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Clamantis in deserto
Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.
In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?
I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.
Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.
But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.
To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.
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].
Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.
In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?
I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.
Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.
But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.
To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.
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].
Actually the complete phrase is "vox clamantis in deserto," and it is the motto of my alma mater. We were told as freshmen that it translated as "a voice crying in the wilderness" – which prior to the Internet, cheap long distance rates, and Interstate 89 seemed to be an apt description of my situation. The words resurfaced in my consciousness a few months ago when I met one of the regular readers of this column. A man of my vintage, he observed that over the 40-plus years he had been in practice, parents had grown increasingly less interested in his views on health and child rearing. He asked if I had experienced the same phenomenon.
In other words, he wondered if we both had become just voices crying in the wilderness. As we discussed his observation in more depth, it became clear that he wasn’t talking about the age-old phenomenon in which young people begin to tune out their elders who have persisted in palavering the same old "when-I-was-your-age" bologna. No, his question was more general. Is anyone listening to what pediatricians of any age are saying? Are our opinions less valued than they were 40 years ago? If our audience is less attentive, then why?
I agree that it does feel like, over the last 40 years, parents are less influenced by our opinions and are using increasing amounts of salt when they do listen. One only needs to consider the issue of vaccine refusal to appreciate that our advice often goes unheeded with potentially dangerous consequences.
Is the muting of our voices simply an example of dilution? Fifty years ago, pediatricians didn’t have much competition for the ears of new parents. There were Ben Spock and the always to be reckoned with army of grandmothers. Yes, there were magazines for parents, but they paled in comparison to the profusion of websites, blogs, and chat rooms that offer advice of varying quality just a mouse click away. Now we share the stage with anyone who cares to venture an opinion on health or parenting. No wonder we have trouble having our voices heard over the cacophony.
But, the din from the media is only part of the problem. I’m not sure exactly why, but over the last several decades, science has lost its mojo. Some of it has to do with the ease with which junk science can find an audience. Some of it is fallout from an educational system that is trying to regain its legs. While a good physician is more of an artist than a scientist, we were all trained as scientists. And, the public sees us as scientists, and as such, we are vulnerable to being painted with the same broad brush strokes of the antiscience folks.
To some degree we have been guilty of diluting our own messages. The trend toward health maintenance visits that are scripted by committee has done little to encourage parents to ask the questions about which they are most concerned. If we return to a model in which the patient or the parent is in the driver’s seat, we may start hearing more questions and discover our answers are given more consideration.
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].
EHR Report: Across the ages
Eighty percent of physicians are now using electronic health records in their offices. We have been impressed that the younger physicians to whom we have spoken often view their experience with EHRs very differently from older physicians. Is such a difference inevitable, perhaps, not just because change is more difficult for many people as they get older but also because expectations are influenced by experience. Noticing these different thoughts and feelings, we’ve asked two physicians more than 55 years old and two younger physicians to share some thoughts on their experiences with electronic records.
Mathew Clark (family physician)
I’ve been in practice for 31 years and using an EHR system for just under 5. I’m not thrilled with it, but I accept that it’s an unavoidable part of my practice now, and so I don’t waste energy being upset about it. I’ve learned to function efficiently with an EHR, doing the best I can. I remember physicians, before the days of SOAP notes, who would write pithy, useful notes such as "probable strep, Pen VK 500 bid for 10 days" on 3x5 index cards. Such notes lacked detail, and it’s not hard to imagine the problems this lack of detail might create, but they were readable at a glance, and told you what you needed to know. On the other hand, the massively detailed, bloated notes we see with our EHRs, obscured by "copy-forward" text and fictional (in other words, never really asked or examined) information, present very significant practical and legal issues of their own, and take hours of physician time to complete. Given a choice, I’d probably go for the index cards.
Natalie McGann (family physician)
I have been a family physician in practice for 4 years since graduating from residency. The advent of the EHR hasn’t been an overwhelming transition for those of us in the early stages of our careers. Much of our schooling to date has included laptops and other electronic devices that for many prove an easier means of communication. Despite that fact that EHRs require a host of extraneous clicks and check boxes, it is still less cumbersome than documenting encounters on paper. For the generation of young physicians accustomed to having answers at their fingertips, the idea of flipping through paper charts to collate a patient’s medical record seems far more complicated than clicking a few tabs without ever leaving your chair. I, and most colleagues in my peer group to whom I’ve spoken, agree that we would not be likely to a join a practice that doesn’t utilize an EHR or have a current plan to adopt one. Anything less would feel like a step back at this point.
Danielle Carcia (intern, family medicine residency)
Overall, I enjoy using electronic medical records. I feel that it places all pertinent information about the patient in an easy-to-follow and concise manner. The ability to read through past providers and even at times specialists visits with a patient can be very helpful when navigating an appointment with a new patient. As a young physician, electronics have been an extension of myself for my entire adult life, so a computer in front of me during an office visit is comforting. I do not feel it distracts from my interaction with patients, or takes away from their experience at all, just the opposite, it allows me to more confidently care for them with up to date, and organized information at my fingertips.
Dave Depietro (family physician)
I have been a family physician for 25 years and feel that the EHRs have affected my office in a number of ways. It has definitely improved the efficacy of office tasks such as doing prescription refills, interoffice communication, and scheduling. Also before EHRs, the turnaround time for a dictated note was about a week, and now most notes are completed by the end of the day. This makes it easier if I am taking care of one of my partner’s patients or dealing with a patient I recently saw. Also in this day of pay for performance we can now gather data much easier. This would be almost impossible to do if we still had paper charts.
EHRs unfortunately also have their downsides. The main problem I see is that they add a significant amount of time for providers to complete tasks. When I dictated a note, I could have completed a note within 1-2 minutes where now with EHRs, it can take maybe 3-5 minutes/patient. Also to approve labs, x-rays, etc. it just takes longer. I feel that EHRs have added about 1½ hr to my day. I feel most of my colleagues have the same complaint. They routinely take work home at night and spend 1-2 hours at home completing notes. Many of my peers seem stressed and frustrated. Even though EHRs make the office more efficient, I feel that the provider pays the price. My other complaint is the cost of IT support to keep the EHRs running smoothly. The promise of EHRs is that they would save physicians’ money and reduce staffing, however I have not seen that happen.
I ask myself, at the end of the day, would I go back to paper charts? The answer is no. Despite their downsides, I feel that the positives of EHRs outweigh the negatives. Older doctors just need to adapt to this new way of practicing medicine.
The Bottom Line
Clearly there is a range of opinion about the effect of electronic health records on our practices and our lives, with those opinions at least partly segregated by age. We are interested in your thoughts and plan to publish some of those thoughts in future columns, so please let us know at [email protected]. Thanks.
Dr. Notte is a family physician and clinical informaticist for Abington 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 (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.
Eighty percent of physicians are now using electronic health records in their offices. We have been impressed that the younger physicians to whom we have spoken often view their experience with EHRs very differently from older physicians. Is such a difference inevitable, perhaps, not just because change is more difficult for many people as they get older but also because expectations are influenced by experience. Noticing these different thoughts and feelings, we’ve asked two physicians more than 55 years old and two younger physicians to share some thoughts on their experiences with electronic records.
Mathew Clark (family physician)
I’ve been in practice for 31 years and using an EHR system for just under 5. I’m not thrilled with it, but I accept that it’s an unavoidable part of my practice now, and so I don’t waste energy being upset about it. I’ve learned to function efficiently with an EHR, doing the best I can. I remember physicians, before the days of SOAP notes, who would write pithy, useful notes such as "probable strep, Pen VK 500 bid for 10 days" on 3x5 index cards. Such notes lacked detail, and it’s not hard to imagine the problems this lack of detail might create, but they were readable at a glance, and told you what you needed to know. On the other hand, the massively detailed, bloated notes we see with our EHRs, obscured by "copy-forward" text and fictional (in other words, never really asked or examined) information, present very significant practical and legal issues of their own, and take hours of physician time to complete. Given a choice, I’d probably go for the index cards.
Natalie McGann (family physician)
I have been a family physician in practice for 4 years since graduating from residency. The advent of the EHR hasn’t been an overwhelming transition for those of us in the early stages of our careers. Much of our schooling to date has included laptops and other electronic devices that for many prove an easier means of communication. Despite that fact that EHRs require a host of extraneous clicks and check boxes, it is still less cumbersome than documenting encounters on paper. For the generation of young physicians accustomed to having answers at their fingertips, the idea of flipping through paper charts to collate a patient’s medical record seems far more complicated than clicking a few tabs without ever leaving your chair. I, and most colleagues in my peer group to whom I’ve spoken, agree that we would not be likely to a join a practice that doesn’t utilize an EHR or have a current plan to adopt one. Anything less would feel like a step back at this point.
Danielle Carcia (intern, family medicine residency)
Overall, I enjoy using electronic medical records. I feel that it places all pertinent information about the patient in an easy-to-follow and concise manner. The ability to read through past providers and even at times specialists visits with a patient can be very helpful when navigating an appointment with a new patient. As a young physician, electronics have been an extension of myself for my entire adult life, so a computer in front of me during an office visit is comforting. I do not feel it distracts from my interaction with patients, or takes away from their experience at all, just the opposite, it allows me to more confidently care for them with up to date, and organized information at my fingertips.
Dave Depietro (family physician)
I have been a family physician for 25 years and feel that the EHRs have affected my office in a number of ways. It has definitely improved the efficacy of office tasks such as doing prescription refills, interoffice communication, and scheduling. Also before EHRs, the turnaround time for a dictated note was about a week, and now most notes are completed by the end of the day. This makes it easier if I am taking care of one of my partner’s patients or dealing with a patient I recently saw. Also in this day of pay for performance we can now gather data much easier. This would be almost impossible to do if we still had paper charts.
EHRs unfortunately also have their downsides. The main problem I see is that they add a significant amount of time for providers to complete tasks. When I dictated a note, I could have completed a note within 1-2 minutes where now with EHRs, it can take maybe 3-5 minutes/patient. Also to approve labs, x-rays, etc. it just takes longer. I feel that EHRs have added about 1½ hr to my day. I feel most of my colleagues have the same complaint. They routinely take work home at night and spend 1-2 hours at home completing notes. Many of my peers seem stressed and frustrated. Even though EHRs make the office more efficient, I feel that the provider pays the price. My other complaint is the cost of IT support to keep the EHRs running smoothly. The promise of EHRs is that they would save physicians’ money and reduce staffing, however I have not seen that happen.
I ask myself, at the end of the day, would I go back to paper charts? The answer is no. Despite their downsides, I feel that the positives of EHRs outweigh the negatives. Older doctors just need to adapt to this new way of practicing medicine.
The Bottom Line
Clearly there is a range of opinion about the effect of electronic health records on our practices and our lives, with those opinions at least partly segregated by age. We are interested in your thoughts and plan to publish some of those thoughts in future columns, so please let us know at [email protected]. Thanks.
Dr. Notte is a family physician and clinical informaticist for Abington 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 (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.
Eighty percent of physicians are now using electronic health records in their offices. We have been impressed that the younger physicians to whom we have spoken often view their experience with EHRs very differently from older physicians. Is such a difference inevitable, perhaps, not just because change is more difficult for many people as they get older but also because expectations are influenced by experience. Noticing these different thoughts and feelings, we’ve asked two physicians more than 55 years old and two younger physicians to share some thoughts on their experiences with electronic records.
Mathew Clark (family physician)
I’ve been in practice for 31 years and using an EHR system for just under 5. I’m not thrilled with it, but I accept that it’s an unavoidable part of my practice now, and so I don’t waste energy being upset about it. I’ve learned to function efficiently with an EHR, doing the best I can. I remember physicians, before the days of SOAP notes, who would write pithy, useful notes such as "probable strep, Pen VK 500 bid for 10 days" on 3x5 index cards. Such notes lacked detail, and it’s not hard to imagine the problems this lack of detail might create, but they were readable at a glance, and told you what you needed to know. On the other hand, the massively detailed, bloated notes we see with our EHRs, obscured by "copy-forward" text and fictional (in other words, never really asked or examined) information, present very significant practical and legal issues of their own, and take hours of physician time to complete. Given a choice, I’d probably go for the index cards.
Natalie McGann (family physician)
I have been a family physician in practice for 4 years since graduating from residency. The advent of the EHR hasn’t been an overwhelming transition for those of us in the early stages of our careers. Much of our schooling to date has included laptops and other electronic devices that for many prove an easier means of communication. Despite that fact that EHRs require a host of extraneous clicks and check boxes, it is still less cumbersome than documenting encounters on paper. For the generation of young physicians accustomed to having answers at their fingertips, the idea of flipping through paper charts to collate a patient’s medical record seems far more complicated than clicking a few tabs without ever leaving your chair. I, and most colleagues in my peer group to whom I’ve spoken, agree that we would not be likely to a join a practice that doesn’t utilize an EHR or have a current plan to adopt one. Anything less would feel like a step back at this point.
Danielle Carcia (intern, family medicine residency)
Overall, I enjoy using electronic medical records. I feel that it places all pertinent information about the patient in an easy-to-follow and concise manner. The ability to read through past providers and even at times specialists visits with a patient can be very helpful when navigating an appointment with a new patient. As a young physician, electronics have been an extension of myself for my entire adult life, so a computer in front of me during an office visit is comforting. I do not feel it distracts from my interaction with patients, or takes away from their experience at all, just the opposite, it allows me to more confidently care for them with up to date, and organized information at my fingertips.
Dave Depietro (family physician)
I have been a family physician for 25 years and feel that the EHRs have affected my office in a number of ways. It has definitely improved the efficacy of office tasks such as doing prescription refills, interoffice communication, and scheduling. Also before EHRs, the turnaround time for a dictated note was about a week, and now most notes are completed by the end of the day. This makes it easier if I am taking care of one of my partner’s patients or dealing with a patient I recently saw. Also in this day of pay for performance we can now gather data much easier. This would be almost impossible to do if we still had paper charts.
EHRs unfortunately also have their downsides. The main problem I see is that they add a significant amount of time for providers to complete tasks. When I dictated a note, I could have completed a note within 1-2 minutes where now with EHRs, it can take maybe 3-5 minutes/patient. Also to approve labs, x-rays, etc. it just takes longer. I feel that EHRs have added about 1½ hr to my day. I feel most of my colleagues have the same complaint. They routinely take work home at night and spend 1-2 hours at home completing notes. Many of my peers seem stressed and frustrated. Even though EHRs make the office more efficient, I feel that the provider pays the price. My other complaint is the cost of IT support to keep the EHRs running smoothly. The promise of EHRs is that they would save physicians’ money and reduce staffing, however I have not seen that happen.
I ask myself, at the end of the day, would I go back to paper charts? The answer is no. Despite their downsides, I feel that the positives of EHRs outweigh the negatives. Older doctors just need to adapt to this new way of practicing medicine.
The Bottom Line
Clearly there is a range of opinion about the effect of electronic health records on our practices and our lives, with those opinions at least partly segregated by age. We are interested in your thoughts and plan to publish some of those thoughts in future columns, so please let us know at [email protected]. Thanks.
Dr. Notte is a family physician and clinical informaticist for Abington 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 (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference Inc., a software company that creates mobile apps.
Mild benefits from diabetes apps so far
Several new mobile applications and platforms for managing diabetes will be announced at the American Diabetes Association annual scientific sessions in San Francisco this month, and the results of a handful of trials of apps will be reported there. As a prelude, it’s helpful to know what’s been reported about diabetes apps previously.
Diabetes management has been one of the most talked-about goals of app development, given the immense costs in patients’ lives and in health care dollars from the disease. Although there are more than 1,000 specific diabetes apps for iOS and Android devices, only 1.2% of people with diabetes who have a smartphone or tablet use these apps, according to the Germany-based market research and consultancy firm research2guidance. The company expects that to grow to 7.8% (24 million people) by 2018. As of now, few diabetes apps incorporate seven standards for quality and functionality, or include them only at the most basic level, according to a recent report for sale on the company’s website.
German investigators analyzed information for 656 currently available diabetes apps and used a representative 65 of them to evaluate their usability for patients aged 50 years or older. Most were for English speakers (85%), and 54% were free, with no clear differences in user ratings between free and paid apps. The majority of apps offered just one function (54%), and only 5% offered an interface to a measurement device such as a glucometer. For older patients, the usability of the 65 tested apps was moderate to good but worsened if the app offered more than one function, especially documentation or analysis functions (J. Med. Internet Res. 2014;16:e101).
A Cochrane meta-analysis of data from 16 randomized controlled trials of Internet-based self-management interventions involving 3,578 adults with type 2 diabetes found 1-12 months of use reduced hemoglobin A1c (HbA1c) levels by 0.2%, compared with HbA1c levels in control groups. Results were somewhat better, however, in the three trials of mobile phone-based interventions, which reduced HbA1c levels by 0.5%, compared with controls. The other interventions studied were on computers or a touch-screen in homes or clinics (Cochrane Database Syst. Rev. 2013 March 28;3[doi:10.1002/14651858.CD008776.pub2]).
An earlier meta-analysis of results from a variety of mobile phone interventions in 15 studies involving a total of 929 children and adults with diabetes suggested overall benefits in managing blood glucose and HbA1c levels, adhering to medical therapy, and maintaining a healthy lifestyle. The 12 trials that measured HbA1c levels showed an average 0.4% reduction after 1-12 months of the intervention, compared with before (J. Mob. Technol. Med. 2012;1:17-24).
Combining usual care with use of the Glucose Buddy smartphone app and weekly text-message feedback from a diabetes educator significantly reduced HbA1c levels, compared with usual care alone, in a randomized controlled trial of 72 Australians with type 1 diabetes. Among 53 patients who completed the 6-month intervention and 3-month follow-up, HbA1c levels decreased from 9% at baseline to 7.8% in the 25 patients in the intervention group and increased from 8.5% at baseline to 8.6% in the control group of 28 patients (J. Med. Internet Res. 2013;15:e235).
A recent pilot study found that 60 adults with diabetes were enthusiastic about using the free SightBook app to monitor visual acuity changes at home but suggested that improvements will be needed to incorporate such apps into existing electronic medical records if they are to facilitate coordination between patients, diabetologists, and ophthalmologists in managing the risk of diabetic retinopathy (J. Diabetes Sci. Technol. 2014 April 14 [doi:10.1177/1932296814529637]).
Several trials have looked at text message–based interventions, including one that found no significant difference in HbA1c levels but found improved medication adherence in 128 adults with poorly controlled diabetes who often relied on emergency departments for care. The effects were larger among Spanish speakers (Ann. Emerg. Med. 2014;63:745-54). A separate randomized controlled trial found that patients receiving text-message reminders when they forgot their diabetes medication took significantly more doses within 1 hour and 4 hours of the appropriate time (Int. J. Med. Inform. 2012;81:594-604).
Health care professionals who want to guide patients seeking to use diabetes apps may want to consider some key factors, a recent article suggested. These may include the age of the patient, the cost of the technology, the fact that most apps work only on Apple operating systems, and whether the app includes features such as blood glucose logging, nutritional databases or tracking, physical activity trackers, data sharing and social support, and text-message reminders. Patients should try using an app for at least a couple of weeks before judging it and be reminded that these are adjuncts, not substitutes for regular visits with their physician, the authors wrote (Diabetes Spectr. 2013;26:211-5).
On Twitter @sherryboschert
Several new mobile applications and platforms for managing diabetes will be announced at the American Diabetes Association annual scientific sessions in San Francisco this month, and the results of a handful of trials of apps will be reported there. As a prelude, it’s helpful to know what’s been reported about diabetes apps previously.
Diabetes management has been one of the most talked-about goals of app development, given the immense costs in patients’ lives and in health care dollars from the disease. Although there are more than 1,000 specific diabetes apps for iOS and Android devices, only 1.2% of people with diabetes who have a smartphone or tablet use these apps, according to the Germany-based market research and consultancy firm research2guidance. The company expects that to grow to 7.8% (24 million people) by 2018. As of now, few diabetes apps incorporate seven standards for quality and functionality, or include them only at the most basic level, according to a recent report for sale on the company’s website.
German investigators analyzed information for 656 currently available diabetes apps and used a representative 65 of them to evaluate their usability for patients aged 50 years or older. Most were for English speakers (85%), and 54% were free, with no clear differences in user ratings between free and paid apps. The majority of apps offered just one function (54%), and only 5% offered an interface to a measurement device such as a glucometer. For older patients, the usability of the 65 tested apps was moderate to good but worsened if the app offered more than one function, especially documentation or analysis functions (J. Med. Internet Res. 2014;16:e101).
A Cochrane meta-analysis of data from 16 randomized controlled trials of Internet-based self-management interventions involving 3,578 adults with type 2 diabetes found 1-12 months of use reduced hemoglobin A1c (HbA1c) levels by 0.2%, compared with HbA1c levels in control groups. Results were somewhat better, however, in the three trials of mobile phone-based interventions, which reduced HbA1c levels by 0.5%, compared with controls. The other interventions studied were on computers or a touch-screen in homes or clinics (Cochrane Database Syst. Rev. 2013 March 28;3[doi:10.1002/14651858.CD008776.pub2]).
An earlier meta-analysis of results from a variety of mobile phone interventions in 15 studies involving a total of 929 children and adults with diabetes suggested overall benefits in managing blood glucose and HbA1c levels, adhering to medical therapy, and maintaining a healthy lifestyle. The 12 trials that measured HbA1c levels showed an average 0.4% reduction after 1-12 months of the intervention, compared with before (J. Mob. Technol. Med. 2012;1:17-24).
Combining usual care with use of the Glucose Buddy smartphone app and weekly text-message feedback from a diabetes educator significantly reduced HbA1c levels, compared with usual care alone, in a randomized controlled trial of 72 Australians with type 1 diabetes. Among 53 patients who completed the 6-month intervention and 3-month follow-up, HbA1c levels decreased from 9% at baseline to 7.8% in the 25 patients in the intervention group and increased from 8.5% at baseline to 8.6% in the control group of 28 patients (J. Med. Internet Res. 2013;15:e235).
A recent pilot study found that 60 adults with diabetes were enthusiastic about using the free SightBook app to monitor visual acuity changes at home but suggested that improvements will be needed to incorporate such apps into existing electronic medical records if they are to facilitate coordination between patients, diabetologists, and ophthalmologists in managing the risk of diabetic retinopathy (J. Diabetes Sci. Technol. 2014 April 14 [doi:10.1177/1932296814529637]).
Several trials have looked at text message–based interventions, including one that found no significant difference in HbA1c levels but found improved medication adherence in 128 adults with poorly controlled diabetes who often relied on emergency departments for care. The effects were larger among Spanish speakers (Ann. Emerg. Med. 2014;63:745-54). A separate randomized controlled trial found that patients receiving text-message reminders when they forgot their diabetes medication took significantly more doses within 1 hour and 4 hours of the appropriate time (Int. J. Med. Inform. 2012;81:594-604).
Health care professionals who want to guide patients seeking to use diabetes apps may want to consider some key factors, a recent article suggested. These may include the age of the patient, the cost of the technology, the fact that most apps work only on Apple operating systems, and whether the app includes features such as blood glucose logging, nutritional databases or tracking, physical activity trackers, data sharing and social support, and text-message reminders. Patients should try using an app for at least a couple of weeks before judging it and be reminded that these are adjuncts, not substitutes for regular visits with their physician, the authors wrote (Diabetes Spectr. 2013;26:211-5).
On Twitter @sherryboschert
Several new mobile applications and platforms for managing diabetes will be announced at the American Diabetes Association annual scientific sessions in San Francisco this month, and the results of a handful of trials of apps will be reported there. As a prelude, it’s helpful to know what’s been reported about diabetes apps previously.
Diabetes management has been one of the most talked-about goals of app development, given the immense costs in patients’ lives and in health care dollars from the disease. Although there are more than 1,000 specific diabetes apps for iOS and Android devices, only 1.2% of people with diabetes who have a smartphone or tablet use these apps, according to the Germany-based market research and consultancy firm research2guidance. The company expects that to grow to 7.8% (24 million people) by 2018. As of now, few diabetes apps incorporate seven standards for quality and functionality, or include them only at the most basic level, according to a recent report for sale on the company’s website.
German investigators analyzed information for 656 currently available diabetes apps and used a representative 65 of them to evaluate their usability for patients aged 50 years or older. Most were for English speakers (85%), and 54% were free, with no clear differences in user ratings between free and paid apps. The majority of apps offered just one function (54%), and only 5% offered an interface to a measurement device such as a glucometer. For older patients, the usability of the 65 tested apps was moderate to good but worsened if the app offered more than one function, especially documentation or analysis functions (J. Med. Internet Res. 2014;16:e101).
A Cochrane meta-analysis of data from 16 randomized controlled trials of Internet-based self-management interventions involving 3,578 adults with type 2 diabetes found 1-12 months of use reduced hemoglobin A1c (HbA1c) levels by 0.2%, compared with HbA1c levels in control groups. Results were somewhat better, however, in the three trials of mobile phone-based interventions, which reduced HbA1c levels by 0.5%, compared with controls. The other interventions studied were on computers or a touch-screen in homes or clinics (Cochrane Database Syst. Rev. 2013 March 28;3[doi:10.1002/14651858.CD008776.pub2]).
An earlier meta-analysis of results from a variety of mobile phone interventions in 15 studies involving a total of 929 children and adults with diabetes suggested overall benefits in managing blood glucose and HbA1c levels, adhering to medical therapy, and maintaining a healthy lifestyle. The 12 trials that measured HbA1c levels showed an average 0.4% reduction after 1-12 months of the intervention, compared with before (J. Mob. Technol. Med. 2012;1:17-24).
Combining usual care with use of the Glucose Buddy smartphone app and weekly text-message feedback from a diabetes educator significantly reduced HbA1c levels, compared with usual care alone, in a randomized controlled trial of 72 Australians with type 1 diabetes. Among 53 patients who completed the 6-month intervention and 3-month follow-up, HbA1c levels decreased from 9% at baseline to 7.8% in the 25 patients in the intervention group and increased from 8.5% at baseline to 8.6% in the control group of 28 patients (J. Med. Internet Res. 2013;15:e235).
A recent pilot study found that 60 adults with diabetes were enthusiastic about using the free SightBook app to monitor visual acuity changes at home but suggested that improvements will be needed to incorporate such apps into existing electronic medical records if they are to facilitate coordination between patients, diabetologists, and ophthalmologists in managing the risk of diabetic retinopathy (J. Diabetes Sci. Technol. 2014 April 14 [doi:10.1177/1932296814529637]).
Several trials have looked at text message–based interventions, including one that found no significant difference in HbA1c levels but found improved medication adherence in 128 adults with poorly controlled diabetes who often relied on emergency departments for care. The effects were larger among Spanish speakers (Ann. Emerg. Med. 2014;63:745-54). A separate randomized controlled trial found that patients receiving text-message reminders when they forgot their diabetes medication took significantly more doses within 1 hour and 4 hours of the appropriate time (Int. J. Med. Inform. 2012;81:594-604).
Health care professionals who want to guide patients seeking to use diabetes apps may want to consider some key factors, a recent article suggested. These may include the age of the patient, the cost of the technology, the fact that most apps work only on Apple operating systems, and whether the app includes features such as blood glucose logging, nutritional databases or tracking, physical activity trackers, data sharing and social support, and text-message reminders. Patients should try using an app for at least a couple of weeks before judging it and be reminded that these are adjuncts, not substitutes for regular visits with their physician, the authors wrote (Diabetes Spectr. 2013;26:211-5).
On Twitter @sherryboschert
About 5 years ago, when I first started speaking to physicians about social media, I’d ask my audience how many of them used Twitter. Typically, one or two hands would go up. Last month I asked my audience of physicians how many were on Twitter, and about 30 people raised their hands.
According to a recent report by London-based FierceHealthcare, only 23 healthcare professionals signed up for Twitter when it launched in 2006. Today, there are over 75,000 healthcare professionals on the site, with the number rising.
Why are they on Twitter? Let’s look at Twitter’s mission statement: "To give everyone the power to create and share ideas and information instantly, without barriers." That’s what we’re hardwired to do: Share ideas and information with each other. Which is why individuals from physicians to celebrities to retired grandparents are on Twitter creating and sharing ideas. Currently, there are over 255 million active Twitter users sending out approximately 500 million tweets a day.
Because Twitter is a real-time social platform, it enables conversations. Topics of conversation are tagged through the use of the # symbol, called a hashtag. If, for example, you’re a dermatologist with an interest in reaching out to teens, you might create the following tweet: "Don’t know what foods are good and bad for #acne? Check out our post on best foods for healthy skin." Then you would include the link to the post on your practice website. Anyone searching for information on diet and acne will easily find your tweet and be able to link through to your website.
Twitter is also unique in that posts, referred to as "tweets," are limited to 140 characters. So, it forces you to be concise and specific and encourages other uses to respond to your tweet or to share it, ("retweeting").
This column isn’t about the nuts and bolts of how to use Twitter; there are numerous tutorials online for that. Simply search "Twitter tutorial," and you’ll get dozens of hits. Instead, I’d like you to see the potential Twitter offers you and your practice.
• Get lots of exposure for minimal investment. I typically spend about 20 minutes a day on Twitter. Since posts are so short, I can scan conversations quickly and easily.
• Reach your target audience quickly and easily with Twitter’s great search ability. For example, a dermatologist might tweet about #skincancer, but a psychiatrist might tweet about #anxiety or #depression, while an oncologist might focus on #ovariancancer or #breastcancer.
• Build and maintain your brand and online reputation. I often tweet about skin care tips and skin cancer facts using the hashtags #dermtip and #skincancer, respectively. Doing so allows me to interact with other healthcare providers, patients, and caregivers. And it lets those people know that I’m a dermatologist who cares about these topics. For example, a recent tweet of mine was retweeted (shared by others) 28 times: "Squamous cell carcinoma has risen 700% in women under 40. There’s no such thing as a safe tan. #skincancer #womenshealth."
• Become a more active member of your medical community. The website www.symplur.com has created The Healthcare Hashtag Project which allows you to discover healthcare conversations taking place on Twitter, including conferences, and who to follow in your specialty. They also list tweet chats that are real-time online chats about specific healthcare topics. Examples include #alzchat (an Alzheimer’s disease and caregiving chat), #rheum (a rheumatoid arthritis chat), and #bcsm (a chat about the intersection of breast cancer and all things social media). Becoming an active participant in chats can help build your online reputation as an expert in the field.
• Improve quality of care by disseminating accurate information. As with any social platform, misinformation abounds about health and healthcare. As a physician you can post vetted information and become a trusted source of knowledge both online and in person. For example, a tweet of mine in April included a link to a newly published study about rising rates of melanoma in adolescents. It read: "Scary truth: #melanoma is rising in kids & teens. 77% aged 15-19 yrs." Then I included the link to the study.
• Engage for an effective networking tool. For example, my interactions on Twitter have led to invitations to speak at conferences as well as media queries. It has also broadened my circle of friends, as I have become real-life friends with people I initially met through Twitter.
• Stay abreast of information from conferences that you can’t attend. Most conferences today use an official hashtag that allows people all over the world to track what is being said at the conference and to engage with conference attendees.
• Create traffic and potential referrals to your practice website. As mentioned earlier in the column, linking tweets to posts is another way to introduce potential patients to your practice via your website. Satisfied patients may retweet your tweets, too.
Are you on Twitter? If so, do you like using it? Has it been helpful to you? Let us know. And if you follow me on Twitter (I’m @dermdoc), I’ll follow you back.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Medical Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
About 5 years ago, when I first started speaking to physicians about social media, I’d ask my audience how many of them used Twitter. Typically, one or two hands would go up. Last month I asked my audience of physicians how many were on Twitter, and about 30 people raised their hands.
According to a recent report by London-based FierceHealthcare, only 23 healthcare professionals signed up for Twitter when it launched in 2006. Today, there are over 75,000 healthcare professionals on the site, with the number rising.
Why are they on Twitter? Let’s look at Twitter’s mission statement: "To give everyone the power to create and share ideas and information instantly, without barriers." That’s what we’re hardwired to do: Share ideas and information with each other. Which is why individuals from physicians to celebrities to retired grandparents are on Twitter creating and sharing ideas. Currently, there are over 255 million active Twitter users sending out approximately 500 million tweets a day.
Because Twitter is a real-time social platform, it enables conversations. Topics of conversation are tagged through the use of the # symbol, called a hashtag. If, for example, you’re a dermatologist with an interest in reaching out to teens, you might create the following tweet: "Don’t know what foods are good and bad for #acne? Check out our post on best foods for healthy skin." Then you would include the link to the post on your practice website. Anyone searching for information on diet and acne will easily find your tweet and be able to link through to your website.
Twitter is also unique in that posts, referred to as "tweets," are limited to 140 characters. So, it forces you to be concise and specific and encourages other uses to respond to your tweet or to share it, ("retweeting").
This column isn’t about the nuts and bolts of how to use Twitter; there are numerous tutorials online for that. Simply search "Twitter tutorial," and you’ll get dozens of hits. Instead, I’d like you to see the potential Twitter offers you and your practice.
• Get lots of exposure for minimal investment. I typically spend about 20 minutes a day on Twitter. Since posts are so short, I can scan conversations quickly and easily.
• Reach your target audience quickly and easily with Twitter’s great search ability. For example, a dermatologist might tweet about #skincancer, but a psychiatrist might tweet about #anxiety or #depression, while an oncologist might focus on #ovariancancer or #breastcancer.
• Build and maintain your brand and online reputation. I often tweet about skin care tips and skin cancer facts using the hashtags #dermtip and #skincancer, respectively. Doing so allows me to interact with other healthcare providers, patients, and caregivers. And it lets those people know that I’m a dermatologist who cares about these topics. For example, a recent tweet of mine was retweeted (shared by others) 28 times: "Squamous cell carcinoma has risen 700% in women under 40. There’s no such thing as a safe tan. #skincancer #womenshealth."
• Become a more active member of your medical community. The website www.symplur.com has created The Healthcare Hashtag Project which allows you to discover healthcare conversations taking place on Twitter, including conferences, and who to follow in your specialty. They also list tweet chats that are real-time online chats about specific healthcare topics. Examples include #alzchat (an Alzheimer’s disease and caregiving chat), #rheum (a rheumatoid arthritis chat), and #bcsm (a chat about the intersection of breast cancer and all things social media). Becoming an active participant in chats can help build your online reputation as an expert in the field.
• Improve quality of care by disseminating accurate information. As with any social platform, misinformation abounds about health and healthcare. As a physician you can post vetted information and become a trusted source of knowledge both online and in person. For example, a tweet of mine in April included a link to a newly published study about rising rates of melanoma in adolescents. It read: "Scary truth: #melanoma is rising in kids & teens. 77% aged 15-19 yrs." Then I included the link to the study.
• Engage for an effective networking tool. For example, my interactions on Twitter have led to invitations to speak at conferences as well as media queries. It has also broadened my circle of friends, as I have become real-life friends with people I initially met through Twitter.
• Stay abreast of information from conferences that you can’t attend. Most conferences today use an official hashtag that allows people all over the world to track what is being said at the conference and to engage with conference attendees.
• Create traffic and potential referrals to your practice website. As mentioned earlier in the column, linking tweets to posts is another way to introduce potential patients to your practice via your website. Satisfied patients may retweet your tweets, too.
Are you on Twitter? If so, do you like using it? Has it been helpful to you? Let us know. And if you follow me on Twitter (I’m @dermdoc), I’ll follow you back.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Medical Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
About 5 years ago, when I first started speaking to physicians about social media, I’d ask my audience how many of them used Twitter. Typically, one or two hands would go up. Last month I asked my audience of physicians how many were on Twitter, and about 30 people raised their hands.
According to a recent report by London-based FierceHealthcare, only 23 healthcare professionals signed up for Twitter when it launched in 2006. Today, there are over 75,000 healthcare professionals on the site, with the number rising.
Why are they on Twitter? Let’s look at Twitter’s mission statement: "To give everyone the power to create and share ideas and information instantly, without barriers." That’s what we’re hardwired to do: Share ideas and information with each other. Which is why individuals from physicians to celebrities to retired grandparents are on Twitter creating and sharing ideas. Currently, there are over 255 million active Twitter users sending out approximately 500 million tweets a day.
Because Twitter is a real-time social platform, it enables conversations. Topics of conversation are tagged through the use of the # symbol, called a hashtag. If, for example, you’re a dermatologist with an interest in reaching out to teens, you might create the following tweet: "Don’t know what foods are good and bad for #acne? Check out our post on best foods for healthy skin." Then you would include the link to the post on your practice website. Anyone searching for information on diet and acne will easily find your tweet and be able to link through to your website.
Twitter is also unique in that posts, referred to as "tweets," are limited to 140 characters. So, it forces you to be concise and specific and encourages other uses to respond to your tweet or to share it, ("retweeting").
This column isn’t about the nuts and bolts of how to use Twitter; there are numerous tutorials online for that. Simply search "Twitter tutorial," and you’ll get dozens of hits. Instead, I’d like you to see the potential Twitter offers you and your practice.
• Get lots of exposure for minimal investment. I typically spend about 20 minutes a day on Twitter. Since posts are so short, I can scan conversations quickly and easily.
• Reach your target audience quickly and easily with Twitter’s great search ability. For example, a dermatologist might tweet about #skincancer, but a psychiatrist might tweet about #anxiety or #depression, while an oncologist might focus on #ovariancancer or #breastcancer.
• Build and maintain your brand and online reputation. I often tweet about skin care tips and skin cancer facts using the hashtags #dermtip and #skincancer, respectively. Doing so allows me to interact with other healthcare providers, patients, and caregivers. And it lets those people know that I’m a dermatologist who cares about these topics. For example, a recent tweet of mine was retweeted (shared by others) 28 times: "Squamous cell carcinoma has risen 700% in women under 40. There’s no such thing as a safe tan. #skincancer #womenshealth."
• Become a more active member of your medical community. The website www.symplur.com has created The Healthcare Hashtag Project which allows you to discover healthcare conversations taking place on Twitter, including conferences, and who to follow in your specialty. They also list tweet chats that are real-time online chats about specific healthcare topics. Examples include #alzchat (an Alzheimer’s disease and caregiving chat), #rheum (a rheumatoid arthritis chat), and #bcsm (a chat about the intersection of breast cancer and all things social media). Becoming an active participant in chats can help build your online reputation as an expert in the field.
• Improve quality of care by disseminating accurate information. As with any social platform, misinformation abounds about health and healthcare. As a physician you can post vetted information and become a trusted source of knowledge both online and in person. For example, a tweet of mine in April included a link to a newly published study about rising rates of melanoma in adolescents. It read: "Scary truth: #melanoma is rising in kids & teens. 77% aged 15-19 yrs." Then I included the link to the study.
• Engage for an effective networking tool. For example, my interactions on Twitter have led to invitations to speak at conferences as well as media queries. It has also broadened my circle of friends, as I have become real-life friends with people I initially met through Twitter.
• Stay abreast of information from conferences that you can’t attend. Most conferences today use an official hashtag that allows people all over the world to track what is being said at the conference and to engage with conference attendees.
• Create traffic and potential referrals to your practice website. As mentioned earlier in the column, linking tweets to posts is another way to introduce potential patients to your practice via your website. Satisfied patients may retweet your tweets, too.
Are you on Twitter? If so, do you like using it? Has it been helpful to you? Let us know. And if you follow me on Twitter (I’m @dermdoc), I’ll follow you back.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Medical Group in San Diego and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.
Critical Care Commentary: Brain death – patient, law, and family
Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.
Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.
Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.
In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.
Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.
In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.
The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).
In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.
‘No reports of clinical recovery’
However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."
It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).
These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.
A single exam
In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.
Confounded by movement
Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.
This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.
Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.
Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO2 of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.
Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.
Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.
In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).
Controversy over ancillary testing
There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.
Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.
It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.
It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).
A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.
Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.
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In this thorough and somber commentary, Dr. Bowton clearly points out how much gray remains in a world that demands black and white certainty.
Brain death, and its implication, is not an exact diagnosis, which impacts the family, society, and the care-giving team, but most of all, the patient.
As there are times that brain death cannot be truly determined, we must be mindful that our primary goal is always the patient, then the families, society, and others. As a practitioner in New York, where family discussion is the law, I have not found this to be a great impediment; with palliative care and pastoral support, most issues can be resolved. As we progress in our knowledge, a more global unified approach would be welcomed.
Dr. Peter Spiro, FCCP Section Editor
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In this thorough and somber commentary, Dr. Bowton clearly points out how much gray remains in a world that demands black and white certainty.
Brain death, and its implication, is not an exact diagnosis, which impacts the family, society, and the care-giving team, but most of all, the patient.
As there are times that brain death cannot be truly determined, we must be mindful that our primary goal is always the patient, then the families, society, and others. As a practitioner in New York, where family discussion is the law, I have not found this to be a great impediment; with palliative care and pastoral support, most issues can be resolved. As we progress in our knowledge, a more global unified approach would be welcomed.
Dr. Peter Spiro, FCCP Section Editor
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|
|
In this thorough and somber commentary, Dr. Bowton clearly points out how much gray remains in a world that demands black and white certainty.
Brain death, and its implication, is not an exact diagnosis, which impacts the family, society, and the care-giving team, but most of all, the patient.
As there are times that brain death cannot be truly determined, we must be mindful that our primary goal is always the patient, then the families, society, and others. As a practitioner in New York, where family discussion is the law, I have not found this to be a great impediment; with palliative care and pastoral support, most issues can be resolved. As we progress in our knowledge, a more global unified approach would be welcomed.
Dr. Peter Spiro, FCCP Section Editor
Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.
Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.
Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.
In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.
Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.
In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.
The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).
In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.
‘No reports of clinical recovery’
However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."
It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).
These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.
A single exam
In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.
Confounded by movement
Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.
This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.
Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.
Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO2 of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.
Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.
Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.
In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).
Controversy over ancillary testing
There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.
Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.
It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.
It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).
A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.
Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.
Perhaps no other concept in modern medicine is surrounded by as much misunderstanding and controversy as that of death by neurologic criteria, or brain death.
Legal challenges to brain death have spanned the gamut of continuing life support for a legally dead patient to denying a family’s request to continue support for their dead child.
Two recent, highly publicized cases highlight the poles of these controversies and concerns. In November 2013, Marlise Muñoz was declared brain dead. She was 33 years old and 14 weeks’ pregnant. Concordant with the patient’s wishes, the husband requested that the hospital remove the patient from mechanical ventilatory support. Citing Texas law that precludes the withholding of life-sustaining treatment to a pregnant patient, the hospital refused, despite the logical fallacy of withholding life support from a person declared dead.
In December 2013, 13-year-old Jahi McMath was declared brain dead. Her parents obtained a court order to prevent the hospital from discontinuing ventilatory support. A better understanding of the development of the concept of brain death and the incorporation of recent evidence into its determination may reduce the confusion and misunderstandings surrounding the determination of brain death.
Three reports in 1959 describe death of the nervous system and brain death (coma dépassé) building upon clinical and laboratory data from the 1930s relating the cessation of brain blood flow and EEG activity to ensuing apnea and subsequent cardiac arrest (Machado et al. J Med Ethics. 2007;33[4]:197). With the increasing sophistication of critical care support, especially mechanical ventilation, the loss of central respiratory drive no longer meant imminent death, and patients could be supported for long periods of time without recovery of brain function.
In 1968, an ad hoc committee at Harvard Medical School proposed a definition of irreversible coma and brain death (Beecher et al. JAMA. 1968;205[6]:337). They posited that any organ that no longer functions and has no possibility of functioning again was "for all practical purposes dead." The goals of the committee were (1) to reduce the suffering of patients and families and the care burden of hospitals; and (2) mitigate the controversies that surrounded obtaining organs for transplantation.
The committee then set out their rationale for their proposed characteristics of the permanently nonfunctioning brain. Subsequently, in 1976, The Conference of the Medical Royal Colleges and their Faculties in the United Kingdom required a deeply comatose state, irremediable structural brain damage, and irreversible cessation of brain stem function to ascertain brain death (Spinello. J Intensive Care Med. May 2014, in press).
In 1981, the National Conference of Commissioners on Uniform State Laws approved the Uniform Determination of Death Act (UDDA), codifying the legal concept of brain death. Thirty-six states and the District of Columbia have enacted the UDDA, but legal precedent and statutes in the remaining states are consistent with the UDDA. New York and New Jersey require that a family’s religious or moral views be considered in the process following the determination of brain death (Gostin. JAMA. 2014;311[9]:903); in all other states, clinicians are not required to consult with family prior to withdrawing ventilatory support from the brain dead patient.
‘No reports of clinical recovery’
However, the UDDA does not define brain death but rather states that "a determination of death must be made with accepted medical standards" (Wijdicks et al. Neurology. 2010;74[23]:1911). The American Academy of Neurology (AAN) published a practice parameter in 1995 to guide clinicians in the determination of brain death; this was updated by their Quality Standards Committee in 2010 (Wijdicks et al. Neurology. 2010;74[23]:1911). In the updated guidance document, the committee stated: "There are no reports of clinical recovery in patients after the clinical diagnosis of brain death has been determined using the AAN practice parameter."
It is striking, however, that there appears to be an inconsistent approach and criteria for the determination of brain death across hospitals, and even amongst specialties within a hospital (Powner et al. Crit Care Med. 2004;32[6]:1284). Further, in most states, any physician is permitted to ascertain brain death, though some states have now added requirements for specific qualifications and/or confirmation by a second physician (Spinello IM. J Intensive Care Med. May 2014, in press).
These inconsistencies in criteria, process, and experience may be responsible for reports in the lay press of recovery following pronouncement of brain death. Every hospital should have a validated, well-defined process for the evaluation of brain death guided by the AAN practice parameter.
A single exam
In most states, a single exam is required to determine brain death. The clinical setting and the results of imaging studies should be used to determine the duration of observation needed to exclude the possibility of recovery. Given that the patient should be normothermic, have a normal systolic blood pressure, have both a history and imaging studies supporting an irreversible cause of coma, and that drugs and toxins must be excluded as a cause of coma, this observation period is uncommonly less than several hours.
Confounded by movement
Movement of the patient with devastating brain injury is often a confounder in the determination of brain death.
This is also a source of confusion and concern for the family. Plantar reflexes have been commonly reported in patients pronounced brain dead. Head turning in response to noxious stimuli, repetitive leg movements, facial myokymia, and other movements have been observed (Wu et al. Crit Care. 2013;17[4]:440; Wijdicks et al. Neurology. 2010;74[23]:1911). When this is observed, knowledge of the potential reflex arcs is needed, and consultation with a neurologist or other physician skilled in brain death determination is usually appropriate.
Movement can sometimes extend to apparent respiratory activity. This can be caused by ventilator autocycling due to variations in circuit pressure (especially in a noncompliant lung or with large tidal volumes) or triggering due to cardiac-induced alterations in transpulmonary pressure. The latter is most common in a hyperdynamic circulatory state.
Apnea is a critical criterion for the determination of brain death and is most reliably assessed when the patient has been removed from the mechanical ventilator. During testing, apnea should be present despite achieving a PaCO2 of greater than or equal to 60 mm Hg, or 20 mm Hg above the baseline to support the diagnosis of brain death.
Some patients, especially those who are hemodynamically unstable or who require high levels of PEEP to support oxygenation, may not tolerate the apnea test without oxygen desaturation or hypotension.
Most commonly, the apnea test is performed with the patient off the ventilator and 6 L/min of oxygen flowing through an insufflation catheter placed near the carina. We prefer to use a modified Mapleson circuit with enough flow to only partially distend the anesthesia bag in the circuit. With this arrangement, one can look not only at the patient’s chest wall and abdomen for signs of respiratory activity but also look for cyclic changes in the level of bag inflation.
In patients with ARDS, trauma involving the chest or other causes of oxygenation failure, CPAP, with or without an antecedent recruitment maneuver may facilitate successful completion of the apnea test (Hocker et al. Neurocrit Care. 2014;20[2]:298).
Controversy over ancillary testing
There are no well-designed prospective studies examining the accuracy of ancillary tests for the determination of brain death using the appropriate control group of patients with coma but who are not brain dead and with blinding of the interpretation of the study results to the clinical setting.
Brain death is not synonymous with complete neuronal death. While cortical areas exhibit moderate to severe histopathologic ischemic changes in the large majority (but not all) of brain dead patients, the basal ganglia and diencephalon inconsistently demonstrate these changes (Wijdicks et al. Neurology. 2008;70[15]:1234). Thus, it may not be surprising that both false-positive (test positive for brain death – clinically not brain dead) and false-negative (test negative for brain death – clinically brain dead) results have been reported for virtually all tests proposed for confirmatory testing, including CT angiography, transcranial Doppler, and nuclear brain scan. Confirmatory testing is most commonly used in patients who cannot complete an apnea test.
It has been forcefully argued that, in adults, confirmatory tests should not be done (Wijdicks. Neurology. 2010;75[1]:77). There will be some patients in whom brain death cannot be definitively determined. When all criteria of the AAN guidelines cannot be fulfilled, clinicians should err on the side of concluding that the patient is not brain dead and turn their efforts toward counseling the family regarding the likelihood of neurologic recovery and assisting the family in ascertaining the desires of the patient under these circumstances.
It is vital that care providers not lose perspective on the plight of the family in these settings. The symbolic power of a beating heart to a parent, spouse, or loved one cannot be underestimated. Family members who observe resuscitation efforts have been shown to have a lower incidence of posttraumatic stress disorder symptoms (Jabre et al. N Engl J Med. 2013;368[11]:1008).
A recent trial demonstrated that family presence during the brain death determination had an increased understanding of brain death without an adverse impact on emotional well being (Tawil et al. Crit Care Med. 2013;42[4]:934). A consistent process for determination of brain death, engagement of the family in the brain death evaluation and helping them understand the meaning of patient movements that can be distressingly misinterpreted, and honesty when a definitive determination of brain death cannot be determined will not remove the misunderstanding or controversy surrounding a diagnosis of brain death but will serve to ensure its accurate and humane application.
Dr. Bowton is Professor, Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina. Read previous Critical Care Commentaries online.
Doing it right
“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).
Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?
Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making. The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.
What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.
Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.
Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.
In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.
Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.
“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.
In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.
So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.
Dr. Rikkers is Editor in Chief of ACS Surgery News
“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).
Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?
Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making. The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.
What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.
Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.
Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.
In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.
Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.
“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.
In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.
So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.
Dr. Rikkers is Editor in Chief of ACS Surgery News
“It is concluded that nasogastric suction should not be used routinely following abdominal surgery." This is the concluding statement from a paper presented at the Pacific Coast Surgical Association and published in the American Journal of Surgery more than 50 years ago (Am. J. Surg 1957;94:257-61).
Since then innumerable randomized controlled trials and meta-analyses have confirmed that nasogastric tubes inserted prophylactically after abdominal surgery, even when gastrointestinal anastomoses have been constructed, are unnecessary. So how did this incontrovertible evidence impact my practice and that of most of my surgical colleagues? Not at all, at least not for many years. We continued our routine of torturing postoperative patients with nasogastric tubes because it had been drummed into us during residency and because we were uncomfortable not doing so. But why did we persist after convincing evidence to the contrary emerged?
Unfortunately it is not uncommon that even when good evidence exists, we fail to incorporate it into decision-making. The comfort we enjoy with our standard way of doing things is often preferred to the discomfort – cognitive dissonance – we experience when confronted with mounting empirical evidence that challenges our beliefs. All too often, the cognitive dissonance is reduced by holding on to those notions with which we are most comfortable and ignoring or rejecting new information no matter how valid.
What is the harm? In the case of prophylactic nasogastric tubes, considerable discomfort has unnecessarily complicated the postoperative courses of millions of patients. Many trials have shown that aspiration and pneumonia, the adverse events for which the tubes were placed to prevent, occurred more frequently in patients with than those without nasogastric tubes.
Prophylactic gastric decompression is but one of many practices that have been continued long after their efficacy was disproven. How many radical mastectomies were performed after modified radical mastectomy, and then later partial mastectomy with radiation were shown with irrefutable data to provide equal survival with less disfigurement and fewer complications such as arm lymphedema? For many years after the indications for tonsillectomy were narrowed, this procedure continued to be more commonly done than was appropriate based on the evidence available.
Some hold on to their cherished habits more persistently and longer than others. In order to maintain consonance and avoid the stress of dissonance, I have known surgeons who have retained nearly all of the practices they learned from their mentors during residency long past their utility. Such individuals may insist that they alone prep their patients and that long outmoded suture and instruments be maintained on the operating room supply list. When new, and often proven to be superior, instruments, sutures, and pathways of care for their patients are introduced in their institutions, they find it difficult or even impossible to change.
In an era when the few controlled trials and meta-analyses available were buried within a surgical literature that was difficult to access and the term evidence-based surgery was not yet a part of our lexicon, such a rigid posture was often tolerated. I would hope that in most institutions and departments of surgery this is no longer the case. We live in a time when the imperatives of renewal and reevaluation of our practices are increasing. Therefore, reviewing new evidence, even that which goes against our established notions, and incorporating new proven methods, are essential to maintaining the highest standard of patient care.
Although many gray areas remain and there is often more than one best way to manage a surgical patient, our treatments should be based on the best evidence available rather than on what we learned 5, 10, or even 30 years ago. Fortunately, such evidence is now readily accessible. A notable example is “Evidence-based decisions in surgery,” surgical practice guidelines recently introduced by the American College of Surgeons (ACS) under the guidance of Dr. Lewis Flint.
“Evidence-based decisions in surgery” presently consists of 15 modules of the most common diseases and conditions encountered by general surgeons. These modules can be easily accessed by ACS Fellows on any mobile device at the point-of-care (http://ebds.facs.org). Surgical recommendations along with the strength of evidence (weak, moderate, or strong) for each are presented in an easy-to-interpret format. The modules have been developed by American College of Surgeons staff and been peer-reviewed by the Best Practices Workgroup of the College’s Board of Governors and by representatives of the Advisory Council for General Surgery. A consensus of the reviewers was used to determine the content of each module. It is emphasized that the purpose of these modules is to guide rather than dictate decision-making.
In addition to the strength of evidence for each recommendation, a clinical decision algorithm for a typical patient, suggested talking points for patient education, and key references on which the recommendations are based are also provided. Although clinical practice guidelines have been developed by a number of specialty surgical societies, I have found none that are as easy to digest and use in a busy clinical practice as “Evidence-based decisions in surgery.
So we no longer have an excuse to hold on to our cherished and venerable practices that are outmoded and possibly not in the best interest of our patients. The information needed to do it right is virtually one click of a mouse away. Try applying “Evidence-based decisions in surgery” in your practice. I am convinced you will find them valuable as you make decisions for the most appropriate care of your patients.
Dr. Rikkers is Editor in Chief of ACS Surgery News
Primary care management of persons infected with HIV
According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.
Initial assessment
The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.
Testing
The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.
It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.
Immunization and preventive health screening
Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:
• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.
• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.
• Influenza. Annual flu shot should be given.
• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.
• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.
Ongoing monitoring
The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.
CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A1c, and liver function studies all require frequent monitoring.
Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.
The bottom line
The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.
References
Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.
Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.
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. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.
According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.
Initial assessment
The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.
Testing
The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.
It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.
Immunization and preventive health screening
Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:
• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.
• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.
• Influenza. Annual flu shot should be given.
• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.
• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.
Ongoing monitoring
The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.
CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A1c, and liver function studies all require frequent monitoring.
Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.
The bottom line
The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.
References
Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.
Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.
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. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.
According to the U.S. Preventive Services Task Force, 1.2 million Americans are living with human immunodeficiency virus infection, and there are 50,000 new cases per year. In 20%-25% of those new cases, patients are unaware of having HIV infection. The recommendation for HIV screening by the USPSTF in 2013 is that all patients between 15 and 65 years of age should receive screening. The HIV Medicine Association of the Infectious Diseases Society of America released updated evidence-based guidelines for primary care management of persons infected with HIV.
Initial assessment
The new guidelines emphasize that all new patients who present to the office with an existing HIV infection undergo a comprehensive assessment, including a complete history, physical, and specific testing. The history must include the date of HIV diagnosis and approximate date of infection. Review the patient’s highest viral load, lowest CD4 count, and past and current treatment regimens; and document any history of opportunistic infections or HIV-related comorbidities. Note any chronic medical conditions, such as cardiovascular disease, diabetes mellitus, and/or renal or liver dysfunction that may impact future treatment regimens for HIV. A general discussion of the person’s understanding of their HIV infection may uncover any mental illness, economic burdens, and lack of social support that may present barriers to treatment adherence.
Testing
The guidelines recommend specific testing that should be performed on initial visit and subsequent further monitoring. It is suggested that the CD4 count be documented and the HIV viral load be quantified in patients who already have the diagnosis of HIV infection. In newly diagnosed patients with HIV infection, it is recommended that you get a CD4 cell count, viral load, and HIV genotype/resistance testing to help choose future antiretroviral therapies. The initial assessment should include testing for possible coexisting conditions, including other sexually transmitted infections: gonorrhea, chlamydia, and syphilis. The patient should be screened for hepatitis A, B, and C; toxoplasmosis; CMV; and tuberculosis. TB screening can be done with either the tuberculin skin test or interferon-gamma release assay.
It is also important to establish a baseline fasting comprehensive metabolic panel, complete blood count, urinalysis, creatinine clearance, and fasting lipid panel because HIV infection and certain antiretroviral therapy (ART) can have a negative effect on a range of organ systems.
Immunization and preventive health screening
Immunization should be routine for all patients with HIV infection. In addition to standard recommendations for all adults, the recommendations for patients with HIV include:
• Hepatitis A and hepatitis B vaccines series. Note that for hepatitis B vaccine, the dose is the 40-mcg dose that is used for immunocompromised patients. Patients should be tested for hepatitis A total, or IgG antibody, 1-2 months after the second dose of the HAV vaccine and HBsAb response 1-2 months after the third dose of the HBV vaccine.
• Pneumococcal vaccine. Patients should receive a dose of PCV13 (Prevnar 13), followed by a dose of PPV23 (Pneumovax) at least 8 weeks later. If a patient was previously vaccinated with PPV23, give PCV13 at least 1 year after PPV23.
• Influenza. Annual flu shot should be given.
• Varicella. Administer to HIV-infected persons with a CD4 count greater than 200 cells/mcL who do not have evidence of immunity to varicella.
• HPV. Indicated for females aged 9-26 years and males aged 9-26 years.
Ongoing monitoring
The main tests to follow in a patient with HIV infection to determine if treatment is successful are viral loads and CD4 counts. The viral load should be checked every 3-4 months after initial diagnosis or more frequently when beginning a new regimen. After 2-3 years of being treated and having their viral load successfully suppressed, a patient is considered stable, and the interval of time to test can be extended to every 6 months.
CD4 counts are a useful tool to assess for the need to start ART urgently as well as the effectiveness of ART. If the count drops below certain numbers, the CD4 count can determine the need for prophylactic therapy against opportunistic infections. For CD4 counts in a stable patient who has a suppressed viral load and an adequate CD4 response, the interval of time between monitoring can be extended to every 6-12 months. There are certain metabolic concerns that need frequent monitoring that are associated with the HIV infection itself and the different side effects of specific treatments. Renal function, complete blood count, lipid panel, fasting glucose, hemoglobin A1c, and liver function studies all require frequent monitoring.
Cervical cancer screening is important, and HIV patients are an exception to the newer lengthened screening interval recommendations. Women with HIV infection should have a pap smear at the time of HIV infection diagnosis, repeated at 6 months, then annually thereafter.
The bottom line
The prognosis of people living with HIV infection continues to improve because of new classes of treatment therapies. HIV infection has become a chronic illness, with which patients can live a long life if they take an active role in their treatment. For this reason, the primary care provider has a vital role in the management of HIV-infected persons. At each visit, the primary care provider should discuss the person’s HIV infection and emphasize the importance of adherence to ART, follow-up visits, and overall participation in their care.
References
Aberg J.A., et al. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. IDSA Guidelines 2013, 1-30.
Moyer, V., et al. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann. Int. Med., April 30, 2013, 1-10.
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. Baranck is a second-year resident and will be one of next year’s chief residents in the Family Medicine Residency Program at Abington Memorial Hospital.
Simplicity of ‘Neighbor Rosicky’ keeps the doctor in me going
How often have you read "Neighbor Rosicky" by Willa Cather?
Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.
It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.
At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.
I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.
But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.
It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").
So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How often have you read "Neighbor Rosicky" by Willa Cather?
Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.
It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.
At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.
I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.
But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.
It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").
So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
How often have you read "Neighbor Rosicky" by Willa Cather?
Really? You should. It’ll take maybe an hour, at most. You can likely find it free online.
It was an assignment for a college literature class I took in 1987. A lot of the things we read weren’t particularly memorable, but this one grabbed me. It’s a simple story about life, aging, and family, partially told through the eyes of a young doctor. At the same time it has both very little and a lot to do with being a doctor. It wasn’t my sole inspiration to become one, but it struck a chord that made me feel like it was the right thing for me.
At its heart and soul, it’s why, I believe, many of us become doctors. In the modern era, it’s also likely more fantasy than reality. But the basic theme is there: helping patients who genuinely need you and who appreciate what you do for them, even when the news isn’t good.
I’m sure there are still areas (though not many in the Western world) where medicine is more like the story. Besides, neurology is a pretty tech-dependent field. We couldn’t do our job without advanced imaging, electroencephalography, electromyography and nerve conduction velocity testing, etc.
But we still care for patients. For all the labels that get put on us (practitioners, providers, defendants, etc.) what we do now is still what the shamans did ages ago: try to help sick people with the tools that are available to us. And that, at the center of things, is what being a doctor is about.
It’s an idea that’s easy to lose sight of these days, with the endless forms for medication and test authorizations; news articles about how we’re overpaid, underpaid, inebriated, suicidal, or dangerous; and where there’s an emphasis on patient satisfaction that doesn’t necessarily involve clinical outcomes ("my migraines are better, but I was disappointed I wasn’t offered a beverage while waiting for the doctor").
So, I keep a copy of "Neighbor Rosicky" on my Kindle, and read it when I need to remind myself why I like this job. Sometimes even grateful patients forget to say thank you, and it’s good to remember that we are, for the most part, appreciated.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Oppositional behavior
Introduction
All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.
Case summary
A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.
Discussion
Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.
There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.
When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role
In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.
These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.
It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.
How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.
Introduction
All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.
Case summary
A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.
Discussion
Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.
There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.
When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role
In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.
These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.
It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.
How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.
Introduction
All children learn to say "no" and want to experiment with asserting their will, but children who frequently refuse to comply are extremely challenging, making oppositional behavior one of the most common presentations to pediatricians and child psychiatrists.
Case summary
A 4-and-a-half-year-old boy whose parents have been divorced for 2 years presents with a 2-year history of aggression toward other kids in day care, biting and kicking, and tantrums and defiance when he doesn’t want to do something, especially transition from one activity to another. These episodes are brief but have been increasing in frequency and severity, and recently, he has been hitting his mother when it is time to leave the playground. His parents have tried reasoning with him, providing warnings, time-outs, and counting to 3. "Nothing works." He argues constantly and gets irritable easily. He also has a high energy level and short attention span and sometimes gets anxious over small issues.
Discussion
Psychologists who systematically observe families that struggle with this kind of behavior often see a cycle of child refusal and parental frustration and desperate attempts to force the child to comply by finding the right punishment. Parents often repeat their instructions over and over without success, getting increasingly frustrated, sometimes yelling or hitting. When parents achieve success after yelling, they may end up thinking that it is only verbal, or even physical, aggression that will force the child to comply. Parents may also give up at other times, teaching the child that sometimes their refusals will help him to avoid a task. There can be gradual escalation in tantrums, yelling, or physical aggression on the part of both parents and the child over the years.
There are often underlying aspects of the child’s temperament and genetic make-up that contribute to this cycle. Aspects of temperament such as difficulties with transitions to new activities, quick negative emotional responses, and stubbornness contribute. Attention deficit/hyperactivity disorder (ADHD) and language difficulties are also common factors. Parents’ own personalities, emotional, and behavioral issues, and outside stressors affecting the family also increase the chance of entering this distressing cycle. In this case, the child’s behavior seemed to start or worsen after the stressor of the divorce, and he has some symptoms suggestive of ADHD as well as irritability and anxiety, which might be an adjustment response to the divorce, an aspect of his temperament, or a more clinical mood disorder.
When facing a complex picture such as this, it can be helpful to obtain general behavioral rating scales such as the Child Behavior Checklist (CBCL) or Behavior Assessment System for Children (BASC) from parents and teachers to assess how severe differing components of the presentation are in comparison to other children of the same age and sex. Developmental assessments including information from schools can help clarify cognitive and language issues that may play a role
In addition to addressing any underlying issues, the intervention best supported by evidence is training parents in behavioral skills to address the oppositional and impulsive behavior. Teaching parents specific skills to notice and reinforce good behaviors while decreasing reinforcement for bad behaviors improves the relationship and motivates children to behave better. The second part of this type of program involves replacing yelling and harsh punishments with mild consequences that are delivered calmly and very consistently.
These skills may sound simple but can be challenging to put in place. Specific programs that give parents abundant opportunities to practice and master the skills through practice with their child in session and role plays have repeatedly been demonstrated to improve compliance and relationships with the child. Specific, very-well-researched programs include Helping the Noncompliant Child, Parent Child Interaction Therapy, The Incredible Years, Triple P, Parent Management Training Oregon, Parent Management Training (Kazdin), and The Defiant Teen and The Defiant Child.
It can sometimes be difficult to find therapists experienced with these programs. It is worth inquiring about the specific programs therapists use or even encouraging therapists to get trained in a specific program. Manuals are readily available for Helping the Noncompliant Child, Parent Management Training (Kazdin), and The Defiant Child and The Defiant Teen among others. The Yale Parenting Center offers online or phone consultation. Information about training in all of the above programs is available online.
How we talk to parents about the complex factors that play into oppositional behavior sets the stage for treatment. Parents often feel overwhelmed, guilty, and defensive. I stress that the difficulties do not originate with the parent but are a mix of the stresses the family experiences, the child’s temperament and genetic make-up, and the parent’s own temperament, and parenting style. I emphasize how challenging children can be and that it is not obvious how to respond to these behaviors. And I stress that we want to address the issue in as many ways as we can and that parents are the most important people in their children’s lives. In the end, such programs often help parents feel empowered and closer to their children.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. She provides periodic trainings in Helping the Noncompliant Child and the use of the manual Parent Management Training by Alan Kazdin but has no financial conflicts relevant to this article.
Bellis perennis
Known also as the common daisy or English daisy, Bellis perennis is a perennial plant belonging to the Asteraceae or Compositae (aster, daisy, or sunflower) family. Native to Europe and North Africa, it has been used in traditional medicine in Europe since the Middle Ages to treat bruises, broken bones, muscle pain, cutaneous wounds, and rheumatism. Other skin applications include eczema, boils, inflammation, and purulent skin disease. In addition, B. perennis has been used in folk medicine to treat upper respiratory tract infections, gastritis, stomachache, diarrhea, bleeding, rheumatism, common colds, and headache (Pharm. Biol. 2014 March 12 [Epub ahead of print]; Pharm. Biol. 2012;50:1031-7; Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; Chem. Pharm. Bull. [Tokyo] 2011;59:889-95; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Chemistry
B. perennis roots and flowers have been shown to contain several important bioactive constituents, including triterpene saponins, anthocyanins, flavonoids, polysaccharides, and polyacetylenes (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; SOFW J. 2005;131:40-9). In 2008, Morikawa et al. identified newly isolated triterpene saponins in B. perennis. These compounds, labeled as perennisosides I-VII, exhibited inhibitory activity on serum triglyceride elevation in olive oil–treated mice (J. Nat. Prod. 2008;71:828-35). That same year, Yoshikawa et al. isolated six new acylated oleanane-type triterpene oligoglycosides (perennisaponins A-F) from the flowers of B. perennis in addition to 14 saponins, 9 flavonoids, and 2 glycosides (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68).
In 2011, Morikawa et al. isolated five new triterpene saponins (perennisosides VIII-XII) from the methanolic extract of B. perennis flowers. The extract was shown to suppress gastric emptying in olive oil–laded mice (Chem. Pharm. Bull. [Tokyo] 2011;59:889-95).
Early in 2014, Pehlivan et al. used bioassay-guided fractionation and isolation procedures to isolate an oleanane-type saponin from B. perennis that exhibited antitumor activity, the first such finding associated with B. perennis flowers. Tumor inhibition of 99% was achieved by the most active fraction at 3,000 mg/L (Pharm. Biol. 2014 March 12 [Epub ahead of print]).
Wound-healing capacity
In 2012, Karakas et al. studied the wound-healing activity displayed by the dried flowers of B. perennis in 12 male adult Wistar albino rats over a 30-day period. Six wounds were introduced onto each animal, with two treated topically once a day with a hydrophilic ointment containing an n-butanol fraction of B. perennis, two treated daily with the ointment minus the B. perennis fraction, and two untreated wounds used as control. Statistically significant differences were noted with 100% wound closure in the B. perennis group, 87% in the control group, and 85% in the other treatment group. The investigators concluded that their findings represented the first scientific confirmation supporting the traditional usage of B. perennis for wound healing. They noted that the topical administration of an ointment formulated with an n-butanol fraction of B. perennis flowers exhibits wound healing activity without inducing scars in a circular excision wound model in rats (Pharm. Biol. 2012;50:1031-7).
Antimicrobial activity against gram-positive and gram-negative bacteria, as well as anticancer activity against human leukemia cells in vitro, has also been associated with B. perennis (Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Skin-lightening activity
Extracts of B. perennis are included in the product Belides that has been combined in a formulation with emblica and licorice for use as a skin-lightening agent. In 2010, Costa et al. conducted a monoblind clinical study to assess the clinical efficacy of the combination of Belides, emblica, and licorice 7%, compared with hydroquinone 2% for the treatment of epidermal or mixed melasma in 56 women aged 18-60 years. Subjects (ranging from Fitzpatrick skin type I to IV) exclusively used an SPF 35 sunscreen for 60 days before being selected for either the herbal combination cream treatment, applied twice daily, or the hydroquinone group, applied nightly.
Depigmentation was observed in 78.3% of the herbal combination group and 88.9% of the hydroquinone group, among the 23 volunteers in the herbal group and 27 in the hydroquinone group who completed the study. No statistically significant differences were found between the treatment regimens in ameliorating melasma, but fewer adverse cutaneous reactions were associated with the herbal treatment. The investigators found the combination of Belides, emblica, and licorice to be a safe and effective option for treating melasma (An. Bras. Dermatol. 2010;85:613-20). Previously, Belides was shown to be nearly twice as active as arbutin and an effective skin-lightening agent in a pilot study with human volunteers (SOFW J. 2005;131:40-9; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Conclusion
The roots and flowers of B. perennis have been used for many years in traditional medicine to treat various conditions, including skin disorders. While modern scientific interest has been piqued, the current body of evidence is meager. Much more research is necessary to determine the potential role of topical B. perennis in the dermatologic armamentarium. But recent data and the history of traditional use suggest that such research is warranted.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Known also as the common daisy or English daisy, Bellis perennis is a perennial plant belonging to the Asteraceae or Compositae (aster, daisy, or sunflower) family. Native to Europe and North Africa, it has been used in traditional medicine in Europe since the Middle Ages to treat bruises, broken bones, muscle pain, cutaneous wounds, and rheumatism. Other skin applications include eczema, boils, inflammation, and purulent skin disease. In addition, B. perennis has been used in folk medicine to treat upper respiratory tract infections, gastritis, stomachache, diarrhea, bleeding, rheumatism, common colds, and headache (Pharm. Biol. 2014 March 12 [Epub ahead of print]; Pharm. Biol. 2012;50:1031-7; Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; Chem. Pharm. Bull. [Tokyo] 2011;59:889-95; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Chemistry
B. perennis roots and flowers have been shown to contain several important bioactive constituents, including triterpene saponins, anthocyanins, flavonoids, polysaccharides, and polyacetylenes (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; SOFW J. 2005;131:40-9). In 2008, Morikawa et al. identified newly isolated triterpene saponins in B. perennis. These compounds, labeled as perennisosides I-VII, exhibited inhibitory activity on serum triglyceride elevation in olive oil–treated mice (J. Nat. Prod. 2008;71:828-35). That same year, Yoshikawa et al. isolated six new acylated oleanane-type triterpene oligoglycosides (perennisaponins A-F) from the flowers of B. perennis in addition to 14 saponins, 9 flavonoids, and 2 glycosides (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68).
In 2011, Morikawa et al. isolated five new triterpene saponins (perennisosides VIII-XII) from the methanolic extract of B. perennis flowers. The extract was shown to suppress gastric emptying in olive oil–laded mice (Chem. Pharm. Bull. [Tokyo] 2011;59:889-95).
Early in 2014, Pehlivan et al. used bioassay-guided fractionation and isolation procedures to isolate an oleanane-type saponin from B. perennis that exhibited antitumor activity, the first such finding associated with B. perennis flowers. Tumor inhibition of 99% was achieved by the most active fraction at 3,000 mg/L (Pharm. Biol. 2014 March 12 [Epub ahead of print]).
Wound-healing capacity
In 2012, Karakas et al. studied the wound-healing activity displayed by the dried flowers of B. perennis in 12 male adult Wistar albino rats over a 30-day period. Six wounds were introduced onto each animal, with two treated topically once a day with a hydrophilic ointment containing an n-butanol fraction of B. perennis, two treated daily with the ointment minus the B. perennis fraction, and two untreated wounds used as control. Statistically significant differences were noted with 100% wound closure in the B. perennis group, 87% in the control group, and 85% in the other treatment group. The investigators concluded that their findings represented the first scientific confirmation supporting the traditional usage of B. perennis for wound healing. They noted that the topical administration of an ointment formulated with an n-butanol fraction of B. perennis flowers exhibits wound healing activity without inducing scars in a circular excision wound model in rats (Pharm. Biol. 2012;50:1031-7).
Antimicrobial activity against gram-positive and gram-negative bacteria, as well as anticancer activity against human leukemia cells in vitro, has also been associated with B. perennis (Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Skin-lightening activity
Extracts of B. perennis are included in the product Belides that has been combined in a formulation with emblica and licorice for use as a skin-lightening agent. In 2010, Costa et al. conducted a monoblind clinical study to assess the clinical efficacy of the combination of Belides, emblica, and licorice 7%, compared with hydroquinone 2% for the treatment of epidermal or mixed melasma in 56 women aged 18-60 years. Subjects (ranging from Fitzpatrick skin type I to IV) exclusively used an SPF 35 sunscreen for 60 days before being selected for either the herbal combination cream treatment, applied twice daily, or the hydroquinone group, applied nightly.
Depigmentation was observed in 78.3% of the herbal combination group and 88.9% of the hydroquinone group, among the 23 volunteers in the herbal group and 27 in the hydroquinone group who completed the study. No statistically significant differences were found between the treatment regimens in ameliorating melasma, but fewer adverse cutaneous reactions were associated with the herbal treatment. The investigators found the combination of Belides, emblica, and licorice to be a safe and effective option for treating melasma (An. Bras. Dermatol. 2010;85:613-20). Previously, Belides was shown to be nearly twice as active as arbutin and an effective skin-lightening agent in a pilot study with human volunteers (SOFW J. 2005;131:40-9; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Conclusion
The roots and flowers of B. perennis have been used for many years in traditional medicine to treat various conditions, including skin disorders. While modern scientific interest has been piqued, the current body of evidence is meager. Much more research is necessary to determine the potential role of topical B. perennis in the dermatologic armamentarium. But recent data and the history of traditional use suggest that such research is warranted.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
Known also as the common daisy or English daisy, Bellis perennis is a perennial plant belonging to the Asteraceae or Compositae (aster, daisy, or sunflower) family. Native to Europe and North Africa, it has been used in traditional medicine in Europe since the Middle Ages to treat bruises, broken bones, muscle pain, cutaneous wounds, and rheumatism. Other skin applications include eczema, boils, inflammation, and purulent skin disease. In addition, B. perennis has been used in folk medicine to treat upper respiratory tract infections, gastritis, stomachache, diarrhea, bleeding, rheumatism, common colds, and headache (Pharm. Biol. 2014 March 12 [Epub ahead of print]; Pharm. Biol. 2012;50:1031-7; Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; Chem. Pharm. Bull. [Tokyo] 2011;59:889-95; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Chemistry
B. perennis roots and flowers have been shown to contain several important bioactive constituents, including triterpene saponins, anthocyanins, flavonoids, polysaccharides, and polyacetylenes (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68; SOFW J. 2005;131:40-9). In 2008, Morikawa et al. identified newly isolated triterpene saponins in B. perennis. These compounds, labeled as perennisosides I-VII, exhibited inhibitory activity on serum triglyceride elevation in olive oil–treated mice (J. Nat. Prod. 2008;71:828-35). That same year, Yoshikawa et al. isolated six new acylated oleanane-type triterpene oligoglycosides (perennisaponins A-F) from the flowers of B. perennis in addition to 14 saponins, 9 flavonoids, and 2 glycosides (Chem. Pharm. Bull. [Tokyo] 2008;56:559-68).
In 2011, Morikawa et al. isolated five new triterpene saponins (perennisosides VIII-XII) from the methanolic extract of B. perennis flowers. The extract was shown to suppress gastric emptying in olive oil–laded mice (Chem. Pharm. Bull. [Tokyo] 2011;59:889-95).
Early in 2014, Pehlivan et al. used bioassay-guided fractionation and isolation procedures to isolate an oleanane-type saponin from B. perennis that exhibited antitumor activity, the first such finding associated with B. perennis flowers. Tumor inhibition of 99% was achieved by the most active fraction at 3,000 mg/L (Pharm. Biol. 2014 March 12 [Epub ahead of print]).
Wound-healing capacity
In 2012, Karakas et al. studied the wound-healing activity displayed by the dried flowers of B. perennis in 12 male adult Wistar albino rats over a 30-day period. Six wounds were introduced onto each animal, with two treated topically once a day with a hydrophilic ointment containing an n-butanol fraction of B. perennis, two treated daily with the ointment minus the B. perennis fraction, and two untreated wounds used as control. Statistically significant differences were noted with 100% wound closure in the B. perennis group, 87% in the control group, and 85% in the other treatment group. The investigators concluded that their findings represented the first scientific confirmation supporting the traditional usage of B. perennis for wound healing. They noted that the topical administration of an ointment formulated with an n-butanol fraction of B. perennis flowers exhibits wound healing activity without inducing scars in a circular excision wound model in rats (Pharm. Biol. 2012;50:1031-7).
Antimicrobial activity against gram-positive and gram-negative bacteria, as well as anticancer activity against human leukemia cells in vitro, has also been associated with B. perennis (Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Skin-lightening activity
Extracts of B. perennis are included in the product Belides that has been combined in a formulation with emblica and licorice for use as a skin-lightening agent. In 2010, Costa et al. conducted a monoblind clinical study to assess the clinical efficacy of the combination of Belides, emblica, and licorice 7%, compared with hydroquinone 2% for the treatment of epidermal or mixed melasma in 56 women aged 18-60 years. Subjects (ranging from Fitzpatrick skin type I to IV) exclusively used an SPF 35 sunscreen for 60 days before being selected for either the herbal combination cream treatment, applied twice daily, or the hydroquinone group, applied nightly.
Depigmentation was observed in 78.3% of the herbal combination group and 88.9% of the hydroquinone group, among the 23 volunteers in the herbal group and 27 in the hydroquinone group who completed the study. No statistically significant differences were found between the treatment regimens in ameliorating melasma, but fewer adverse cutaneous reactions were associated with the herbal treatment. The investigators found the combination of Belides, emblica, and licorice to be a safe and effective option for treating melasma (An. Bras. Dermatol. 2010;85:613-20). Previously, Belides was shown to be nearly twice as active as arbutin and an effective skin-lightening agent in a pilot study with human volunteers (SOFW J. 2005;131:40-9; Lim, T.K. Edible Medicinal and Non-Medicinal Plants. Springer: Dordrecht, 2014, pp. 204-11).
Conclusion
The roots and flowers of B. perennis have been used for many years in traditional medicine to treat various conditions, including skin disorders. While modern scientific interest has been piqued, the current body of evidence is meager. Much more research is necessary to determine the potential role of topical B. perennis in the dermatologic armamentarium. But recent data and the history of traditional use suggest that such research is warranted.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in Miami Beach. She founded the cosmetic dermatology center at the University of Miami in 1997. Dr. Baumann wrote the textbook "Cosmetic Dermatology: Principles and Practice" (McGraw-Hill, April 2002), and a book for consumers, "The Skin Type Solution" (Bantam, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001 and joined the editorial advisory board in 2004. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Galderma, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Stiefel, Topix Pharmaceuticals, and Unilever.
