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A cigarette in one hand and a Fitbit on the other
A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A1c.
My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …
My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.
The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.
When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.
With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.
When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.
Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.
For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …
We are interested in your thoughts. Please email us at [email protected].
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A1c.
My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …
My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.
The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.
When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.
With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.
When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.
Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.
For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …
We are interested in your thoughts. Please email us at [email protected].
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
A cardiologist friend of mine told me a story about one of his patients. The man had recently been in to see him for an office visit. He had quite a scare needing two stents after an episode of prolonged chest pain and, during the office visit, apparently had said that he had “found religion” and was going to change his ways. He showed off the Fitbit that he had gotten and shared his excitement about using a new app to track his diet on his smart phone. His blood pressure was a little elevated, so my friend added a third antihypertensive in an effort to get his blood pressure under control. He referred the patient back to his primary care physician to address his elevated hemoglobin A1c.
My friend saw the patient again a couple of weeks later – this time at the mall. As he was driving through the parking lot, he noticed his patient sitting on a bench outside the entrance. He also noticed a cigarette in his patient’s right hand and saw the Fitbit still on his wrist. Now, it’s not that there is anything wrong with wearing a Fitbit, but …
My friend is an incredibly respectful person, and very nice. He decided not to say hello and risk embarrassing his patient, so he walked to a different door far from the bench and went inside. Nonetheless, the image bothered him. It bothered him enough to repeat the story to me 2 weeks later. It bothers me too.
The other day I was talking to a healthy young nurse with whom I work. She has been trying to get into shape, and her goal is to get to the gym 5 days a week after work. She read on a popular website that she should use a heart rate monitor to keep track of her training and that, if her heart rate is too slow, she should run faster and, if her heart rate is too fast, she should slow down. She was discouraged the other day, however, because her watch indicated that her pulse was going up to 170 while she was running hard, and she had heard that could be dangerous for her heart.
When she doesn’t push hard, though, she told me that her heart rate often plateaus at about 110, sometimes 115. She has been finding it difficult to achieve her calculated target heart rate of 120-160 beats per minute. She is frustrated and was going to skip her workout that evening. I explained to her that she should stop checking her pulse and just run – if she felt she was running too slow she could run faster.
With everything that we have learned about science and technology, the reality is that we are still people, with all our weaknesses and strengths. We often set goals with ambivalence, then rush forward hoping that a technological solution will move us in the direction we think we want to move. Unfortunately, owning a Fitbit will not make us more fit, and checking our pulse every five minutes while working out will not lead to a better exercise session. With the availability of so much technology for tracking our daily exercise, vital signs, and various other measures of health, we need to be more careful than ever to determine specifically what it is that we are trying to accomplish with the use of our technology.
When it comes to good health, it is the fundamentals that matter, and achieving the fundamentals requires being mindful and making repeated efforts to master them. For almost all adults, the most important habits to develop are still related to diet and exercise. Consuming the right diet and exercising adequately requires that the correct choices be made each and every day, all day long. Technology can help but will not do it for us. We need to be thoughtful about how we use technology and explicit about how we expect it to help. After a reasonable amount of time, we should evaluate to see if it is working for us. If it is, then we should continue to use it. If it is not, then we should stop using it or make a different change, like performing a new type of exercise.
Our goal should be to have intelligent empathic integration of technological and behavioral techniques to achieve an optimal health outcome. Putting running shoes by the bed at night is a great thing to do to encourage us to run in the morning. Choosing motivational music can help us get the energy and enthusiasm to go for that run (our favorites include the Rocky theme song and “I Didn’t Come this Far to Only Come this Far”). A visual reminder over the refrigerator can “nudge” us to make good choices as we open the door.
For those who want to learn more about how to integrate behavioral management into their advice for patients we highly recommend reading “Switch: How to Change Things When Change Is Hard” by Chip Heath and “Nudge: Improving Decisions About Health, Wealth, and Happiness” by Richard Thaler. We have always been, and remain, excited about the promise of technology to help us accomplish our goals. That said, we told the nurse to stop checking her pulse, to put on some music, and to appreciate the leaves on the trees this autumn while she was running. As for the gentleman outside the mall, well …
We are interested in your thoughts. Please email us at [email protected].
Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on Twitter @doctornotte. Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington Jefferson Health.
Is carpal tunnel syndrome the tip of the iceberg?
He takes the following medications: felodipine and atorvastatin. On exam, his blood pressure is 110/60 mm Hg, and his pulse is 90 beats per minute.
A cardiac examination found normal heart sounds with no murmurs.
A chest examination found dullness to percussion at both bases and rales.
A chest x-ray showed bilateral effusions and mild pulmonary edema.
The brain natriuretic peptide test found a level of 1,300 picograms/mL.
An ECG found increased ventricular wall thickness, an ejection fraction of 32%, and normal aortic and mitral valves.
What history would be the most helpful in making a diagnosis?
A. History of prostate cancer
B. History of carpal tunnel syndrome
C. History of playing professional football
D. History of hyperlipidemia
E. History of ulcerative colitis
The correct answer here would be B. history of carpal tunnel syndrome (CTS). This patient has clinical heart failure, without a history of clinical ischemic disease. The differential diagnosis for causes of heart failure is long, with the most common causes being chronic hypertension and ischemic heart disease. Other common causes include chronic untreated sleep apnea and valvular heart disease.
This patient really does not have clear reasons for having clinical heart failure. His cardiovascular risk factors have been well controlled, and no valvular disease was found on ECG.
Several recent reports have raised the importance of a history of CTS significantly increasing the likelihood of amyloidosis being the cause of underlying heart failure.
CTS is such a common clinical entity that it is easy to not appreciate its presence as a clue to possible amyloid cardiomyopathy. Fosbøl et al. reported that a diagnosis of CTS was associated with a higher incidence of heart failure (hazard ratio, 1.54; CI, 1.45-1.64).1 They found a highly increased risk of amyloid (HR, 12.2) in patients who had surgery for CTS.
Sperry et al. found that over 10% of patients who underwent carpal tunnel release stained for amyloid on biopsy specimens, and that concomitant cardiac evaluation identified patients with cardiac involvement.2
Pinney et al. found that 48% of patients with transthyretin amyloidosis had a history of CTS.3
In a retrospective study of patients with wild-type transthyretin amyloid (253), patients with hereditary transthyretin amyloid (136), and asymptomatic gene carriers (77), participants were screened for a history of spinal stenosis and CTS.4 Almost 60% of the patients with amyloid had a history of CTS, and 11% had a history of spinal stenosis. Patients with CTS and hereditary amyloid had thicker interventricular septums, higher left ventricular mass, and lower Karnovsky index than those without CTS.
The diagnosis of CTS, especially in those who need surgery for treatment or have bilateral disease, should make us consider the possibility of underlying amyloidosis.
Pearl: In patients who have heart failure and a history of CTS, amyloidosis should be considered as a cause.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at [email protected].
References
1. Fosbøl EL et al. J Am Coll Cardiol. 2019;74:15-23.
2. Sperry BW et al. J Am Coll Cardiol. 2018 Oct 23;72(17):2040-50.
3. Pinney JH et al. J Am Heart Assoc. 2013 Apr 22;2(2):e000098.
4. Aus dem Siepen F et al. Clin Res Cardiol. 2019 Apr 5. doi: 10.1007/s00392-019-01467-1.
He takes the following medications: felodipine and atorvastatin. On exam, his blood pressure is 110/60 mm Hg, and his pulse is 90 beats per minute.
A cardiac examination found normal heart sounds with no murmurs.
A chest examination found dullness to percussion at both bases and rales.
A chest x-ray showed bilateral effusions and mild pulmonary edema.
The brain natriuretic peptide test found a level of 1,300 picograms/mL.
An ECG found increased ventricular wall thickness, an ejection fraction of 32%, and normal aortic and mitral valves.
What history would be the most helpful in making a diagnosis?
A. History of prostate cancer
B. History of carpal tunnel syndrome
C. History of playing professional football
D. History of hyperlipidemia
E. History of ulcerative colitis
The correct answer here would be B. history of carpal tunnel syndrome (CTS). This patient has clinical heart failure, without a history of clinical ischemic disease. The differential diagnosis for causes of heart failure is long, with the most common causes being chronic hypertension and ischemic heart disease. Other common causes include chronic untreated sleep apnea and valvular heart disease.
This patient really does not have clear reasons for having clinical heart failure. His cardiovascular risk factors have been well controlled, and no valvular disease was found on ECG.
Several recent reports have raised the importance of a history of CTS significantly increasing the likelihood of amyloidosis being the cause of underlying heart failure.
CTS is such a common clinical entity that it is easy to not appreciate its presence as a clue to possible amyloid cardiomyopathy. Fosbøl et al. reported that a diagnosis of CTS was associated with a higher incidence of heart failure (hazard ratio, 1.54; CI, 1.45-1.64).1 They found a highly increased risk of amyloid (HR, 12.2) in patients who had surgery for CTS.
Sperry et al. found that over 10% of patients who underwent carpal tunnel release stained for amyloid on biopsy specimens, and that concomitant cardiac evaluation identified patients with cardiac involvement.2
Pinney et al. found that 48% of patients with transthyretin amyloidosis had a history of CTS.3
In a retrospective study of patients with wild-type transthyretin amyloid (253), patients with hereditary transthyretin amyloid (136), and asymptomatic gene carriers (77), participants were screened for a history of spinal stenosis and CTS.4 Almost 60% of the patients with amyloid had a history of CTS, and 11% had a history of spinal stenosis. Patients with CTS and hereditary amyloid had thicker interventricular septums, higher left ventricular mass, and lower Karnovsky index than those without CTS.
The diagnosis of CTS, especially in those who need surgery for treatment or have bilateral disease, should make us consider the possibility of underlying amyloidosis.
Pearl: In patients who have heart failure and a history of CTS, amyloidosis should be considered as a cause.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at [email protected].
References
1. Fosbøl EL et al. J Am Coll Cardiol. 2019;74:15-23.
2. Sperry BW et al. J Am Coll Cardiol. 2018 Oct 23;72(17):2040-50.
3. Pinney JH et al. J Am Heart Assoc. 2013 Apr 22;2(2):e000098.
4. Aus dem Siepen F et al. Clin Res Cardiol. 2019 Apr 5. doi: 10.1007/s00392-019-01467-1.
He takes the following medications: felodipine and atorvastatin. On exam, his blood pressure is 110/60 mm Hg, and his pulse is 90 beats per minute.
A cardiac examination found normal heart sounds with no murmurs.
A chest examination found dullness to percussion at both bases and rales.
A chest x-ray showed bilateral effusions and mild pulmonary edema.
The brain natriuretic peptide test found a level of 1,300 picograms/mL.
An ECG found increased ventricular wall thickness, an ejection fraction of 32%, and normal aortic and mitral valves.
What history would be the most helpful in making a diagnosis?
A. History of prostate cancer
B. History of carpal tunnel syndrome
C. History of playing professional football
D. History of hyperlipidemia
E. History of ulcerative colitis
The correct answer here would be B. history of carpal tunnel syndrome (CTS). This patient has clinical heart failure, without a history of clinical ischemic disease. The differential diagnosis for causes of heart failure is long, with the most common causes being chronic hypertension and ischemic heart disease. Other common causes include chronic untreated sleep apnea and valvular heart disease.
This patient really does not have clear reasons for having clinical heart failure. His cardiovascular risk factors have been well controlled, and no valvular disease was found on ECG.
Several recent reports have raised the importance of a history of CTS significantly increasing the likelihood of amyloidosis being the cause of underlying heart failure.
CTS is such a common clinical entity that it is easy to not appreciate its presence as a clue to possible amyloid cardiomyopathy. Fosbøl et al. reported that a diagnosis of CTS was associated with a higher incidence of heart failure (hazard ratio, 1.54; CI, 1.45-1.64).1 They found a highly increased risk of amyloid (HR, 12.2) in patients who had surgery for CTS.
Sperry et al. found that over 10% of patients who underwent carpal tunnel release stained for amyloid on biopsy specimens, and that concomitant cardiac evaluation identified patients with cardiac involvement.2
Pinney et al. found that 48% of patients with transthyretin amyloidosis had a history of CTS.3
In a retrospective study of patients with wild-type transthyretin amyloid (253), patients with hereditary transthyretin amyloid (136), and asymptomatic gene carriers (77), participants were screened for a history of spinal stenosis and CTS.4 Almost 60% of the patients with amyloid had a history of CTS, and 11% had a history of spinal stenosis. Patients with CTS and hereditary amyloid had thicker interventricular septums, higher left ventricular mass, and lower Karnovsky index than those without CTS.
The diagnosis of CTS, especially in those who need surgery for treatment or have bilateral disease, should make us consider the possibility of underlying amyloidosis.
Pearl: In patients who have heart failure and a history of CTS, amyloidosis should be considered as a cause.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at that university. Contact Dr. Paauw at [email protected].
References
1. Fosbøl EL et al. J Am Coll Cardiol. 2019;74:15-23.
2. Sperry BW et al. J Am Coll Cardiol. 2018 Oct 23;72(17):2040-50.
3. Pinney JH et al. J Am Heart Assoc. 2013 Apr 22;2(2):e000098.
4. Aus dem Siepen F et al. Clin Res Cardiol. 2019 Apr 5. doi: 10.1007/s00392-019-01467-1.
Flu vaccine: Larger impact on influenza burden than you thought?
ID Week, the annual meeting of the Infectious Disease Society of America, provided valuable insights into past season’s endemic influenza burden and the effectiveness of prevention strategies. Each year, there are from 9million to 49 million influenza cases in the United States, 140,000-960,000 hospitalized cases, and 12,000-70,000 deaths directly attributable to influenza infection. The burden disproportionately falls on infants and adults 65 years of age and older; 11,000-48,000 children are hospitalized, and as many as several hundred children may die from influenza and related complications. School age children (aged 5-19 years) and adults (aged 30-39 years) are a major part of the transmission cycle. Influenza vaccine underlies the prevention strategy for limiting the burden of disease in U.S. populations. ID Week provided new insights into critical questions about influenza vaccines.
1. What is the effectiveness of influenza vaccine against severe disease (hospitalization) in children? Does it vary by age? By type or subtype?
Angela P. Campbell, MD, MPH, of the Centers for Disease Control and Prevention, and associates presented data on influenza vaccine effectiveness from the New Vaccine Surveillance Network in children for the 2016-2017 and 2017-2018 season (ID Week session 99; Abstract 899). During both 2016-2017 and 2017-2018, H3N2 was the dominant virus and influenza B represented about one-third of cases, and H1N1 was a greater percentage of cases in 2017-2018. Influenza positivity among children younger than 18 years of age admitted to hospital with respiratory disease was 14% among unvaccinated and 8% among vaccinated children; effectiveness again hospitalization was 50%. Vaccine effectiveness (VE) was not statistically different between children younger than 8 years of age and those older that 8 years but did differ by vaccine type. VE was 76% against H1N1 disease, 59% again B disease, and only 33% against H3N2 disease.
Clearly, vaccination with influenza vaccine prevents serious respiratory disease. However, the impact of vaccine will vary by season and by which influenza stains are circulating in the community. The authors concluded that further understanding of the lower VE against H3N2 disease is needed.
2. Does the priming dose of influenza vaccine improve vaccine effectiveness?
Current recommendations call for a two-dose series for influenza vaccine in children aged 6 months through 8 years who have not had prior influenza vaccine. The recommendation is based on evidence demonstrating higher antibody responses in children receiving two doses, compared with a single dose. Using data from the U.S. Influenza Vaccine Effectiveness Network, Jessie R. Chung, MPH, of the CDC, and associates compared VE in children younger than 2 years receiving two doses in the first year of flu immunization (fully immunized), compared with those who received only one dose (partially immunized) (ID Week session 99; Abstract 900). VE was 53% for fully immunized and 23% for partially immunized children. Receipt of a single dose did not provide statistically significant protection against influenza. Surprisingly (to me), of 5,355 children aged 6 months to less than 2 years with no prior influenza vaccine, 1,870 (35%) received only one dose in the season.
The data strongly support the current recommendations for a priming dose, especially in young children, in the first season of influenza vaccine and warrants increased efforts to increase the update of second doses during the season. Hopefully we can do better in 2019!
3. Should we wait to vaccinate with influenza vaccine?
Some evidence suggests that waning immunity to influenza vaccine, primarily in those aged 65 years and older, may explain increased disease activity toward the end of influenza season. Other explanations include increasing viral diversity throughout the season, resulting in reduced effectiveness. Do such concerns warrant delaying immunization? The onset and peak of influenza season varies by year; in October 2019, 3% of tests performed on patients with respiratory illness were influenza positive. The trade-offs for delaying immunization until October are the unpredictability of onset of influenza season, the requirement for two doses in infants, the need for 2 weeks to achieve peak antibody concentrations, and the potential that fewer individuals will be vaccinated. Kathy Neuzil, MD, MPH, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, reviewed recent modeling (for adults aged 65 years and older) and reported that delaying vaccine programs until October is associated with greater burden of hospitalization if 14% fewer individuals (who would be vaccinated in August/September) are vaccinated (ID Week; Session 940).
In response to these concerns, the CDC recommendations for 2019 are that, in children aged 6 months through 8 years who need two doses, start early so that you can achieve both doses before influenza season (MMWR 2019 Aug 23;68[3]:1-21).In older children and adults, who need only a single dose, early vaccination (August and early September) may lead to reduced protection late in the influenza season?
4. How can we optimize vaccine impact?
Vaccine impact refers to the affect on a population level and not at an individual level. Meagan C. Fitzpatrick, PhD, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, evaluated the benefits of our moderately effective influenza vaccines (VE 40%-60%) to the population beyond those who are vaccinated. Her conclusions were that even a modestly effective vaccine prevents 21 million cases of influenza, 129,000 hospitalizations, and 62,000 deaths. And that two-thirds of the deaths prevented are from herd benefit (or indirect effects). Although both coverage and vaccine effectiveness are important, she reported that population impact was most sensitive to coverage, compared with vaccine effectiveness. Dr. Fitzpatrick found that targeting school-age children 6-19 years of age and adults 30-39 years of age maximizes the public health benefits (herd effects) of influenza vaccine. In 2018 season, influenza coverage was 63% for at least one dose in children aged 6 months through 17 years and 45% in adults aged 18 years and older; in the two target age groups 5-17 and 30-39 years, coverage was 59% and approximately 35%, respectively (ID Week; Session 939).
Clearly, even our modestly effective influenza vaccines have significant public health benefit in protecting the U.S. populations from serious disease and death. Efforts to increase vaccine uptake in school-age children, both those with and without comorbidity, and the 30- to 39-year-old adult cohort would likely further reduce the burden of serious disease from influenza.
In summary, despite a vaccine that is only moderately effective, there is clear evidence to support current recommendations of universal immunization beginning at 6 months of age. Delaying until October 1 is a good idea only if the same number of individuals will receive influenza vaccine, otherwise the hypothetical benefit is lost.
Dr. Pelton is professor of pediatrics and epidemiology at Boston University schools of medicine and public health and is senior attending physician, Boston Medical Center. Dr. Pelton has investigator-initiated research awards to Boston Medical Center from Pfizer and Merck Vaccines. He also received honorarium as an advisory board member, participation in symposium and consultation from Seqirus and Merck Vaccine, Pfizer, and Sanofi Pasteur. Email him at [email protected].
ID Week, the annual meeting of the Infectious Disease Society of America, provided valuable insights into past season’s endemic influenza burden and the effectiveness of prevention strategies. Each year, there are from 9million to 49 million influenza cases in the United States, 140,000-960,000 hospitalized cases, and 12,000-70,000 deaths directly attributable to influenza infection. The burden disproportionately falls on infants and adults 65 years of age and older; 11,000-48,000 children are hospitalized, and as many as several hundred children may die from influenza and related complications. School age children (aged 5-19 years) and adults (aged 30-39 years) are a major part of the transmission cycle. Influenza vaccine underlies the prevention strategy for limiting the burden of disease in U.S. populations. ID Week provided new insights into critical questions about influenza vaccines.
1. What is the effectiveness of influenza vaccine against severe disease (hospitalization) in children? Does it vary by age? By type or subtype?
Angela P. Campbell, MD, MPH, of the Centers for Disease Control and Prevention, and associates presented data on influenza vaccine effectiveness from the New Vaccine Surveillance Network in children for the 2016-2017 and 2017-2018 season (ID Week session 99; Abstract 899). During both 2016-2017 and 2017-2018, H3N2 was the dominant virus and influenza B represented about one-third of cases, and H1N1 was a greater percentage of cases in 2017-2018. Influenza positivity among children younger than 18 years of age admitted to hospital with respiratory disease was 14% among unvaccinated and 8% among vaccinated children; effectiveness again hospitalization was 50%. Vaccine effectiveness (VE) was not statistically different between children younger than 8 years of age and those older that 8 years but did differ by vaccine type. VE was 76% against H1N1 disease, 59% again B disease, and only 33% against H3N2 disease.
Clearly, vaccination with influenza vaccine prevents serious respiratory disease. However, the impact of vaccine will vary by season and by which influenza stains are circulating in the community. The authors concluded that further understanding of the lower VE against H3N2 disease is needed.
2. Does the priming dose of influenza vaccine improve vaccine effectiveness?
Current recommendations call for a two-dose series for influenza vaccine in children aged 6 months through 8 years who have not had prior influenza vaccine. The recommendation is based on evidence demonstrating higher antibody responses in children receiving two doses, compared with a single dose. Using data from the U.S. Influenza Vaccine Effectiveness Network, Jessie R. Chung, MPH, of the CDC, and associates compared VE in children younger than 2 years receiving two doses in the first year of flu immunization (fully immunized), compared with those who received only one dose (partially immunized) (ID Week session 99; Abstract 900). VE was 53% for fully immunized and 23% for partially immunized children. Receipt of a single dose did not provide statistically significant protection against influenza. Surprisingly (to me), of 5,355 children aged 6 months to less than 2 years with no prior influenza vaccine, 1,870 (35%) received only one dose in the season.
The data strongly support the current recommendations for a priming dose, especially in young children, in the first season of influenza vaccine and warrants increased efforts to increase the update of second doses during the season. Hopefully we can do better in 2019!
3. Should we wait to vaccinate with influenza vaccine?
Some evidence suggests that waning immunity to influenza vaccine, primarily in those aged 65 years and older, may explain increased disease activity toward the end of influenza season. Other explanations include increasing viral diversity throughout the season, resulting in reduced effectiveness. Do such concerns warrant delaying immunization? The onset and peak of influenza season varies by year; in October 2019, 3% of tests performed on patients with respiratory illness were influenza positive. The trade-offs for delaying immunization until October are the unpredictability of onset of influenza season, the requirement for two doses in infants, the need for 2 weeks to achieve peak antibody concentrations, and the potential that fewer individuals will be vaccinated. Kathy Neuzil, MD, MPH, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, reviewed recent modeling (for adults aged 65 years and older) and reported that delaying vaccine programs until October is associated with greater burden of hospitalization if 14% fewer individuals (who would be vaccinated in August/September) are vaccinated (ID Week; Session 940).
In response to these concerns, the CDC recommendations for 2019 are that, in children aged 6 months through 8 years who need two doses, start early so that you can achieve both doses before influenza season (MMWR 2019 Aug 23;68[3]:1-21).In older children and adults, who need only a single dose, early vaccination (August and early September) may lead to reduced protection late in the influenza season?
4. How can we optimize vaccine impact?
Vaccine impact refers to the affect on a population level and not at an individual level. Meagan C. Fitzpatrick, PhD, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, evaluated the benefits of our moderately effective influenza vaccines (VE 40%-60%) to the population beyond those who are vaccinated. Her conclusions were that even a modestly effective vaccine prevents 21 million cases of influenza, 129,000 hospitalizations, and 62,000 deaths. And that two-thirds of the deaths prevented are from herd benefit (or indirect effects). Although both coverage and vaccine effectiveness are important, she reported that population impact was most sensitive to coverage, compared with vaccine effectiveness. Dr. Fitzpatrick found that targeting school-age children 6-19 years of age and adults 30-39 years of age maximizes the public health benefits (herd effects) of influenza vaccine. In 2018 season, influenza coverage was 63% for at least one dose in children aged 6 months through 17 years and 45% in adults aged 18 years and older; in the two target age groups 5-17 and 30-39 years, coverage was 59% and approximately 35%, respectively (ID Week; Session 939).
Clearly, even our modestly effective influenza vaccines have significant public health benefit in protecting the U.S. populations from serious disease and death. Efforts to increase vaccine uptake in school-age children, both those with and without comorbidity, and the 30- to 39-year-old adult cohort would likely further reduce the burden of serious disease from influenza.
In summary, despite a vaccine that is only moderately effective, there is clear evidence to support current recommendations of universal immunization beginning at 6 months of age. Delaying until October 1 is a good idea only if the same number of individuals will receive influenza vaccine, otherwise the hypothetical benefit is lost.
Dr. Pelton is professor of pediatrics and epidemiology at Boston University schools of medicine and public health and is senior attending physician, Boston Medical Center. Dr. Pelton has investigator-initiated research awards to Boston Medical Center from Pfizer and Merck Vaccines. He also received honorarium as an advisory board member, participation in symposium and consultation from Seqirus and Merck Vaccine, Pfizer, and Sanofi Pasteur. Email him at [email protected].
ID Week, the annual meeting of the Infectious Disease Society of America, provided valuable insights into past season’s endemic influenza burden and the effectiveness of prevention strategies. Each year, there are from 9million to 49 million influenza cases in the United States, 140,000-960,000 hospitalized cases, and 12,000-70,000 deaths directly attributable to influenza infection. The burden disproportionately falls on infants and adults 65 years of age and older; 11,000-48,000 children are hospitalized, and as many as several hundred children may die from influenza and related complications. School age children (aged 5-19 years) and adults (aged 30-39 years) are a major part of the transmission cycle. Influenza vaccine underlies the prevention strategy for limiting the burden of disease in U.S. populations. ID Week provided new insights into critical questions about influenza vaccines.
1. What is the effectiveness of influenza vaccine against severe disease (hospitalization) in children? Does it vary by age? By type or subtype?
Angela P. Campbell, MD, MPH, of the Centers for Disease Control and Prevention, and associates presented data on influenza vaccine effectiveness from the New Vaccine Surveillance Network in children for the 2016-2017 and 2017-2018 season (ID Week session 99; Abstract 899). During both 2016-2017 and 2017-2018, H3N2 was the dominant virus and influenza B represented about one-third of cases, and H1N1 was a greater percentage of cases in 2017-2018. Influenza positivity among children younger than 18 years of age admitted to hospital with respiratory disease was 14% among unvaccinated and 8% among vaccinated children; effectiveness again hospitalization was 50%. Vaccine effectiveness (VE) was not statistically different between children younger than 8 years of age and those older that 8 years but did differ by vaccine type. VE was 76% against H1N1 disease, 59% again B disease, and only 33% against H3N2 disease.
Clearly, vaccination with influenza vaccine prevents serious respiratory disease. However, the impact of vaccine will vary by season and by which influenza stains are circulating in the community. The authors concluded that further understanding of the lower VE against H3N2 disease is needed.
2. Does the priming dose of influenza vaccine improve vaccine effectiveness?
Current recommendations call for a two-dose series for influenza vaccine in children aged 6 months through 8 years who have not had prior influenza vaccine. The recommendation is based on evidence demonstrating higher antibody responses in children receiving two doses, compared with a single dose. Using data from the U.S. Influenza Vaccine Effectiveness Network, Jessie R. Chung, MPH, of the CDC, and associates compared VE in children younger than 2 years receiving two doses in the first year of flu immunization (fully immunized), compared with those who received only one dose (partially immunized) (ID Week session 99; Abstract 900). VE was 53% for fully immunized and 23% for partially immunized children. Receipt of a single dose did not provide statistically significant protection against influenza. Surprisingly (to me), of 5,355 children aged 6 months to less than 2 years with no prior influenza vaccine, 1,870 (35%) received only one dose in the season.
The data strongly support the current recommendations for a priming dose, especially in young children, in the first season of influenza vaccine and warrants increased efforts to increase the update of second doses during the season. Hopefully we can do better in 2019!
3. Should we wait to vaccinate with influenza vaccine?
Some evidence suggests that waning immunity to influenza vaccine, primarily in those aged 65 years and older, may explain increased disease activity toward the end of influenza season. Other explanations include increasing viral diversity throughout the season, resulting in reduced effectiveness. Do such concerns warrant delaying immunization? The onset and peak of influenza season varies by year; in October 2019, 3% of tests performed on patients with respiratory illness were influenza positive. The trade-offs for delaying immunization until October are the unpredictability of onset of influenza season, the requirement for two doses in infants, the need for 2 weeks to achieve peak antibody concentrations, and the potential that fewer individuals will be vaccinated. Kathy Neuzil, MD, MPH, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, reviewed recent modeling (for adults aged 65 years and older) and reported that delaying vaccine programs until October is associated with greater burden of hospitalization if 14% fewer individuals (who would be vaccinated in August/September) are vaccinated (ID Week; Session 940).
In response to these concerns, the CDC recommendations for 2019 are that, in children aged 6 months through 8 years who need two doses, start early so that you can achieve both doses before influenza season (MMWR 2019 Aug 23;68[3]:1-21).In older children and adults, who need only a single dose, early vaccination (August and early September) may lead to reduced protection late in the influenza season?
4. How can we optimize vaccine impact?
Vaccine impact refers to the affect on a population level and not at an individual level. Meagan C. Fitzpatrick, PhD, from the Center for Vaccine Development and Global Health, University of Maryland School of Medicine, evaluated the benefits of our moderately effective influenza vaccines (VE 40%-60%) to the population beyond those who are vaccinated. Her conclusions were that even a modestly effective vaccine prevents 21 million cases of influenza, 129,000 hospitalizations, and 62,000 deaths. And that two-thirds of the deaths prevented are from herd benefit (or indirect effects). Although both coverage and vaccine effectiveness are important, she reported that population impact was most sensitive to coverage, compared with vaccine effectiveness. Dr. Fitzpatrick found that targeting school-age children 6-19 years of age and adults 30-39 years of age maximizes the public health benefits (herd effects) of influenza vaccine. In 2018 season, influenza coverage was 63% for at least one dose in children aged 6 months through 17 years and 45% in adults aged 18 years and older; in the two target age groups 5-17 and 30-39 years, coverage was 59% and approximately 35%, respectively (ID Week; Session 939).
Clearly, even our modestly effective influenza vaccines have significant public health benefit in protecting the U.S. populations from serious disease and death. Efforts to increase vaccine uptake in school-age children, both those with and without comorbidity, and the 30- to 39-year-old adult cohort would likely further reduce the burden of serious disease from influenza.
In summary, despite a vaccine that is only moderately effective, there is clear evidence to support current recommendations of universal immunization beginning at 6 months of age. Delaying until October 1 is a good idea only if the same number of individuals will receive influenza vaccine, otherwise the hypothetical benefit is lost.
Dr. Pelton is professor of pediatrics and epidemiology at Boston University schools of medicine and public health and is senior attending physician, Boston Medical Center. Dr. Pelton has investigator-initiated research awards to Boston Medical Center from Pfizer and Merck Vaccines. He also received honorarium as an advisory board member, participation in symposium and consultation from Seqirus and Merck Vaccine, Pfizer, and Sanofi Pasteur. Email him at [email protected].
Primary CNS lymphoma: R-CHOP hits back
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive form of non-Hodgkin lymphoma solely confined to the CNS. The majority of PCNSL histologically presents as diffuse large B-cell lymphoma (DLBCL). However, outcomes in these patients are notably inferior, compared with nodal or other extranodal DLBCL. In order to achieve long-term progression-free survival, high-dose methotrexate (HD-MTX)–based chemotherapy followed by consolidation is needed. However, this treatment is associated with high toxicity burden and it is restricted to a select patient population – the young and fit – and requires administration at specialized hematological centers.
In the 1990s, the conventional DLBCL treatment regimen with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) was tested in PCNSL patients. The results were rather disappointing. The addition of CHOP to whole brain radiation or HD-MTX could not improve survival.1-3 The reason for CHOP failure was poor CNS penetration of doxorubicin and cyclophosphamide because of their high molecular weight. Consequently, it was concluded that there is no role for CHOP-like chemotherapy in the treatment of PCNSL.4
But is this really the case? Twenty years later, this traditional view has been challenged by Andres J.M. Ferreri, MD, and colleagues in the INGRID trial.5 Dr. Ferreri presented findings from the trial at the International Conference on Malignant Lymphoma in Lugano, Switzerland, which was greeted with much excitement.6
INGRID is a phase 2 trial conducted on patients with refractory/relapsed PCNSL. It consisted of a CHOP plus rituximab (R-CHOP) regimen, which was upgraded by engineered tumor necrosis factor–alpha (TNF-alpha). The idea was to enhance the blood-brain barrier (BBB) permeability and consequently improve the efficacy of R-CHOP in PCNSL. The use of human TNF-alpha is limited by relevant toxicities. In order to avoid that, a fusion of human TNF-alpha and CNGRCG peptide (called NGR-TNF) was developed.
CNGRCG peptide is a ligand of CD13, an aminopeptidase that is expressed almost exclusively on tumor blood vessels. Preclinical data showed that binding of CNGRCG to CD13 results in targeted – local, not systemic – delivery of TNF-alpha to the tumor blood vessels. Consequently, TNF-alpha led to increased vascular permeability in tumor tissue and enabled higher penetration of chemotherapeutic agents.7,8
Altogether, 12 heavily pretreated PCNSL patients were included in the INGRID trial. Seven patients had two or more previous treatment regimens. Within this trial, patients received R-CHOP with NGR-TNF (0.8 mcg/m2) applied 2 hours prior to R-CHOP. The great majority of grade 3/4 adverse events were hematological toxicities. Importantly, no neurological side effects of any grade occurred.
The primary aim of this study was to investigate the CD13 expression on tumor tissue and provide a proof of concept for the use of NGR-TNF/R-CHOP. Indeed, CD13 expression was observed on tumor vessels in all patients. Consequently, increased BBB permeability in tumor tissue after NGR-TNF infusion was observed using dynamic contrast-enhanced MRI and by brain scintigraphy (SPECT). This was assessed 1 day after NGR-TNF/R-CHOP treatment. More importantly, this effect on BBB seems to be sustained because it was also observed after the last cycle of NGR-TNF/R-CHOP. The fact that there was no change of drug concentrations of R-CHOP components in plasma or cerebrospinal fluid suggests that the effect of NGR-TNF is restricted to tumor vessels.
The authors also reported preliminary results regarding response rates to NGR-TNF/R-CHOP. The overall response rate was 75%. Of note, six patients achieved complete remission and one patient achieved a partial remission. The median duration of response was 10 months (range, 7-14 months), and nine patients were able to proceed to consolidation treatment.
These preliminary results are encouraging and open a new window for the treatment strategies in PCNSL patients. NGR-TNF/R-CHOP treatment induced responses in 75% of these heavily pretreated patients. The low toxicity profile and feasibility of this regimen could allow clinicians to carry out this treatment approach in outpatient settings, as well as in older and comorbid patients. Extensive supportive therapy – such as intensive hydration or leucovorin-rescue by HD-MTX – is not needed.
These results will need to be confirmed through testing in a larger patient population. Dr. Ferreri and colleagues are currently conducting the extended phase of this study and aim to recruit 28 patients. If they report positive results from that study, evaluation of NGR-TNF/R-CHOP as a first-line treatment of PCNSL seems to be the next reasonable step.
Dr. Zeremski and Dr. Fischer are both in the department of hematology/oncology and affiliated with the Health Campus Immunology, Infectiology and Inflammation at Otto-von-Guericke University Magdeburg (Germany). Dr. Fischer is a member of the editorial advisory board of Hematology News. The authors reported having no conflicts of interest.
References
1. J Clin Oncol. 1996;14:556-64.
2. Cancer. 2000;89:1359-70.
3. J Neurooncol. 1996;30:257-65.
4. Guidelines on the diagnosis and management of adult patients with primary CNS lymphoma (PCNSL) and primary intra-ocular lymphoma (PIOL). British Society for Haematology/British Committee for Standards in Haematology; HO/016, 2009.
5. Blood. 2019;134:252-62.
6. Hematol Oncol. 2019; 37:159.
7. BioDrugs. 2013;27:591-603.
8. J Clin Invest. 2002;110:475-82.
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive form of non-Hodgkin lymphoma solely confined to the CNS. The majority of PCNSL histologically presents as diffuse large B-cell lymphoma (DLBCL). However, outcomes in these patients are notably inferior, compared with nodal or other extranodal DLBCL. In order to achieve long-term progression-free survival, high-dose methotrexate (HD-MTX)–based chemotherapy followed by consolidation is needed. However, this treatment is associated with high toxicity burden and it is restricted to a select patient population – the young and fit – and requires administration at specialized hematological centers.
In the 1990s, the conventional DLBCL treatment regimen with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) was tested in PCNSL patients. The results were rather disappointing. The addition of CHOP to whole brain radiation or HD-MTX could not improve survival.1-3 The reason for CHOP failure was poor CNS penetration of doxorubicin and cyclophosphamide because of their high molecular weight. Consequently, it was concluded that there is no role for CHOP-like chemotherapy in the treatment of PCNSL.4
But is this really the case? Twenty years later, this traditional view has been challenged by Andres J.M. Ferreri, MD, and colleagues in the INGRID trial.5 Dr. Ferreri presented findings from the trial at the International Conference on Malignant Lymphoma in Lugano, Switzerland, which was greeted with much excitement.6
INGRID is a phase 2 trial conducted on patients with refractory/relapsed PCNSL. It consisted of a CHOP plus rituximab (R-CHOP) regimen, which was upgraded by engineered tumor necrosis factor–alpha (TNF-alpha). The idea was to enhance the blood-brain barrier (BBB) permeability and consequently improve the efficacy of R-CHOP in PCNSL. The use of human TNF-alpha is limited by relevant toxicities. In order to avoid that, a fusion of human TNF-alpha and CNGRCG peptide (called NGR-TNF) was developed.
CNGRCG peptide is a ligand of CD13, an aminopeptidase that is expressed almost exclusively on tumor blood vessels. Preclinical data showed that binding of CNGRCG to CD13 results in targeted – local, not systemic – delivery of TNF-alpha to the tumor blood vessels. Consequently, TNF-alpha led to increased vascular permeability in tumor tissue and enabled higher penetration of chemotherapeutic agents.7,8
Altogether, 12 heavily pretreated PCNSL patients were included in the INGRID trial. Seven patients had two or more previous treatment regimens. Within this trial, patients received R-CHOP with NGR-TNF (0.8 mcg/m2) applied 2 hours prior to R-CHOP. The great majority of grade 3/4 adverse events were hematological toxicities. Importantly, no neurological side effects of any grade occurred.
The primary aim of this study was to investigate the CD13 expression on tumor tissue and provide a proof of concept for the use of NGR-TNF/R-CHOP. Indeed, CD13 expression was observed on tumor vessels in all patients. Consequently, increased BBB permeability in tumor tissue after NGR-TNF infusion was observed using dynamic contrast-enhanced MRI and by brain scintigraphy (SPECT). This was assessed 1 day after NGR-TNF/R-CHOP treatment. More importantly, this effect on BBB seems to be sustained because it was also observed after the last cycle of NGR-TNF/R-CHOP. The fact that there was no change of drug concentrations of R-CHOP components in plasma or cerebrospinal fluid suggests that the effect of NGR-TNF is restricted to tumor vessels.
The authors also reported preliminary results regarding response rates to NGR-TNF/R-CHOP. The overall response rate was 75%. Of note, six patients achieved complete remission and one patient achieved a partial remission. The median duration of response was 10 months (range, 7-14 months), and nine patients were able to proceed to consolidation treatment.
These preliminary results are encouraging and open a new window for the treatment strategies in PCNSL patients. NGR-TNF/R-CHOP treatment induced responses in 75% of these heavily pretreated patients. The low toxicity profile and feasibility of this regimen could allow clinicians to carry out this treatment approach in outpatient settings, as well as in older and comorbid patients. Extensive supportive therapy – such as intensive hydration or leucovorin-rescue by HD-MTX – is not needed.
These results will need to be confirmed through testing in a larger patient population. Dr. Ferreri and colleagues are currently conducting the extended phase of this study and aim to recruit 28 patients. If they report positive results from that study, evaluation of NGR-TNF/R-CHOP as a first-line treatment of PCNSL seems to be the next reasonable step.
Dr. Zeremski and Dr. Fischer are both in the department of hematology/oncology and affiliated with the Health Campus Immunology, Infectiology and Inflammation at Otto-von-Guericke University Magdeburg (Germany). Dr. Fischer is a member of the editorial advisory board of Hematology News. The authors reported having no conflicts of interest.
References
1. J Clin Oncol. 1996;14:556-64.
2. Cancer. 2000;89:1359-70.
3. J Neurooncol. 1996;30:257-65.
4. Guidelines on the diagnosis and management of adult patients with primary CNS lymphoma (PCNSL) and primary intra-ocular lymphoma (PIOL). British Society for Haematology/British Committee for Standards in Haematology; HO/016, 2009.
5. Blood. 2019;134:252-62.
6. Hematol Oncol. 2019; 37:159.
7. BioDrugs. 2013;27:591-603.
8. J Clin Invest. 2002;110:475-82.
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive form of non-Hodgkin lymphoma solely confined to the CNS. The majority of PCNSL histologically presents as diffuse large B-cell lymphoma (DLBCL). However, outcomes in these patients are notably inferior, compared with nodal or other extranodal DLBCL. In order to achieve long-term progression-free survival, high-dose methotrexate (HD-MTX)–based chemotherapy followed by consolidation is needed. However, this treatment is associated with high toxicity burden and it is restricted to a select patient population – the young and fit – and requires administration at specialized hematological centers.
In the 1990s, the conventional DLBCL treatment regimen with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) was tested in PCNSL patients. The results were rather disappointing. The addition of CHOP to whole brain radiation or HD-MTX could not improve survival.1-3 The reason for CHOP failure was poor CNS penetration of doxorubicin and cyclophosphamide because of their high molecular weight. Consequently, it was concluded that there is no role for CHOP-like chemotherapy in the treatment of PCNSL.4
But is this really the case? Twenty years later, this traditional view has been challenged by Andres J.M. Ferreri, MD, and colleagues in the INGRID trial.5 Dr. Ferreri presented findings from the trial at the International Conference on Malignant Lymphoma in Lugano, Switzerland, which was greeted with much excitement.6
INGRID is a phase 2 trial conducted on patients with refractory/relapsed PCNSL. It consisted of a CHOP plus rituximab (R-CHOP) regimen, which was upgraded by engineered tumor necrosis factor–alpha (TNF-alpha). The idea was to enhance the blood-brain barrier (BBB) permeability and consequently improve the efficacy of R-CHOP in PCNSL. The use of human TNF-alpha is limited by relevant toxicities. In order to avoid that, a fusion of human TNF-alpha and CNGRCG peptide (called NGR-TNF) was developed.
CNGRCG peptide is a ligand of CD13, an aminopeptidase that is expressed almost exclusively on tumor blood vessels. Preclinical data showed that binding of CNGRCG to CD13 results in targeted – local, not systemic – delivery of TNF-alpha to the tumor blood vessels. Consequently, TNF-alpha led to increased vascular permeability in tumor tissue and enabled higher penetration of chemotherapeutic agents.7,8
Altogether, 12 heavily pretreated PCNSL patients were included in the INGRID trial. Seven patients had two or more previous treatment regimens. Within this trial, patients received R-CHOP with NGR-TNF (0.8 mcg/m2) applied 2 hours prior to R-CHOP. The great majority of grade 3/4 adverse events were hematological toxicities. Importantly, no neurological side effects of any grade occurred.
The primary aim of this study was to investigate the CD13 expression on tumor tissue and provide a proof of concept for the use of NGR-TNF/R-CHOP. Indeed, CD13 expression was observed on tumor vessels in all patients. Consequently, increased BBB permeability in tumor tissue after NGR-TNF infusion was observed using dynamic contrast-enhanced MRI and by brain scintigraphy (SPECT). This was assessed 1 day after NGR-TNF/R-CHOP treatment. More importantly, this effect on BBB seems to be sustained because it was also observed after the last cycle of NGR-TNF/R-CHOP. The fact that there was no change of drug concentrations of R-CHOP components in plasma or cerebrospinal fluid suggests that the effect of NGR-TNF is restricted to tumor vessels.
The authors also reported preliminary results regarding response rates to NGR-TNF/R-CHOP. The overall response rate was 75%. Of note, six patients achieved complete remission and one patient achieved a partial remission. The median duration of response was 10 months (range, 7-14 months), and nine patients were able to proceed to consolidation treatment.
These preliminary results are encouraging and open a new window for the treatment strategies in PCNSL patients. NGR-TNF/R-CHOP treatment induced responses in 75% of these heavily pretreated patients. The low toxicity profile and feasibility of this regimen could allow clinicians to carry out this treatment approach in outpatient settings, as well as in older and comorbid patients. Extensive supportive therapy – such as intensive hydration or leucovorin-rescue by HD-MTX – is not needed.
These results will need to be confirmed through testing in a larger patient population. Dr. Ferreri and colleagues are currently conducting the extended phase of this study and aim to recruit 28 patients. If they report positive results from that study, evaluation of NGR-TNF/R-CHOP as a first-line treatment of PCNSL seems to be the next reasonable step.
Dr. Zeremski and Dr. Fischer are both in the department of hematology/oncology and affiliated with the Health Campus Immunology, Infectiology and Inflammation at Otto-von-Guericke University Magdeburg (Germany). Dr. Fischer is a member of the editorial advisory board of Hematology News. The authors reported having no conflicts of interest.
References
1. J Clin Oncol. 1996;14:556-64.
2. Cancer. 2000;89:1359-70.
3. J Neurooncol. 1996;30:257-65.
4. Guidelines on the diagnosis and management of adult patients with primary CNS lymphoma (PCNSL) and primary intra-ocular lymphoma (PIOL). British Society for Haematology/British Committee for Standards in Haematology; HO/016, 2009.
5. Blood. 2019;134:252-62.
6. Hematol Oncol. 2019; 37:159.
7. BioDrugs. 2013;27:591-603.
8. J Clin Invest. 2002;110:475-82.
‘Clean’ and ‘natural’ beauty products
Clean beauty products have taken over the skin care market. A wave of new indie brands has entered the skin care market, some of which have garnered fame from bloggers and celebrities and via social media. There has also been a shift towards larger, more-established brands developing and marketing cleaner alternatives to their established skin care lines.
As consumers, physicians, and parents, we all want nontoxic products. However, as highlighted in a recent editorial by Bruce Brod, MD, and Courtney Blair Rubin, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, the Food and Drug Administration has “failed to define clean and natural, leaving these labels open to interpretation by nondermatologist retailers, bloggers, and celebrities who have set out to define clean beauty for themselves” (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2724). This vague interpretation has given rise to a billion-dollar industry of products that is unregulated and may, in fact, not be safer than other products.
For the last decade, to skin care products have also been on the rise. Some of the ingredients deemed toxic include petrolatum and parabens, which have good safety profiles and clinically, are among the least allergenic ingredients in skin products, particularly among patients with the most sensitive skin. In contrast, botanical oils, essential oils, and plant-based natural fragrances are chronic culprits of contact sensitivities and severe skin allergies.
I encourage all dermatologists to read this viewpoint as this topic will inevitably be a point of discussion with many patients. Large studies and expert consensus of safety profiles of chemicals – particularly those deemed carcinogenic, endocrine disruptors, and environmental hazards – are often lacking, leading to confusion for consumers. Our professional organizations and industry should be leading the efforts to establish standardized definitions and FDA regulations of skin care products deemed clean and natural so that the differentiation between marketing taglines and true, substantiated FDA-supported claims are clearer for consumers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
Clean beauty products have taken over the skin care market. A wave of new indie brands has entered the skin care market, some of which have garnered fame from bloggers and celebrities and via social media. There has also been a shift towards larger, more-established brands developing and marketing cleaner alternatives to their established skin care lines.
As consumers, physicians, and parents, we all want nontoxic products. However, as highlighted in a recent editorial by Bruce Brod, MD, and Courtney Blair Rubin, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, the Food and Drug Administration has “failed to define clean and natural, leaving these labels open to interpretation by nondermatologist retailers, bloggers, and celebrities who have set out to define clean beauty for themselves” (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2724). This vague interpretation has given rise to a billion-dollar industry of products that is unregulated and may, in fact, not be safer than other products.
For the last decade, to skin care products have also been on the rise. Some of the ingredients deemed toxic include petrolatum and parabens, which have good safety profiles and clinically, are among the least allergenic ingredients in skin products, particularly among patients with the most sensitive skin. In contrast, botanical oils, essential oils, and plant-based natural fragrances are chronic culprits of contact sensitivities and severe skin allergies.
I encourage all dermatologists to read this viewpoint as this topic will inevitably be a point of discussion with many patients. Large studies and expert consensus of safety profiles of chemicals – particularly those deemed carcinogenic, endocrine disruptors, and environmental hazards – are often lacking, leading to confusion for consumers. Our professional organizations and industry should be leading the efforts to establish standardized definitions and FDA regulations of skin care products deemed clean and natural so that the differentiation between marketing taglines and true, substantiated FDA-supported claims are clearer for consumers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
Clean beauty products have taken over the skin care market. A wave of new indie brands has entered the skin care market, some of which have garnered fame from bloggers and celebrities and via social media. There has also been a shift towards larger, more-established brands developing and marketing cleaner alternatives to their established skin care lines.
As consumers, physicians, and parents, we all want nontoxic products. However, as highlighted in a recent editorial by Bruce Brod, MD, and Courtney Blair Rubin, MD, of the department of dermatology at the University of Pennsylvania, Philadelphia, the Food and Drug Administration has “failed to define clean and natural, leaving these labels open to interpretation by nondermatologist retailers, bloggers, and celebrities who have set out to define clean beauty for themselves” (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2724). This vague interpretation has given rise to a billion-dollar industry of products that is unregulated and may, in fact, not be safer than other products.
For the last decade, to skin care products have also been on the rise. Some of the ingredients deemed toxic include petrolatum and parabens, which have good safety profiles and clinically, are among the least allergenic ingredients in skin products, particularly among patients with the most sensitive skin. In contrast, botanical oils, essential oils, and plant-based natural fragrances are chronic culprits of contact sensitivities and severe skin allergies.
I encourage all dermatologists to read this viewpoint as this topic will inevitably be a point of discussion with many patients. Large studies and expert consensus of safety profiles of chemicals – particularly those deemed carcinogenic, endocrine disruptors, and environmental hazards – are often lacking, leading to confusion for consumers. Our professional organizations and industry should be leading the efforts to establish standardized definitions and FDA regulations of skin care products deemed clean and natural so that the differentiation between marketing taglines and true, substantiated FDA-supported claims are clearer for consumers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
Violaceous papules on calf & foot
that usually presents on the distal lower extremities or feet as red to violaceous papules, patches, and plaques.
Clinically, lesions may look similar to Kaposi sarcoma (KS). It is considered to be a variant of stasis dermatitis or severe chronic venous stasis with a more exuberant vascular proliferation of preexisting vasculature. Although the exact etiology is unknown, it is thought that chronic edema, increased venous pressure, and tissue hypoxia may induce fibroblast and vascular proliferation.
It has also been described in association with vascular anomalies, such as Klippel-Trenaunay syndrome, Stewart-Bluefarb syndrome, and Prader-Labhart-Willi syndrome, and is caused by arteriovenous fistulae. Paralysis of lower extremities and amputation stumps are predisposing factors.
KS has four clinical variants: classic KS, African endemic KS, KS in immunocompromised patients, and AIDS-related epidemic KS. All types are caused by the human herpesvirus-8 (HHV-8). Violaceous lesions generally begin as macules and may progress to nodules or tumors.
Punch biopsies were performed in our patient. Histologically, thin-walled, dilated, capillary-like structures were present with a thin layer of surrounding pericytes with reactive fibrosis, hemorrhage, hemosiderin, and a scant chronic inflammatory cell infiltrate. The endothelial cells did not show atypia or mitotic activity. Endothelial cells were positive for CD31, CD34, and CD99. Pericytes and some of the endothelial cells were positive for actin and negative for D2-40, desmin, and HHV-8. In KS, vessels appear like slitlike or jagged spaces lined by spindled endothelial cells. Mild cytologic atypia is usually present. Endothelial cells are characteristically plump. A distinguishing feature in KS is the “promontory sign,” in which new vessels protrude into the vascular space. CD34 is usually negative and HHV-8 is positive.
Acroangiodermatitis of Mali may improve when the underlying venous insufficiency is addressed with compression stockings, pumps, or vascular intervention. Laser ablation of individual lesions has been described in the literature. Dapsone, oral erythromycin, and topical corticosteroids have been reported as helpful in some patients.
This case and these photos were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
that usually presents on the distal lower extremities or feet as red to violaceous papules, patches, and plaques.
Clinically, lesions may look similar to Kaposi sarcoma (KS). It is considered to be a variant of stasis dermatitis or severe chronic venous stasis with a more exuberant vascular proliferation of preexisting vasculature. Although the exact etiology is unknown, it is thought that chronic edema, increased venous pressure, and tissue hypoxia may induce fibroblast and vascular proliferation.
It has also been described in association with vascular anomalies, such as Klippel-Trenaunay syndrome, Stewart-Bluefarb syndrome, and Prader-Labhart-Willi syndrome, and is caused by arteriovenous fistulae. Paralysis of lower extremities and amputation stumps are predisposing factors.
KS has four clinical variants: classic KS, African endemic KS, KS in immunocompromised patients, and AIDS-related epidemic KS. All types are caused by the human herpesvirus-8 (HHV-8). Violaceous lesions generally begin as macules and may progress to nodules or tumors.
Punch biopsies were performed in our patient. Histologically, thin-walled, dilated, capillary-like structures were present with a thin layer of surrounding pericytes with reactive fibrosis, hemorrhage, hemosiderin, and a scant chronic inflammatory cell infiltrate. The endothelial cells did not show atypia or mitotic activity. Endothelial cells were positive for CD31, CD34, and CD99. Pericytes and some of the endothelial cells were positive for actin and negative for D2-40, desmin, and HHV-8. In KS, vessels appear like slitlike or jagged spaces lined by spindled endothelial cells. Mild cytologic atypia is usually present. Endothelial cells are characteristically plump. A distinguishing feature in KS is the “promontory sign,” in which new vessels protrude into the vascular space. CD34 is usually negative and HHV-8 is positive.
Acroangiodermatitis of Mali may improve when the underlying venous insufficiency is addressed with compression stockings, pumps, or vascular intervention. Laser ablation of individual lesions has been described in the literature. Dapsone, oral erythromycin, and topical corticosteroids have been reported as helpful in some patients.
This case and these photos were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
that usually presents on the distal lower extremities or feet as red to violaceous papules, patches, and plaques.
Clinically, lesions may look similar to Kaposi sarcoma (KS). It is considered to be a variant of stasis dermatitis or severe chronic venous stasis with a more exuberant vascular proliferation of preexisting vasculature. Although the exact etiology is unknown, it is thought that chronic edema, increased venous pressure, and tissue hypoxia may induce fibroblast and vascular proliferation.
It has also been described in association with vascular anomalies, such as Klippel-Trenaunay syndrome, Stewart-Bluefarb syndrome, and Prader-Labhart-Willi syndrome, and is caused by arteriovenous fistulae. Paralysis of lower extremities and amputation stumps are predisposing factors.
KS has four clinical variants: classic KS, African endemic KS, KS in immunocompromised patients, and AIDS-related epidemic KS. All types are caused by the human herpesvirus-8 (HHV-8). Violaceous lesions generally begin as macules and may progress to nodules or tumors.
Punch biopsies were performed in our patient. Histologically, thin-walled, dilated, capillary-like structures were present with a thin layer of surrounding pericytes with reactive fibrosis, hemorrhage, hemosiderin, and a scant chronic inflammatory cell infiltrate. The endothelial cells did not show atypia or mitotic activity. Endothelial cells were positive for CD31, CD34, and CD99. Pericytes and some of the endothelial cells were positive for actin and negative for D2-40, desmin, and HHV-8. In KS, vessels appear like slitlike or jagged spaces lined by spindled endothelial cells. Mild cytologic atypia is usually present. Endothelial cells are characteristically plump. A distinguishing feature in KS is the “promontory sign,” in which new vessels protrude into the vascular space. CD34 is usually negative and HHV-8 is positive.
Acroangiodermatitis of Mali may improve when the underlying venous insufficiency is addressed with compression stockings, pumps, or vascular intervention. Laser ablation of individual lesions has been described in the literature. Dapsone, oral erythromycin, and topical corticosteroids have been reported as helpful in some patients.
This case and these photos were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].
Making and using guidelines
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Help wanted
In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.
Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.
You may have survived the gauntlet of medical school and residency relatively unscathed. But Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?
Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.
You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.
This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.
Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.
As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.
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.” Email him at [email protected].
In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.
Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.
You may have survived the gauntlet of medical school and residency relatively unscathed. But Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?
Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.
You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.
This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.
Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.
As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.
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.” Email him at [email protected].
In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.
Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.
You may have survived the gauntlet of medical school and residency relatively unscathed. But Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?
Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.
You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.
This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.
Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.
As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.
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.” Email him at [email protected].
It’s all in the timing
It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.
Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.
Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”
When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.
Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.
There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.
The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.
I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.
Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.
Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.
Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”
When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.
Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.
There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.
The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.
I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.
Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
It is often fun and sometimes exhausting watching the speed with which children run around or switch from one game to another. A lot of us were attracted to pediatrics to share the quick joy of children and also the speed of their physical recovery. We get to see premature infants gain an ounce a day, and see wounds heal in less than a week. We give advice on sleep and see success in a month. We and the families get used to quick fixes.
Parents and children are forewarned and reassured by our knowledge about how long things typically take: Respiratory syncytial virus (RSV) peaks in 5 days, colic lessens in 3 months, changing sleep patterns takes 3 weeks, habit formation 6 weeks, menses come 2 years after breast development, and so on. But the timing of daily parenting is rarely as predictable. Sometimes a child’s clock is running fast, making waiting even seconds for a snack or a bathroom difficult; other times are slow, as when walking down the sidewalk noticing every leaf. The child’s clock is independent of the adult’s – and complicated by clocks of siblings.
Parent pace also is determined by many factors unrelated to the child: work demands, deadlines, train schedules, something in the oven, needs of siblings, and so on. To those can be added intrinsic factors affecting parent’s tolerance to shifting pace to the child’s such as temperament, fatigue, illness, pain, or even adult ADHD. And don’t forget caffeine (or other drugs) affecting the internal metronome. When impatience with the child is a complaint, it is useful to ask, “What makes waiting for your child difficult for you?”
When discussing time, I find it important to discuss the poison “s-word” of parenting – “should.” This trickster often comes from time illusions in childrearing. After seeing so many behaviors change quickly, parents expect all change to be equally fast. She should be able to sleep through the night by now! He should be able to dress and get to the table in 5 minutes. And sometimes it is the parent’s s-word that creates pain – I should love pushing for as long as she wants to swing, if I am a good parent. The problem with thinking “should” is that it implies willful or moral behavior, and it may prompt a judgmental or punitive parental response.
Otherwise well intentioned, cooperative children who take longer to shift their attention from homework to shower can be seen as oppositional. Worse yet, if the example used is from playing video games (something fun) to getting to the bus stop (an undesirable shift), you may hear parents critically say, “He only wants to do what he wants to do.” When examining examples (always key to helping with behavior), pointing out that all kinds of transitions are difficult for this child may be educational and allow for a more reasoned response. And specifically being on electronics puts adults as well as children in a time warp which is hard to escape.
There are many kinds of thwarted expectations, but expectations about how long things take are pretty universal. Frustration generates anger and even can lead to violence, such as road rage. Children – who all step to the beat of a different drummer, especially those with different “clocks” such as in ADHD – may experience frustration most of the day. This can manifest as irritability for them and sometimes as an irritable response back from the parent.
The first step in adapting to differences in parent and child pace is to realize that time is the problem. Naming it, saying “we are on toddler time,” can be a “signal to self” to slow down. Generations of children loved Mr. Rogers because he always conveyed having all the time in the world for the person he was with. It actually does not take as long as it feels at first to do this. Listening while keeping eye contact, breathing deeply, and waiting until two breaths after the child goes silent before speaking or moving conveys your interest and respect. For some behaviors, such as tantrums, such quiet attention may be all that is needed to resolve the issue. We adults can practice this, but even infants can be helped to develop patience by reinforcement with brief attention from their caregivers for tiny increments of waiting.
I sometimes suggest that parents time behaviors to develop perspective, reset expectations, practice waiting, and perhaps even distract themselves from intervening and making things worse by lending attention to negative behaviors. Timing as observation can be helpful for tantrums, breath holding spells, whining, and sibling squabbles; maximum times for baths and video games; minimum times for meals, sitting to poop, and special time. Timers are not just for Time Out! “Visual timers” that show green then yellow then red and sometimes flashing lights as warnings of an upcoming stopping point are helpful for children preschool and older. These timers help them to develop a better sense of time and begin managing their own transitions. A game of guessing how long things take can build timing skills and patience. I think every child past preschool benefits from a wristwatch, first to build time sense, and second to avoid looking at a smartphone to see the hour, then being distracted by content! Diaries of behaviors over time are a staple of behavior change plans, with the added benefit of lending perspective on actually how often and how long a troublesome behavior occurs. Practicing mindfulness – nonjudgmental watching of our thoughts and feelings, often with deep breathing and relaxation – also can help both children and adults build time tolerance.
Children have little control over their daily schedule. Surrendering when you can for them to do things at their own pace can reduce their frustration, build the parent-child relationship, and promote positive behaviors. Plus family life is more enjoyable lived slower. You even can remind parents that “the days are long but the years are short” before their children will be grown and gone.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].
Bringing focus to the issue: Dr. Elizabeth Loder on gender in medicine
The recently published “Eleven Things Not to Say to Your Female Colleagues,” has sparked debate on medical Twitter. Senior author Elizabeth Loder, MD, developed the content collaboratively with members of the Migraine Mavens, a private Facebook group of North American headache practitioners and researchers.
In an interview, Dr. Loder, chief of the headache division in the neurology department at Brigham and Women’s Hospital, Boston, and professor of neurology at Harvard Medical School, Boston, shared the background and context for the article.
Q: Could you explain the impetus for putting this together? How did you arrive at the chart that is the center of the article?
A: In June, I gave the Seymour Solomon lecture at the American Headache Society annual scientific meeting. Because it was an award lecture, I was able to choose the topic. I decided to talk about gender-based problems faced by women in medicine, with a focus on the headache field.
These problems include sexual harassment, hurtful sex-based comments, gender-based barriers to career advancement, as well as the difficulties women face in getting institutions or professional societies to pay attention to these problems.
I wanted to provide real, recent examples of troubling behavior or comments, so I appealed to the Migraine Mavens group to describe their own experiences. I was not expecting the response I got. Not only did people post many examples of such behavior in the group, but I also received many private messages describing things that were so hurtful or private that the woman involved did not even feel comfortable posting them in our group.
I ended up with plenty of real-life vignettes. The title of my talk was “Time’s Up: Headache Medicine in the #MeToo Era.” Shortly after the talk, a member of the group posted this:
“Oh, Dr. Elizabeth Loder, how timely was your talk yesterday, and we have so much further to progress. ...
“Just now, I had this experience: I have been recently selected for a leadership position within AHS and I was talking to one of our male colleagues about it. ... He expressed his doubt in my ability to serve this role well.
“I thought it was because I am early in my career, and as I was reassuring him that I would reach out to him and others for mentorship, he then said ‘AND you have two small children. ... You don’t have time for this.’ ”
There was lively discussion in the group about how this poster could have responded and what bystanders could have said. One of the group members, Clarimar Borrero-Mejias, MD, a pediatric neurologist at Phoenix Children’s Hospital, pointed out that many men and women might benefit from knowing what kinds of things not to say to other colleagues. I suggested that we should take some of the problems we had discussed and write a paper, and that she should be the first author. We then crowdsourced the scenarios to be included.
The grid format came immediately to mind because I know that tables and charts and boxes are good ways to organize and present information. We also wanted to keep the article short and accessible, and thus the idea of “Ten Things” was born. At the end of our work, though, someone posted the vignette about the salary discussion. It was amazing to me how many women, even in this day and age, are still told that men deserve more money because of their family or other responsibilities. We thus decided that it had to be 11, not 10, things.
The article was possible only because of the supportive reaction of the editor of Headache, Thomas Ward, MD. He not only published the piece rapidly, but also agreed to make it free so that anyone who wanted to could access the entire article without hitting a paywall (Headache. 2019 Sep 26. doi: 10.1111/head.13647).
Q: Could you share some of the reactions you’ve gotten? I did see that Esther Choo, MD – an emergency medicine physician and prominent proponent for gender equity in medicine – highlighted the article on Twitter; are there other highlights, or surprising reactions, or pushback, that you’d like to share?
A: We were thrilled to be the subject of a “tweetorial” by Dr. Choo. It’s impossible to overestimate the boost this gave to the paper. She has over 75,000 Twitter followers, and it was quite impressive to watch the exponential increase in the article’s Altmetrics score after her tweetorial. This brought the article to the attention of people outside our own subspecialty. The experiences we described seem to be familiar to women doctors in every specialty and subspecialty, and also relevant outside medicine. I saw tweets from women lawyers, engineers, and others, many of whom said this sort of behavior is a problem in their own fields.
It’s probably not surprising that the vast majority of reactions came from women. A number of men tweeted the article, though, and recommended it to other men. This sort of #HeForShe support is gratifying. We did get some negative reactions, but there are Migraine Mavens on Twitter and we’ve taken them on.
Q: You offer suggestions for reframing many behaviors that reflect implicit bias. You also offer suggestions for bystanders to challenge these biases and support women who are on the receiving end of the behaviors you call out. Do you think exhibiting more of this kind of solidarity can help change the culture of medicine?
A: I believe many people who witness the behaviors are uncomfortable and would like to help but just don’t know what to say. Often, they are caught off guard. Some of our suggested responses are all-purpose lines that can be effective simply by calling attention to the behavior, for example, “What did you just say?” or “Why would you say something like that?” As Dr. Choo said, “Learn them, say them often.”
It’s critical to remember that problems like this are not in the past. This article gave real examples of things that have happened to real women recently. The sheer number of women who retweeted the article with statements such as, “How many of these have been said to you? Straw poll. I got 9,” demonstrates that behavior like this is common.
I recently received an email that forwarded a message written by a medical assistant. I’ve changed the names, but it otherwise read “Dr. Smith wants this patient to have a nerve block. ... You can schedule them with Abigail or Nancy.” Guess what? Abigail and Nancy are doctors. Not only that, they are Dr. Smith’s true peers in every way imaginable, having been hired at exactly the same time and having exactly the same titles and duties. There seems to be only one reason they are not addressed as doctor while their male colleague is, and that is their gender. So the struggle highlighted by #MyFirstNameIsDoctor is real. Women doctors live it every day.
The recently published “Eleven Things Not to Say to Your Female Colleagues,” has sparked debate on medical Twitter. Senior author Elizabeth Loder, MD, developed the content collaboratively with members of the Migraine Mavens, a private Facebook group of North American headache practitioners and researchers.
In an interview, Dr. Loder, chief of the headache division in the neurology department at Brigham and Women’s Hospital, Boston, and professor of neurology at Harvard Medical School, Boston, shared the background and context for the article.
Q: Could you explain the impetus for putting this together? How did you arrive at the chart that is the center of the article?
A: In June, I gave the Seymour Solomon lecture at the American Headache Society annual scientific meeting. Because it was an award lecture, I was able to choose the topic. I decided to talk about gender-based problems faced by women in medicine, with a focus on the headache field.
These problems include sexual harassment, hurtful sex-based comments, gender-based barriers to career advancement, as well as the difficulties women face in getting institutions or professional societies to pay attention to these problems.
I wanted to provide real, recent examples of troubling behavior or comments, so I appealed to the Migraine Mavens group to describe their own experiences. I was not expecting the response I got. Not only did people post many examples of such behavior in the group, but I also received many private messages describing things that were so hurtful or private that the woman involved did not even feel comfortable posting them in our group.
I ended up with plenty of real-life vignettes. The title of my talk was “Time’s Up: Headache Medicine in the #MeToo Era.” Shortly after the talk, a member of the group posted this:
“Oh, Dr. Elizabeth Loder, how timely was your talk yesterday, and we have so much further to progress. ...
“Just now, I had this experience: I have been recently selected for a leadership position within AHS and I was talking to one of our male colleagues about it. ... He expressed his doubt in my ability to serve this role well.
“I thought it was because I am early in my career, and as I was reassuring him that I would reach out to him and others for mentorship, he then said ‘AND you have two small children. ... You don’t have time for this.’ ”
There was lively discussion in the group about how this poster could have responded and what bystanders could have said. One of the group members, Clarimar Borrero-Mejias, MD, a pediatric neurologist at Phoenix Children’s Hospital, pointed out that many men and women might benefit from knowing what kinds of things not to say to other colleagues. I suggested that we should take some of the problems we had discussed and write a paper, and that she should be the first author. We then crowdsourced the scenarios to be included.
The grid format came immediately to mind because I know that tables and charts and boxes are good ways to organize and present information. We also wanted to keep the article short and accessible, and thus the idea of “Ten Things” was born. At the end of our work, though, someone posted the vignette about the salary discussion. It was amazing to me how many women, even in this day and age, are still told that men deserve more money because of their family or other responsibilities. We thus decided that it had to be 11, not 10, things.
The article was possible only because of the supportive reaction of the editor of Headache, Thomas Ward, MD. He not only published the piece rapidly, but also agreed to make it free so that anyone who wanted to could access the entire article without hitting a paywall (Headache. 2019 Sep 26. doi: 10.1111/head.13647).
Q: Could you share some of the reactions you’ve gotten? I did see that Esther Choo, MD – an emergency medicine physician and prominent proponent for gender equity in medicine – highlighted the article on Twitter; are there other highlights, or surprising reactions, or pushback, that you’d like to share?
A: We were thrilled to be the subject of a “tweetorial” by Dr. Choo. It’s impossible to overestimate the boost this gave to the paper. She has over 75,000 Twitter followers, and it was quite impressive to watch the exponential increase in the article’s Altmetrics score after her tweetorial. This brought the article to the attention of people outside our own subspecialty. The experiences we described seem to be familiar to women doctors in every specialty and subspecialty, and also relevant outside medicine. I saw tweets from women lawyers, engineers, and others, many of whom said this sort of behavior is a problem in their own fields.
It’s probably not surprising that the vast majority of reactions came from women. A number of men tweeted the article, though, and recommended it to other men. This sort of #HeForShe support is gratifying. We did get some negative reactions, but there are Migraine Mavens on Twitter and we’ve taken them on.
Q: You offer suggestions for reframing many behaviors that reflect implicit bias. You also offer suggestions for bystanders to challenge these biases and support women who are on the receiving end of the behaviors you call out. Do you think exhibiting more of this kind of solidarity can help change the culture of medicine?
A: I believe many people who witness the behaviors are uncomfortable and would like to help but just don’t know what to say. Often, they are caught off guard. Some of our suggested responses are all-purpose lines that can be effective simply by calling attention to the behavior, for example, “What did you just say?” or “Why would you say something like that?” As Dr. Choo said, “Learn them, say them often.”
It’s critical to remember that problems like this are not in the past. This article gave real examples of things that have happened to real women recently. The sheer number of women who retweeted the article with statements such as, “How many of these have been said to you? Straw poll. I got 9,” demonstrates that behavior like this is common.
I recently received an email that forwarded a message written by a medical assistant. I’ve changed the names, but it otherwise read “Dr. Smith wants this patient to have a nerve block. ... You can schedule them with Abigail or Nancy.” Guess what? Abigail and Nancy are doctors. Not only that, they are Dr. Smith’s true peers in every way imaginable, having been hired at exactly the same time and having exactly the same titles and duties. There seems to be only one reason they are not addressed as doctor while their male colleague is, and that is their gender. So the struggle highlighted by #MyFirstNameIsDoctor is real. Women doctors live it every day.
The recently published “Eleven Things Not to Say to Your Female Colleagues,” has sparked debate on medical Twitter. Senior author Elizabeth Loder, MD, developed the content collaboratively with members of the Migraine Mavens, a private Facebook group of North American headache practitioners and researchers.
In an interview, Dr. Loder, chief of the headache division in the neurology department at Brigham and Women’s Hospital, Boston, and professor of neurology at Harvard Medical School, Boston, shared the background and context for the article.
Q: Could you explain the impetus for putting this together? How did you arrive at the chart that is the center of the article?
A: In June, I gave the Seymour Solomon lecture at the American Headache Society annual scientific meeting. Because it was an award lecture, I was able to choose the topic. I decided to talk about gender-based problems faced by women in medicine, with a focus on the headache field.
These problems include sexual harassment, hurtful sex-based comments, gender-based barriers to career advancement, as well as the difficulties women face in getting institutions or professional societies to pay attention to these problems.
I wanted to provide real, recent examples of troubling behavior or comments, so I appealed to the Migraine Mavens group to describe their own experiences. I was not expecting the response I got. Not only did people post many examples of such behavior in the group, but I also received many private messages describing things that were so hurtful or private that the woman involved did not even feel comfortable posting them in our group.
I ended up with plenty of real-life vignettes. The title of my talk was “Time’s Up: Headache Medicine in the #MeToo Era.” Shortly after the talk, a member of the group posted this:
“Oh, Dr. Elizabeth Loder, how timely was your talk yesterday, and we have so much further to progress. ...
“Just now, I had this experience: I have been recently selected for a leadership position within AHS and I was talking to one of our male colleagues about it. ... He expressed his doubt in my ability to serve this role well.
“I thought it was because I am early in my career, and as I was reassuring him that I would reach out to him and others for mentorship, he then said ‘AND you have two small children. ... You don’t have time for this.’ ”
There was lively discussion in the group about how this poster could have responded and what bystanders could have said. One of the group members, Clarimar Borrero-Mejias, MD, a pediatric neurologist at Phoenix Children’s Hospital, pointed out that many men and women might benefit from knowing what kinds of things not to say to other colleagues. I suggested that we should take some of the problems we had discussed and write a paper, and that she should be the first author. We then crowdsourced the scenarios to be included.
The grid format came immediately to mind because I know that tables and charts and boxes are good ways to organize and present information. We also wanted to keep the article short and accessible, and thus the idea of “Ten Things” was born. At the end of our work, though, someone posted the vignette about the salary discussion. It was amazing to me how many women, even in this day and age, are still told that men deserve more money because of their family or other responsibilities. We thus decided that it had to be 11, not 10, things.
The article was possible only because of the supportive reaction of the editor of Headache, Thomas Ward, MD. He not only published the piece rapidly, but also agreed to make it free so that anyone who wanted to could access the entire article without hitting a paywall (Headache. 2019 Sep 26. doi: 10.1111/head.13647).
Q: Could you share some of the reactions you’ve gotten? I did see that Esther Choo, MD – an emergency medicine physician and prominent proponent for gender equity in medicine – highlighted the article on Twitter; are there other highlights, or surprising reactions, or pushback, that you’d like to share?
A: We were thrilled to be the subject of a “tweetorial” by Dr. Choo. It’s impossible to overestimate the boost this gave to the paper. She has over 75,000 Twitter followers, and it was quite impressive to watch the exponential increase in the article’s Altmetrics score after her tweetorial. This brought the article to the attention of people outside our own subspecialty. The experiences we described seem to be familiar to women doctors in every specialty and subspecialty, and also relevant outside medicine. I saw tweets from women lawyers, engineers, and others, many of whom said this sort of behavior is a problem in their own fields.
It’s probably not surprising that the vast majority of reactions came from women. A number of men tweeted the article, though, and recommended it to other men. This sort of #HeForShe support is gratifying. We did get some negative reactions, but there are Migraine Mavens on Twitter and we’ve taken them on.
Q: You offer suggestions for reframing many behaviors that reflect implicit bias. You also offer suggestions for bystanders to challenge these biases and support women who are on the receiving end of the behaviors you call out. Do you think exhibiting more of this kind of solidarity can help change the culture of medicine?
A: I believe many people who witness the behaviors are uncomfortable and would like to help but just don’t know what to say. Often, they are caught off guard. Some of our suggested responses are all-purpose lines that can be effective simply by calling attention to the behavior, for example, “What did you just say?” or “Why would you say something like that?” As Dr. Choo said, “Learn them, say them often.”
It’s critical to remember that problems like this are not in the past. This article gave real examples of things that have happened to real women recently. The sheer number of women who retweeted the article with statements such as, “How many of these have been said to you? Straw poll. I got 9,” demonstrates that behavior like this is common.
I recently received an email that forwarded a message written by a medical assistant. I’ve changed the names, but it otherwise read “Dr. Smith wants this patient to have a nerve block. ... You can schedule them with Abigail or Nancy.” Guess what? Abigail and Nancy are doctors. Not only that, they are Dr. Smith’s true peers in every way imaginable, having been hired at exactly the same time and having exactly the same titles and duties. There seems to be only one reason they are not addressed as doctor while their male colleague is, and that is their gender. So the struggle highlighted by #MyFirstNameIsDoctor is real. Women doctors live it every day.