywork in the office that yields very little benefit for practitioners or patients.

The EHR incentive program consists of three stages.

• Stage 1, which many practitioners have already accomplished and received incentive dollars for completing, focused on basic data capture.

• Stage 2, which focuses on more advanced processes including additional requirements for e-prescribing, incorporating lab results into the record, electronic transmission of patient summaries across systems, and increased patient engagement.

• Stage 3, which will utilize the processes put in place in the first two stages and focus on improved patient outcomes.

For stage 2 of meaningful use, clinicians must meet or exceed the thresholds for the 17 core objectives and 3 menu objectives, as well as report on defined Clinical Quality Measures (CQMs). Many of the objectives in stage 2 are the same as those from stage 1. Some objectives that were in the set of choices in stage 1 are now part of the mandatory core set for stage 2, required for all providers. Some objectives that were in the core set in stage 1 now have higher thresholds or percentages of patients that must meet the criteria in order to qualify for meaningful use in stage 2. The data reported to the Centers for Medicare & Medicaid Services for CQMs must originate from an EHR that has been certified for 2014 standards. This rule requires that clinicians upgrade their EHR to current technology standards, a rule that is good for EHR vendors, makes sense when we look at the system as a whole, but may be very expensive for many practitioners.

In addition to the 17 core objectives, and 3 out of 6 menu objectives, clinicians will need to report on nine CQMs. We will review the details of reporting on CQMs in next month in part 2 of our overview of Meaningful Use Stage 2.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

Atrial fibrillation is a common disorder with a lifetime prevalence of approximately 10%-15%. Risk factors include advancing age, diabetes, myocardial infarction, valvular disease, smoking, hypertension, obstructive sleep apnea, hyperthyroidism, alcohol abuse, illicit drug use, and obesity.

The diagnosis of AF should be based on the patient’s history and physical exam, including an ECG and lab work to evaluate thyroid, renal, and hepatic function, as well as a blood count. Further testing should be individualized and may include exercise testing, Holter monitoring, transesophageal echocardiogram (TEE), electrophysiology study, sleep study, or chest x-ray.

An important consideration in the approach to AF is prevention of thromboembolic events; multiple scoring systems have been developed to help stratify risk. The guideline recommends using the newer CHA2DS2-VASc scoring system, rather than the older CHADS2 scoring system, for patients with nonvalvular AF. Points are awarded as follows: congestive heart failure, 1; hypertension, 1; age of 75 years or older, 2; diabetes mellitus, 1; stroke/transient ischemic attack, 2; vascular disease (myocardial infarction, peripheral arterial disease, or aortic plaque), 1; age 65-74 years, 1; sex category (female), 1; for a maximum of 9 points. The CHA2DS2-VASc system reflects the increased risk attributed to age of 75 years or older, vascular disease, and female sex not accounted for in the CHADS2 system, and it is better than CHADS2 at discriminating among low-risk individuals. The annual risk of stroke ranges from less than 1% for a score of 0, to greater than 15% with a score of 9.

In patients with nonvalvular AF with a CHA2DS2-VASc score of 0, it is reasonable to forego antithrombotic therapy altogether. For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, it is reasonable to choose either no anticoagulation therapy or use of daily aspirin or an oral anticoagulant. For a CHA2DS2-VASc score of 2, using an oral anticoagulant is recommended, either warfarin or a newer agent – dabigatran, rivaroxaban, or apixaban. For patients who have mechanical heart valves, warfarin is the only recommended choice for anticoagulation, with dabigatran specifically noted as causing harm.

Prevention of thromboembolism is just one of the treatment goals in AF. Affected patients generally require either rate- or rhythm-control therapy. Choosing which treatment to pursue depends on multiple individualized factors. The guideline points out that over time, attempting to maintain sinus rhythm results in more hospitalizations than does therapy focused on rate control, with no decrease in mortality. The guidelines state: "Routine use of a rhythm-control strategy is not warranted for some patients." Persistent symptoms are the most important indication for a rhythm-control strategy.

If a rate-control approach is chosen, the guideline recommends choosing a beta-blocker or nondihydropyridine calcium channel blocker as first-line therapy unless contraindicated, regardless of whether the AF is paroxysmal, persistent, or permanent. The dose of these medications should be titrated according to resting heart rate. Previously a target of fewer than 80 bpm was recommended; however, findings from the RACE-II (Rate Control Efficacy in Permanent Atrial Fibrillation) trial demonstrated no higher rates of cardiovascular death, hospitalization for heart failure, stroke, embolism, bleeding, or life-threatening arrhythmic events in patients with permanent AF who were allowed a target heart rate of fewer than 110 bpm.

While it is not clear if the conclusions of the RACE-II trial are applicable to all patients, the guideline recommends that for patients with permanent AF, it is reasonable to use a goal heart rate of fewer than 110 bpm if the patient is still asymptomatic and maintains normal left ventricular function. If rate control cannot be achieved using beta-blockers or calcium channel blockers, amiodarone may be a reasonable choice.

It may be reasonable to pursue restoration of sinus rhythm in patients with persistent, bothersome symptoms, a first episode of AF, or an acute illness or event leading to the onset of AF. Other situations where a rhythm-control approach may be reasonable include young patient age, inadequate rate control despite appropriate therapy, tachycardia-mediated cardiomyopathy, or patient preference.

If considering cardioversion, the length of time the patient has been in AF is critical. If the onset of AF can be reliably pinpointed to fewer than 48 hours ago, the guideline states that cardioversion is reasonable at that point, and preprocedure anticoagulation is not necessary if the patient is at low risk for thromboembolic events. If the duration of AF is 48 hours or unknown, anticoagulation with warfarin or a newer agent for 3 weeks prior to and 4 weeks after cardioversion is recommended. Alternatively, the preprocedure period of anticoagulation can be eliminated if anticoagulation can be established and a TEE performed that shows no thrombus in the left atrium (LA) or left atrium appendage (LAA).

For patients who achieve sinus rhythm, there are several choices of antiarrhythmic agent to be considered for a rhythm-control strategy, including amiodarone, dofetilide, dronedarone, flecainide, propafenone, and sotalol. It is important to note that these medications are reasonable to continue even if the patient experiences episodes of AF, if the medication decreases the number of episodes or the symptoms associated with them. These medications should be stopped, however, if AF becomes permanent.

The bottom line

Atrial fibrillation is a common rhythm disorder that requires ongoing management of thromboembolic risk as well as adherence to either a rate-control or rhythm-control strategy. The choice for anticoagulation should be made jointly between the patient and physician, and should be based on the CHA2DS2-VASc score.

Reference

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society (Circulation 2014 March 28 [doi: 10.1161/CIR.0000000000000040]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. George-Reichley is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

Atrial fibrillation is a common disorder with a lifetime prevalence of approximately 10%-15%. Risk factors include advancing age, diabetes, myocardial infarction, valvular disease, smoking, hypertension, obstructive sleep apnea, hyperthyroidism, alcohol abuse, illicit drug use, and obesity.

The diagnosis of AF should be based on the patient’s history and physical exam, including an ECG and lab work to evaluate thyroid, renal, and hepatic function, as well as a blood count. Further testing should be individualized and may include exercise testing, Holter monitoring, transesophageal echocardiogram (TEE), electrophysiology study, sleep study, or chest x-ray.

An important consideration in the approach to AF is prevention of thromboembolic events; multiple scoring systems have been developed to help stratify risk. The guideline recommends using the newer CHA2DS2-VASc scoring system, rather than the older CHADS2 scoring system, for patients with nonvalvular AF. Points are awarded as follows: congestive heart failure, 1; hypertension, 1; age of 75 years or older, 2; diabetes mellitus, 1; stroke/transient ischemic attack, 2; vascular disease (myocardial infarction, peripheral arterial disease, or aortic plaque), 1; age 65-74 years, 1; sex category (female), 1; for a maximum of 9 points. The CHA2DS2-VASc system reflects the increased risk attributed to age of 75 years or older, vascular disease, and female sex not accounted for in the CHADS2 system, and it is better than CHADS2 at discriminating among low-risk individuals. The annual risk of stroke ranges from less than 1% for a score of 0, to greater than 15% with a score of 9.

In patients with nonvalvular AF with a CHA2DS2-VASc score of 0, it is reasonable to forego antithrombotic therapy altogether. For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, it is reasonable to choose either no anticoagulation therapy or use of daily aspirin or an oral anticoagulant. For a CHA2DS2-VASc score of 2, using an oral anticoagulant is recommended, either warfarin or a newer agent – dabigatran, rivaroxaban, or apixaban. For patients who have mechanical heart valves, warfarin is the only recommended choice for anticoagulation, with dabigatran specifically noted as causing harm.

Prevention of thromboembolism is just one of the treatment goals in AF. Affected patients generally require either rate- or rhythm-control therapy. Choosing which treatment to pursue depends on multiple individualized factors. The guideline points out that over time, attempting to maintain sinus rhythm results in more hospitalizations than does therapy focused on rate control, with no decrease in mortality. The guidelines state: "Routine use of a rhythm-control strategy is not warranted for some patients." Persistent symptoms are the most important indication for a rhythm-control strategy.

If a rate-control approach is chosen, the guideline recommends choosing a beta-blocker or nondihydropyridine calcium channel blocker as first-line therapy unless contraindicated, regardless of whether the AF is paroxysmal, persistent, or permanent. The dose of these medications should be titrated according to resting heart rate. Previously a target of fewer than 80 bpm was recommended; however, findings from the RACE-II (Rate Control Efficacy in Permanent Atrial Fibrillation) trial demonstrated no higher rates of cardiovascular death, hospitalization for heart failure, stroke, embolism, bleeding, or life-threatening arrhythmic events in patients with permanent AF who were allowed a target heart rate of fewer than 110 bpm.

While it is not clear if the conclusions of the RACE-II trial are applicable to all patients, the guideline recommends that for patients with permanent AF, it is reasonable to use a goal heart rate of fewer than 110 bpm if the patient is still asymptomatic and maintains normal left ventricular function. If rate control cannot be achieved using beta-blockers or calcium channel blockers, amiodarone may be a reasonable choice.

It may be reasonable to pursue restoration of sinus rhythm in patients with persistent, bothersome symptoms, a first episode of AF, or an acute illness or event leading to the onset of AF. Other situations where a rhythm-control approach may be reasonable include young patient age, inadequate rate control despite appropriate therapy, tachycardia-mediated cardiomyopathy, or patient preference.

If considering cardioversion, the length of time the patient has been in AF is critical. If the onset of AF can be reliably pinpointed to fewer than 48 hours ago, the guideline states that cardioversion is reasonable at that point, and preprocedure anticoagulation is not necessary if the patient is at low risk for thromboembolic events. If the duration of AF is 48 hours or unknown, anticoagulation with warfarin or a newer agent for 3 weeks prior to and 4 weeks after cardioversion is recommended. Alternatively, the preprocedure period of anticoagulation can be eliminated if anticoagulation can be established and a TEE performed that shows no thrombus in the left atrium (LA) or left atrium appendage (LAA).

For patients who achieve sinus rhythm, there are several choices of antiarrhythmic agent to be considered for a rhythm-control strategy, including amiodarone, dofetilide, dronedarone, flecainide, propafenone, and sotalol. It is important to note that these medications are reasonable to continue even if the patient experiences episodes of AF, if the medication decreases the number of episodes or the symptoms associated with them. These medications should be stopped, however, if AF becomes permanent.

The bottom line

Atrial fibrillation is a common rhythm disorder that requires ongoing management of thromboembolic risk as well as adherence to either a rate-control or rhythm-control strategy. The choice for anticoagulation should be made jointly between the patient and physician, and should be based on the CHA2DS2-VASc score.

Reference

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society (Circulation 2014 March 28 [doi: 10.1161/CIR.0000000000000040]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. George-Reichley is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

Atrial fibrillation is a common disorder with a lifetime prevalence of approximately 10%-15%. Risk factors include advancing age, diabetes, myocardial infarction, valvular disease, smoking, hypertension, obstructive sleep apnea, hyperthyroidism, alcohol abuse, illicit drug use, and obesity.

The diagnosis of AF should be based on the patient’s history and physical exam, including an ECG and lab work to evaluate thyroid, renal, and hepatic function, as well as a blood count. Further testing should be individualized and may include exercise testing, Holter monitoring, transesophageal echocardiogram (TEE), electrophysiology study, sleep study, or chest x-ray.

An important consideration in the approach to AF is prevention of thromboembolic events; multiple scoring systems have been developed to help stratify risk. The guideline recommends using the newer CHA2DS2-VASc scoring system, rather than the older CHADS2 scoring system, for patients with nonvalvular AF. Points are awarded as follows: congestive heart failure, 1; hypertension, 1; age of 75 years or older, 2; diabetes mellitus, 1; stroke/transient ischemic attack, 2; vascular disease (myocardial infarction, peripheral arterial disease, or aortic plaque), 1; age 65-74 years, 1; sex category (female), 1; for a maximum of 9 points. The CHA2DS2-VASc system reflects the increased risk attributed to age of 75 years or older, vascular disease, and female sex not accounted for in the CHADS2 system, and it is better than CHADS2 at discriminating among low-risk individuals. The annual risk of stroke ranges from less than 1% for a score of 0, to greater than 15% with a score of 9.

In patients with nonvalvular AF with a CHA2DS2-VASc score of 0, it is reasonable to forego antithrombotic therapy altogether. For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, it is reasonable to choose either no anticoagulation therapy or use of daily aspirin or an oral anticoagulant. For a CHA2DS2-VASc score of 2, using an oral anticoagulant is recommended, either warfarin or a newer agent – dabigatran, rivaroxaban, or apixaban. For patients who have mechanical heart valves, warfarin is the only recommended choice for anticoagulation, with dabigatran specifically noted as causing harm.

Prevention of thromboembolism is just one of the treatment goals in AF. Affected patients generally require either rate- or rhythm-control therapy. Choosing which treatment to pursue depends on multiple individualized factors. The guideline points out that over time, attempting to maintain sinus rhythm results in more hospitalizations than does therapy focused on rate control, with no decrease in mortality. The guidelines state: "Routine use of a rhythm-control strategy is not warranted for some patients." Persistent symptoms are the most important indication for a rhythm-control strategy.

If a rate-control approach is chosen, the guideline recommends choosing a beta-blocker or nondihydropyridine calcium channel blocker as first-line therapy unless contraindicated, regardless of whether the AF is paroxysmal, persistent, or permanent. The dose of these medications should be titrated according to resting heart rate. Previously a target of fewer than 80 bpm was recommended; however, findings from the RACE-II (Rate Control Efficacy in Permanent Atrial Fibrillation) trial demonstrated no higher rates of cardiovascular death, hospitalization for heart failure, stroke, embolism, bleeding, or life-threatening arrhythmic events in patients with permanent AF who were allowed a target heart rate of fewer than 110 bpm.

While it is not clear if the conclusions of the RACE-II trial are applicable to all patients, the guideline recommends that for patients with permanent AF, it is reasonable to use a goal heart rate of fewer than 110 bpm if the patient is still asymptomatic and maintains normal left ventricular function. If rate control cannot be achieved using beta-blockers or calcium channel blockers, amiodarone may be a reasonable choice.

It may be reasonable to pursue restoration of sinus rhythm in patients with persistent, bothersome symptoms, a first episode of AF, or an acute illness or event leading to the onset of AF. Other situations where a rhythm-control approach may be reasonable include young patient age, inadequate rate control despite appropriate therapy, tachycardia-mediated cardiomyopathy, or patient preference.

If considering cardioversion, the length of time the patient has been in AF is critical. If the onset of AF can be reliably pinpointed to fewer than 48 hours ago, the guideline states that cardioversion is reasonable at that point, and preprocedure anticoagulation is not necessary if the patient is at low risk for thromboembolic events. If the duration of AF is 48 hours or unknown, anticoagulation with warfarin or a newer agent for 3 weeks prior to and 4 weeks after cardioversion is recommended. Alternatively, the preprocedure period of anticoagulation can be eliminated if anticoagulation can be established and a TEE performed that shows no thrombus in the left atrium (LA) or left atrium appendage (LAA).

For patients who achieve sinus rhythm, there are several choices of antiarrhythmic agent to be considered for a rhythm-control strategy, including amiodarone, dofetilide, dronedarone, flecainide, propafenone, and sotalol. It is important to note that these medications are reasonable to continue even if the patient experiences episodes of AF, if the medication decreases the number of episodes or the symptoms associated with them. These medications should be stopped, however, if AF becomes permanent.

The bottom line

Atrial fibrillation is a common rhythm disorder that requires ongoing management of thromboembolic risk as well as adherence to either a rate-control or rhythm-control strategy. The choice for anticoagulation should be made jointly between the patient and physician, and should be based on the CHA2DS2-VASc score.

Reference

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society (Circulation 2014 March 28 [doi: 10.1161/CIR.0000000000000040]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. George-Reichley is a third-year resident in the family medicine residency program at Abington Memorial Hospital.

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].

I didn’t have a piggy bank when I was a child. But, I did have a bank. Instead of a porcelain porcine, my coin repository was a fiendishly designed miniature cash register. It would accept pennies, but it only acknowledged the receipt of nickels, dimes, and quarters by revealing the total amount in a window next to the register arm. It was surprisingly complex given that this was many decades prior to the invention of computer chips.

The contents only could be retrieved through a spring-loaded cash drawer that opened when the devilish instrument of torture perceived that it had been fully fed with $10 worth of silver coins. The spring that held the door tight was one tough spring. Trust me, I tried every tool on my dad’s workbench to try to open the door before it was ready. This bank demanded patience, and as a 5-year-old without an allowance, it was painful to wait and then wait and then wait some more until I had accumulated $10.

Once I was in grade school, my classmates and I opened our own accounts with a bank that provided the service to the school. I assume the bank hoped they would harvest a bountiful crop of future customers to whom they could offer mortgages and auto loans. On Wednesdays, we all arrived with our handful of coins, and the teacher recorded the amounts in our little bankbooks. I can’t recall how the interest was calculated, but we all understood that in some mysterious fashion our money was making money.

My diabolical cash register bank and my grade school bank account provided me with an introduction to the concept of saving for the future that has stayed with me to this day. It turns out that those two exercises in financial health may have contributed to my physical health.

In a recent New York Times article ("Your 401(k) Is Healthy. So Maybe You Are, Too." Aug. 16, 2014), I learned about a study published in the journal Psychological Science that found that regular contributors to their 401(k)’s were more likely to take steps to improve their health. Two business school professors at Washington University, St. Louis, studied 200 workers at an industrial laundry business. The subjects were given a baseline health evaluation that included blood tests. When the workers were informed of the results of the evaluation, they also were offered suggestions on how they could address any concerning findings. In follow-up, the regular 401(k) contributors as a group had a 27% improvement in their lab results, while noncontributors continued to suffer health declines (Psychol. Sci. 2014 June 27 [doi: 10.1177/0956797614540467]).

As a pediatrician, wouldn’t you like to know if these healthier investors were born that way? Or, were there factors in their childhood that molded them into adults who will choose to invest in the future, of both their finances and their health? We didn’t talk about money in my family as I was growing up, nor have my wife and I raised the topic with our children. But, we all fund our IRAs and try to lead healthy lifestyles. Were there subliminal messages that my parents conveyed to me and then I passed on to my children?

This country is going through a spell in which saving has slipped out of fashion. This study from St. Louis suggests that it may be linked to our difficulty in getting patients to take better care of themselves. Most of you know that we ask pediatricians to address too many issues at well-child visits. But, maybe we should begin asking every 4-year-old if he or she has a piggy bank. Maybe we even should be giving out piggy banks the way we give out children’s books, and take a moment to discuss the concept of saving. If we can convince this next generation that the future is something worth investing in now, then maybe they will be more receptive to advice about their health when they are adults.

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." E-mail him at [email protected].

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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." E-mail him at [email protected].

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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." E-mail him at [email protected].

Last week I was on the last leg of my usual three-peninsula bicycle ride. Every now and then, I turned my gaze away from the spectacular ocean scenery and looked down at the road ahead. On one of those glances, I saw a small orange, noodlelike object that seemed to move. I braked and pedaled back, and I was surprised to find it was a salamander. I had not seen an orange salamander in nearly 60 years.

There are several reasons for that 6-decade gap. First, as I approached adolescence, I spent increasingly less time poking around in the woods and along the stream beds around my home, natural habitats for salamanders. However, after I finished my training and was a few years into practice, I returned to a woodsier lifestyle, and I spent hours on my hands and knees gardening in what should have been amphibian- and reptilian-friendly environs. I occasionally saw a toad, but never a salamander. While I had been metamorphing into an adult physician, the amphibians had been suffering a serious global decline, the causes of which are still largely unknown and hotly debated.

As I continued on my ride home, my mind drifted back to my childhood and my life with reptiles and amphibians. I spent hours on solitary forays along the streams and ponds in our neighborhood, collecting specimens. Most of my buddies were doing the same. There were tadpoles in Mason jars, toads in an old cracked aquarium I got from the neighbors, and turtles in cardboard boxes and discarded dishpans. Snakes were more of a challenge to catch and house, but every now and then I got lucky. None of the inhabitants of my menagerie ever made it into our house. My mother had a few, but sensible, rules.

These animals weren’t pets. Dog and cats were pets. Amphibians and reptiles were curiosities to be observed and studied, not stroked or petted. Those that survived their brief captivities were returned to the wild.

One could buy small turtles at the pet store. At the circus, there were racks of small perforated cellophane bags for sale, in which small lizards and chameleon were encased. Even as I child I knew those poor little captives were never going to survive for long after their car ride home. No, my friends and I were into wild specimens, caught for scientific study. Although there has been a surge of health warnings about the health risks from handling reptiles and amphibians, none of us ever got salmonella poisoning. Granted, our sample size was small, but our exposure was extensive.

When I arrived home from my ride, I decided to review the Centers for Disease Control and Prevention warnings, and to look a little bit more deeply into the real risks that we had survived from our amphibian and reptilian encounters. The CDC website list of cautions and recommendations are for the most part reasonable ... and not much different from my mother’s house rules and requirements for basic hygiene.

However, I was troubled by one warning that "children younger than 5 years old ... should not handle or touch reptiles, or anything in the area where they live and roam." If my parents had followed this recommendation, they would have set me down me in front of the television and never let me play outside. No more stream side exploring, no more turning over rocks and old logs, no more building fairy houses in the mossy woods.

No distinction is made in the CDC warnings between wild and captive animals. In the little research I could find on the subject, it turns out that wild reptiles are less likely to carry and shed salmonella. A study of red-sliders, a common pet store turtle with a long rap sheet of salmonella outbreaks, could find no salmonella in the wild specimens tested. Another study found that the tadpoles they cultured had no salmonella. One author postulated that the stress of captivity renders reptiles and amphibians more vulnerable to infection, as it has been found to do in other animals.

So it turns out that, as usual, my mother was correct. Go out and explore. Don’t buy at the pet store. Don’t bring ’em into the house. Sadly, even if we are successful in getting kids off the couch and into the woods, they will be less likely to find reptiles and amphibians when they go exploring. But, I am a hopeful guy. Maybe the little orange salamander I saw is the vanguard of an amphibian return.

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." E-mail him at [email protected].

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive, and psychiatric symptoms.

Fortunately, these injuries tend to have a more favorable outcome than do more severe brain injuries, with the vast majority of patients returning to usual functioning within days to weeks, with time and a guided return-to-activity plan. However, there is a subset of patients whose symptoms persist into what has been loosely defined as postconcussive syndrome. These individuals tend to be the greatest challenge for clinicians, and usually benefit from a multidisciplinary team approach, including neurologists, neuropsychologists, physical therapists, and speech pathologists.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

Neurologic symptoms usually present as headache, light and noise sensitivity, dizziness, and balance issues. Cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion. Psychiatric symptoms often include irritability, lability, and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

The treatment strategy for managing the emotional and mental health needs of the adolescent concussion patient is dictated by the underlying etiology. It is reasonable to suspect that irritability, a short fuse, and frequent crying during the first few days following injury are a direct result of neurologic disruption, which are not amenable to reason and behavioral interventions. In these cases, the best treatment is to educate the family that this is a transient neurologic state, while ensuring that the patient is protected from environmental stressors. One analogy that parents and patients find helpful is "weathering the storm," and with time, these symptoms tend to abate. The key here is to normalize the recovery process and provide parents with a realistic recovery trajectory.

The more challenging patient is the child whose symptoms persist for weeks or develop over time, or, even more complicated, the child who had preexisting known or unknown mental health issues. A common theme in working with TBI patients is that brain injuries tend to exacerbate preexisting conditions. In these cases, good history taking is the foundation for good mental health management.

Key questions include: Is there a preexisting history of learning disability and/or attention-deficit/hyperactivity disorder (ADHD)? Are there preexisting or current family stressors? Has the child ever been in therapy before? How much school has the child missed? How has the school responded to the child missing tests and assignments? Is the child being pressured by teachers or coaches to return to activity? The answer to these and other questions will dictate how mental health issues should be addressed.

As a pediatrician, a release to talk with the school can clear up many of the return-to-activity stressors or may help to better understand the contribution of preexisting learning struggles or ADHD. Again, it is particularly important to have an awareness of premorbid history, as head injuries tend to exacerbate or accentuate preexisting symptoms. The full utility of the multidisciplinary team is accentuated in these situations, and a referral to a psychologist familiar with concussion is often the next step. Short-term medication management also may be considered, with additional referral to a psychiatrist for long-term management as necessary.

Although fairly uncommon, the circumstances of a concussion can result in posttraumatic stress disorder (PTSD) or acute stress disorder, particularly when considering that concussions do not have to result in loss of consciousness during the event. It is important to at least screen for PTSD in situations in which there is the strong potential for this (in other words, an event that involved threatened death or serious injury to self or other, was the result of an assault, and resulted in intense fear or horror). Some symptoms to look for include intense psychological distress, recurrent distressing recollection, and frequent nightmares of the event, flashbacks, hypervigilance, and exaggerated startle response, and feelings of detachment from others. If these symptoms are present, a mental health evaluation and treatment would be the next logical step.

Concussion is a relatively common occurrence in adolescence and has received increased interest in recent years. It is important for pediatricians to be aware of the neurologic, cognitive, and psychiatric/emotional symptoms of concussion and how these symptoms often overlap. The management of mental health issues in concussion depends on the stage of recovery, the impact of the concussion on academic and social functions, whether preexisting issues exist, and the circumstances of the injury. In certain situations, mental health symptoms can be headed off in the pediatrician’s office, while more complicated and protracted recoveries necessitate a multidisciplinary team that includes mental health professionals.

Dr. Romain is a neuropsychologist at the Children’s Hospital of Orange County, Calif., and was the primary author of this commentary. He provides neuropsychological evaluations at the CHOC multidisciplinary concussion clinic. Dr. Taraman is a pediatric neurologist at the hospital. Dr. Romain and Dr. Taraman said they have no relevant financial disclosures.

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive, and psychiatric symptoms.

Fortunately, these injuries tend to have a more favorable outcome than do more severe brain injuries, with the vast majority of patients returning to usual functioning within days to weeks, with time and a guided return-to-activity plan. However, there is a subset of patients whose symptoms persist into what has been loosely defined as postconcussive syndrome. These individuals tend to be the greatest challenge for clinicians, and usually benefit from a multidisciplinary team approach, including neurologists, neuropsychologists, physical therapists, and speech pathologists.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

Neurologic symptoms usually present as headache, light and noise sensitivity, dizziness, and balance issues. Cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion. Psychiatric symptoms often include irritability, lability, and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

The treatment strategy for managing the emotional and mental health needs of the adolescent concussion patient is dictated by the underlying etiology. It is reasonable to suspect that irritability, a short fuse, and frequent crying during the first few days following injury are a direct result of neurologic disruption, which are not amenable to reason and behavioral interventions. In these cases, the best treatment is to educate the family that this is a transient neurologic state, while ensuring that the patient is protected from environmental stressors. One analogy that parents and patients find helpful is "weathering the storm," and with time, these symptoms tend to abate. The key here is to normalize the recovery process and provide parents with a realistic recovery trajectory.

The more challenging patient is the child whose symptoms persist for weeks or develop over time, or, even more complicated, the child who had preexisting known or unknown mental health issues. A common theme in working with TBI patients is that brain injuries tend to exacerbate preexisting conditions. In these cases, good history taking is the foundation for good mental health management.

Key questions include: Is there a preexisting history of learning disability and/or attention-deficit/hyperactivity disorder (ADHD)? Are there preexisting or current family stressors? Has the child ever been in therapy before? How much school has the child missed? How has the school responded to the child missing tests and assignments? Is the child being pressured by teachers or coaches to return to activity? The answer to these and other questions will dictate how mental health issues should be addressed.

As a pediatrician, a release to talk with the school can clear up many of the return-to-activity stressors or may help to better understand the contribution of preexisting learning struggles or ADHD. Again, it is particularly important to have an awareness of premorbid history, as head injuries tend to exacerbate or accentuate preexisting symptoms. The full utility of the multidisciplinary team is accentuated in these situations, and a referral to a psychologist familiar with concussion is often the next step. Short-term medication management also may be considered, with additional referral to a psychiatrist for long-term management as necessary.

Although fairly uncommon, the circumstances of a concussion can result in posttraumatic stress disorder (PTSD) or acute stress disorder, particularly when considering that concussions do not have to result in loss of consciousness during the event. It is important to at least screen for PTSD in situations in which there is the strong potential for this (in other words, an event that involved threatened death or serious injury to self or other, was the result of an assault, and resulted in intense fear or horror). Some symptoms to look for include intense psychological distress, recurrent distressing recollection, and frequent nightmares of the event, flashbacks, hypervigilance, and exaggerated startle response, and feelings of detachment from others. If these symptoms are present, a mental health evaluation and treatment would be the next logical step.

Concussion is a relatively common occurrence in adolescence and has received increased interest in recent years. It is important for pediatricians to be aware of the neurologic, cognitive, and psychiatric/emotional symptoms of concussion and how these symptoms often overlap. The management of mental health issues in concussion depends on the stage of recovery, the impact of the concussion on academic and social functions, whether preexisting issues exist, and the circumstances of the injury. In certain situations, mental health symptoms can be headed off in the pediatrician’s office, while more complicated and protracted recoveries necessitate a multidisciplinary team that includes mental health professionals.

Dr. Romain is a neuropsychologist at the Children’s Hospital of Orange County, Calif., and was the primary author of this commentary. He provides neuropsychological evaluations at the CHOC multidisciplinary concussion clinic. Dr. Taraman is a pediatric neurologist at the hospital. Dr. Romain and Dr. Taraman said they have no relevant financial disclosures.

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive, and psychiatric symptoms.

Fortunately, these injuries tend to have a more favorable outcome than do more severe brain injuries, with the vast majority of patients returning to usual functioning within days to weeks, with time and a guided return-to-activity plan. However, there is a subset of patients whose symptoms persist into what has been loosely defined as postconcussive syndrome. These individuals tend to be the greatest challenge for clinicians, and usually benefit from a multidisciplinary team approach, including neurologists, neuropsychologists, physical therapists, and speech pathologists.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

Neurologic symptoms usually present as headache, light and noise sensitivity, dizziness, and balance issues. Cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion. Psychiatric symptoms often include irritability, lability, and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

The treatment strategy for managing the emotional and mental health needs of the adolescent concussion patient is dictated by the underlying etiology. It is reasonable to suspect that irritability, a short fuse, and frequent crying during the first few days following injury are a direct result of neurologic disruption, which are not amenable to reason and behavioral interventions. In these cases, the best treatment is to educate the family that this is a transient neurologic state, while ensuring that the patient is protected from environmental stressors. One analogy that parents and patients find helpful is "weathering the storm," and with time, these symptoms tend to abate. The key here is to normalize the recovery process and provide parents with a realistic recovery trajectory.

The more challenging patient is the child whose symptoms persist for weeks or develop over time, or, even more complicated, the child who had preexisting known or unknown mental health issues. A common theme in working with TBI patients is that brain injuries tend to exacerbate preexisting conditions. In these cases, good history taking is the foundation for good mental health management.

Key questions include: Is there a preexisting history of learning disability and/or attention-deficit/hyperactivity disorder (ADHD)? Are there preexisting or current family stressors? Has the child ever been in therapy before? How much school has the child missed? How has the school responded to the child missing tests and assignments? Is the child being pressured by teachers or coaches to return to activity? The answer to these and other questions will dictate how mental health issues should be addressed.

As a pediatrician, a release to talk with the school can clear up many of the return-to-activity stressors or may help to better understand the contribution of preexisting learning struggles or ADHD. Again, it is particularly important to have an awareness of premorbid history, as head injuries tend to exacerbate or accentuate preexisting symptoms. The full utility of the multidisciplinary team is accentuated in these situations, and a referral to a psychologist familiar with concussion is often the next step. Short-term medication management also may be considered, with additional referral to a psychiatrist for long-term management as necessary.

Although fairly uncommon, the circumstances of a concussion can result in posttraumatic stress disorder (PTSD) or acute stress disorder, particularly when considering that concussions do not have to result in loss of consciousness during the event. It is important to at least screen for PTSD in situations in which there is the strong potential for this (in other words, an event that involved threatened death or serious injury to self or other, was the result of an assault, and resulted in intense fear or horror). Some symptoms to look for include intense psychological distress, recurrent distressing recollection, and frequent nightmares of the event, flashbacks, hypervigilance, and exaggerated startle response, and feelings of detachment from others. If these symptoms are present, a mental health evaluation and treatment would be the next logical step.

Concussion is a relatively common occurrence in adolescence and has received increased interest in recent years. It is important for pediatricians to be aware of the neurologic, cognitive, and psychiatric/emotional symptoms of concussion and how these symptoms often overlap. The management of mental health issues in concussion depends on the stage of recovery, the impact of the concussion on academic and social functions, whether preexisting issues exist, and the circumstances of the injury. In certain situations, mental health symptoms can be headed off in the pediatrician’s office, while more complicated and protracted recoveries necessitate a multidisciplinary team that includes mental health professionals.

Dr. Romain is a neuropsychologist at the Children’s Hospital of Orange County, Calif., and was the primary author of this commentary. He provides neuropsychological evaluations at the CHOC multidisciplinary concussion clinic. Dr. Taraman is a pediatric neurologist at the hospital. Dr. Romain and Dr. Taraman said they have no relevant financial disclosures.

It is such a common situation that you would think it would be a cut-and-dried decision. But in some ways it reflects at the core of medical professionalism. A 2-month-old infant presents to the emergency department with a 101.6° F fever. The history provides no hint at a specific diagnosis and the physical exam is unremarkable with a well-appearing baby. I’ve been using the Rochester criteria in this situation for nigh on 20 years. I need a CBC and urinalysis. Then I can decide on whether to do a lumbar puncture. The mother, however, resists the idea of doing a catheter for a urine sample. Now what?

The merits of bagged vs. catheter urine specimens have been debated for decades. In the United States, the experts have been in agreement for many years that catheter specimens are recommended.

My cause for skepticism has been that experts elsewhere have made contrary recommendations.

For many illnesses, I find the online resources of the Royal Children’s Hospital in Melbourne to be very helpful because they are so specific yet thorough, including those for urinary tract infections (UTIs).

Those guidelines were last updated in 2011. These are only two pages of bulleted items, so I strongly recommend reading them. You may find them eye opening. Those guidelines believe suprapubic aspiration remains the preferred method, at least in sick children. They also state that there is no indication for culture of urine from a bag specimen.

In Britain, the National Institute for Health and Care Excellence (NICE) guidelines have taken another approach. For them, "Noninvasive methods such as pads or bags should be used before trying to gain a sample by invasive methods," such as catheter or suprapubic aspiration. Those were 2007 NICE guidelines, referenced and reaffirmed in a 2013 guideline at the Royal Cornwall Hospitals Trust.

The British also have a protocol in which the baby is left undiapered and a parent waits to catch the urine in a sterile cup with the next void.

Furthermore, at least in the recent past, decisions in Britain about treating UTIs often were made based on dipstick alone if the child was well appearing. This made sterile collection less stringent. The costs of culture were thought excessive, compared with the improvement in accuracy of the diagnosis. This was analogous to the ongoing debate over whether to always test for strep throats before treating vs. treating empirically. The United States has moved strongly in the other direction. The 2011 American Academy of Pediatrics guidelines now require both a positive culture and a positive urinalysis to diagnose a UTI (Pediatrics 2011;128:595-610).

Why this difference? Because the diagnosis of a UTI in a young child in the United States under the now-discredited 1999 guidelines led to unnecessary admissions, intravenous therapy, renal ultrasounds, repeated voiding cystourethrograms, and long-term antibiotic prophylaxis. Invasive overtreatment certainly can be used to justify overly invasive diagnostic tests. The wiser course would be to stop the overtreatment.

All this knowledge and perspective didn’t help me in the ED with this mother. I suggested that to a control-freak toddler wearing a urine bag can be perceived as at least as invasive as the quick catheterization. I was not persuasive. Fortunately, the ED was empty at 3 a.m. So, if mom wanted to spend those extra 3 hours waiting for the child to pee into a bag, I could accommodate her autonomy.

My colleagues have differing opinions on what to do in this situation. One is a strong advocate for evidence-based medicine (EBM). Because the guidelines state that catheterization is the recommended method, he would argue that that is the only option that should be presented to the parent. That emphasis on EBM becomes his definition of professionalism. Other colleagues are less dogmatic. They will point out that at 10 p.m. with all the ED rooms full and the waiting room overflowing, accommodating this situation would be more problematic.

I think my experiences working in so many different parts of the country have shaped me to value flexibility and accommodation. I’ve seen many situations where differing locations are dogmatic in differing directions in how the local doctors believe care should be delivered. I’ve also anxiously received minor medical treatment while overseas when I didn’t speak the local language, so the phrase "delivering care" is a particularly meaningful concept.

I think I could have used my knowledge and status to bully this mother into permitting her infant to be catheterized. Perhaps that is the scientifically ideal approach. I worry, though, that it would not be the most compassionate approach. The risk to the infant in both scenarios is very small. So to me, it wasn’t a choice of catheter vs. bag. It was a choice of expressing compassion rather than expertise.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. 

It is such a common situation that you would think it would be a cut-and-dried decision. But in some ways it reflects at the core of medical professionalism. A 2-month-old infant presents to the emergency department with a 101.6° F fever. The history provides no hint at a specific diagnosis and the physical exam is unremarkable with a well-appearing baby. I’ve been using the Rochester criteria in this situation for nigh on 20 years. I need a CBC and urinalysis. Then I can decide on whether to do a lumbar puncture. The mother, however, resists the idea of doing a catheter for a urine sample. Now what?

The merits of bagged vs. catheter urine specimens have been debated for decades. In the United States, the experts have been in agreement for many years that catheter specimens are recommended.

My cause for skepticism has been that experts elsewhere have made contrary recommendations.

For many illnesses, I find the online resources of the Royal Children’s Hospital in Melbourne to be very helpful because they are so specific yet thorough, including those for urinary tract infections (UTIs).

Those guidelines were last updated in 2011. These are only two pages of bulleted items, so I strongly recommend reading them. You may find them eye opening. Those guidelines believe suprapubic aspiration remains the preferred method, at least in sick children. They also state that there is no indication for culture of urine from a bag specimen.

In Britain, the National Institute for Health and Care Excellence (NICE) guidelines have taken another approach. For them, "Noninvasive methods such as pads or bags should be used before trying to gain a sample by invasive methods," such as catheter or suprapubic aspiration. Those were 2007 NICE guidelines, referenced and reaffirmed in a 2013 guideline at the Royal Cornwall Hospitals Trust.

The British also have a protocol in which the baby is left undiapered and a parent waits to catch the urine in a sterile cup with the next void.

Furthermore, at least in the recent past, decisions in Britain about treating UTIs often were made based on dipstick alone if the child was well appearing. This made sterile collection less stringent. The costs of culture were thought excessive, compared with the improvement in accuracy of the diagnosis. This was analogous to the ongoing debate over whether to always test for strep throats before treating vs. treating empirically. The United States has moved strongly in the other direction. The 2011 American Academy of Pediatrics guidelines now require both a positive culture and a positive urinalysis to diagnose a UTI (Pediatrics 2011;128:595-610).

Why this difference? Because the diagnosis of a UTI in a young child in the United States under the now-discredited 1999 guidelines led to unnecessary admissions, intravenous therapy, renal ultrasounds, repeated voiding cystourethrograms, and long-term antibiotic prophylaxis. Invasive overtreatment certainly can be used to justify overly invasive diagnostic tests. The wiser course would be to stop the overtreatment.

All this knowledge and perspective didn’t help me in the ED with this mother. I suggested that to a control-freak toddler wearing a urine bag can be perceived as at least as invasive as the quick catheterization. I was not persuasive. Fortunately, the ED was empty at 3 a.m. So, if mom wanted to spend those extra 3 hours waiting for the child to pee into a bag, I could accommodate her autonomy.

My colleagues have differing opinions on what to do in this situation. One is a strong advocate for evidence-based medicine (EBM). Because the guidelines state that catheterization is the recommended method, he would argue that that is the only option that should be presented to the parent. That emphasis on EBM becomes his definition of professionalism. Other colleagues are less dogmatic. They will point out that at 10 p.m. with all the ED rooms full and the waiting room overflowing, accommodating this situation would be more problematic.

I think my experiences working in so many different parts of the country have shaped me to value flexibility and accommodation. I’ve seen many situations where differing locations are dogmatic in differing directions in how the local doctors believe care should be delivered. I’ve also anxiously received minor medical treatment while overseas when I didn’t speak the local language, so the phrase "delivering care" is a particularly meaningful concept.

I think I could have used my knowledge and status to bully this mother into permitting her infant to be catheterized. Perhaps that is the scientifically ideal approach. I worry, though, that it would not be the most compassionate approach. The risk to the infant in both scenarios is very small. So to me, it wasn’t a choice of catheter vs. bag. It was a choice of expressing compassion rather than expertise.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. 

It is such a common situation that you would think it would be a cut-and-dried decision. But in some ways it reflects at the core of medical professionalism. A 2-month-old infant presents to the emergency department with a 101.6° F fever. The history provides no hint at a specific diagnosis and the physical exam is unremarkable with a well-appearing baby. I’ve been using the Rochester criteria in this situation for nigh on 20 years. I need a CBC and urinalysis. Then I can decide on whether to do a lumbar puncture. The mother, however, resists the idea of doing a catheter for a urine sample. Now what?

The merits of bagged vs. catheter urine specimens have been debated for decades. In the United States, the experts have been in agreement for many years that catheter specimens are recommended.

My cause for skepticism has been that experts elsewhere have made contrary recommendations.

For many illnesses, I find the online resources of the Royal Children’s Hospital in Melbourne to be very helpful because they are so specific yet thorough, including those for urinary tract infections (UTIs).

Those guidelines were last updated in 2011. These are only two pages of bulleted items, so I strongly recommend reading them. You may find them eye opening. Those guidelines believe suprapubic aspiration remains the preferred method, at least in sick children. They also state that there is no indication for culture of urine from a bag specimen.

In Britain, the National Institute for Health and Care Excellence (NICE) guidelines have taken another approach. For them, "Noninvasive methods such as pads or bags should be used before trying to gain a sample by invasive methods," such as catheter or suprapubic aspiration. Those were 2007 NICE guidelines, referenced and reaffirmed in a 2013 guideline at the Royal Cornwall Hospitals Trust.

The British also have a protocol in which the baby is left undiapered and a parent waits to catch the urine in a sterile cup with the next void.

Furthermore, at least in the recent past, decisions in Britain about treating UTIs often were made based on dipstick alone if the child was well appearing. This made sterile collection less stringent. The costs of culture were thought excessive, compared with the improvement in accuracy of the diagnosis. This was analogous to the ongoing debate over whether to always test for strep throats before treating vs. treating empirically. The United States has moved strongly in the other direction. The 2011 American Academy of Pediatrics guidelines now require both a positive culture and a positive urinalysis to diagnose a UTI (Pediatrics 2011;128:595-610).

Why this difference? Because the diagnosis of a UTI in a young child in the United States under the now-discredited 1999 guidelines led to unnecessary admissions, intravenous therapy, renal ultrasounds, repeated voiding cystourethrograms, and long-term antibiotic prophylaxis. Invasive overtreatment certainly can be used to justify overly invasive diagnostic tests. The wiser course would be to stop the overtreatment.

All this knowledge and perspective didn’t help me in the ED with this mother. I suggested that to a control-freak toddler wearing a urine bag can be perceived as at least as invasive as the quick catheterization. I was not persuasive. Fortunately, the ED was empty at 3 a.m. So, if mom wanted to spend those extra 3 hours waiting for the child to pee into a bag, I could accommodate her autonomy.

My colleagues have differing opinions on what to do in this situation. One is a strong advocate for evidence-based medicine (EBM). Because the guidelines state that catheterization is the recommended method, he would argue that that is the only option that should be presented to the parent. That emphasis on EBM becomes his definition of professionalism. Other colleagues are less dogmatic. They will point out that at 10 p.m. with all the ED rooms full and the waiting room overflowing, accommodating this situation would be more problematic.

I think my experiences working in so many different parts of the country have shaped me to value flexibility and accommodation. I’ve seen many situations where differing locations are dogmatic in differing directions in how the local doctors believe care should be delivered. I’ve also anxiously received minor medical treatment while overseas when I didn’t speak the local language, so the phrase "delivering care" is a particularly meaningful concept.

I think I could have used my knowledge and status to bully this mother into permitting her infant to be catheterized. Perhaps that is the scientifically ideal approach. I worry, though, that it would not be the most compassionate approach. The risk to the infant in both scenarios is very small. So to me, it wasn’t a choice of catheter vs. bag. It was a choice of expressing compassion rather than expertise.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Dr. Powell said he had no relevant financial disclosures. 

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

This month marks the 100th consecutive month of EM editorials. The accompanying editorial was written for EM way back in 1986, when, as a member of EM’s editorial board, I was asked to inaugurate a series of editorial/viewpoints by board members on the issues that “boiled to the surface” at the time. I chose to write about the relatively new and frightening epidemic of HIV infections and AIDS overwhelming EDs across the country. At that time, AIDS was a lethal illness accompanied by fears that it could accidentally spread to health care workers by needle sticks etc.

Predicting the future is a risky exercise but, young and undaunted, I wondered if we would have a vaccine in 3 to 5 years, a cure in 5 to 10 years, and by the latter, “cure cancer.” Though none of these possibilities actually occurred, by the beginning of the 21^st century AIDS had been transformed into a chronic and mostly manageable illness—at least in the compliant patient. But in the years since 1986, we have indeed seen rapid scientific advances in identification of causative agents, followed by accurate tests for infection, and effective treatments or vaccines—all of which helped prevent the spread of SARS and other potentially lethal infections. In terms of outcome, not a bad forecast for 1986, though it would be more than 20 years before EM asked me to write another editorial!

Also next month, readers will be introduced to several new EM Advisory Board members who have achieved national recognition for their work in newer EM disciplines such as prehospital care, critical care, geriatric emergency medicine, wilderness medicine, and bedside ultrasonography.

Emergency Medicine, the first and oldest publication devoted to our specialty since 1969, continues to be the newest!

We live in a time when the meanings of words often change dramatically—when bad sometimes means good and “cutting up” more often refers to a way of attempting suicide rather than to clowning around. In the 1982 edition of The American Heritage Dictionary you’ll find the entry: “aid (ad) v. aid-ed, aid-ing, aids. –intr. To help: assist. –tr. To give help or assistance to. –n.  1. The act or result of helping; assistance 2. One that helps; an assistant or helper …” But who among us will ever again be comforted by the prospect of assistance upon hearing the word “aids”? Today, we immediately think of AIDS, the acronym for acquired immunodeficiency syndrome.

Until very recently, AIDS was neither a word nor a recognized disease. Then—as noted in the article “AIDS on the Frontline” [June 1981 issue of EM], the CDC’s Morbidity and mortality Weekly Report described a cluster of cases of Pneumocystis carinii pneumonia, candidiasis, and cytomegalovirus infections occurring in young homosexual men. In November of [1981], the first of many articles on various aspects of AIDS appeared in EM and was entitled “The Riddle of Kaposi’s Sarcoma.”

Those initial reports proved to be the tip of the iceberg. Since 1981, both the tip and the iceberg have become much larger. One current estimate suggests that half of the approximately 2,550,000 intravenous drug users in the Northeast may now have a positive HTLV-III (HIV) antibody blood test, indicating exposure to the virus. Another estimate suggests that 5% or more of those with positive blood tests will eventually be stricken with AIDS, while even more may be afflicted with AIDS-related complex, or ARC—another word that used to mean something else.

If one were asked to choose the half-dozen most significant events of [the 20^th] century, along with the world at war, the theory of relativity and development of nuclear weapons, the use of antibiotics and vaccines, and the widespread employment of effective birth control methods, one would now have to include the phenomenon of AIDS—“phenomenon” because it remains to be seen whether by the end of the century it will be listed as “the AIDS epidemic and cure.” Whatever the outcome, AIDS is the scientific, clinical, and bioethical challenge to the medical profession in the last quarter of the 20^th century.

The challenge is enormous. During our medical school training and clinical practice did we have any real understanding of what is was like to be physicians during an epidemic such as plague, the catastrophic influenza of 1918-19, or smallpox? We will probably learn. Did we consider how to negotiate the impossible demands by the public for the absolute truth—including our admission of vast areas of scientific ignorance—on the one hand, and their equally insistent demands for guarantees and reassurance beyond the limits of current scientific knowledge on the other? We do every day, now.

The ironies of AIDS are incredible. Until a few years ago, we were struggling along “just” trying to come up with a cure (cures) for cancer, when suddenly the struggle became a science-fiction nightmare no one would have believed possible: an infectious disease that causes cancer, spread both sexually and intravenously. And yet while the problem itself has grown, the scientific advances toward a solution have also been progressing in an incredibly short period of time—identification of an etiologic organism followed by a blood test indicating exposure in just a few years.

If we could consider the scientific advances alone, we could all stand around and justifiably congratulate ourselves. But of course, the advances are overshadowed by the disease itself. Will a vaccine be available in 3 to 5 years? A cure in 5 to 10? Will we ultimately cure cancer in curing AIDS? Or will we see a new “Darwinian selection” of the biologically fittest?

To get to the year 2000, we will have to continue to set aside nuclear weapons, effectively balance the world population with the world food supply, and cure or control AIDS and any similar new disease that may develop. To get to 1987, those of us who deal with medical emergencies daily will have to treat the complications of AIDS with the medications and antibiotics available, counsel our patients as best we can, reassure the public to the limits of current scientific knowledge, and neither panic ourselves nor become complacent in handling the needles and biological material that are part of everyday patient care.

It almost makes one long for the “good old days” of the 1970s, when aids were aids and the practice of medicine seemed so much simpler.

—Neal Flomenbaum, MD, New York

We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”

Case series can lead us astray, but on the other hand, they can be the first step in medical breakthroughs. I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.

On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,² and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.³

In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.

In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.

We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”

We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”

Case series can lead us astray, but on the other hand, they can be the first step in medical breakthroughs. I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.

On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,² and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.³

In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.

In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.

We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”

We can all agree that this study is not the definitive study of this highly restrictive vegetarian diet. It is a case series of highly motivated patients, and we do not know how these findings would apply to others. Dr. Esselstyn and his colleagues admit that “(w)ithout a control group, it is challenging to establish causality and assess how much of the observed changes are specifically due to the diet.”

Case series can lead us astray, but on the other hand, they can be the first step in medical breakthroughs. I think we can agree, too, that case series can lead us astray. A good example is the randomized trials of knee arthroscopy for relief of knee pain from meniscal tears that found lack of benefit compared to earlier case series that showed significant improvement (see “Surgery for persistent knee pain? Not so fast”). In a case series, it is not possible to answer the important question: compared to what? Without a control group and randomization, we cannot know if outcomes are due to the treatment, another factor, or the natural course of the disease.

On the other hand, case series can be the first step in medical breakthroughs. The first known successful trial of penicillin was a case series of 5 patients with eye infections performed in 1930,² and the first published description of acquired immunodeficiency syndrome involved case reports of 5 patients with pneumocystis carinii pneumonia.³

In the present case, I was intrigued by Dr. Esselstyn’s findings and believe the methods and biological plausibility were good enough to get the word out, mostly to stimulate others’ thinking and actions. That is why, after the manuscript underwent peer review, we decided to publish it.

In a separate letter to me, Dr. Silverstein wrote, “Sometimes if something seems too good to be true, it isn’t [true].” I could not agree more. But the flip side of that statement is that sometimes something that seems too good to be true, actually is true.

We do not yet know which of these statements applies to Dr. Esselstyn’s work. I do, however, agree with Dr. Esselstyn and his colleagues that “...the time is right for a controlled trial.”