Doug Brunk

SAN DIEGO — If you think that providing your patients with their own electronic personal health record is a waste of time and money, think again.

“If you can communicate more effectively with an online personal health record, then you're enhancing that physician-patient relationship to make sure that patients have the care that they need,” Dr. Mark M. Simonian said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Dr. Simonian, executive member and past chair of the AAP's Council on Clinical Information Technology, explained that a personal health record (PHR) is accessed through the Internet and may be affiliated with the patient's physician, but it's under the primary control of the patient. “It's not a practice-based electronic medical record, but it's capable of being integrated with the electronic medical record,” he noted.

The goal is to provide an Internet-based health record that coordinates lifelong health information and is accessible and portable. PHRs also may include integrated, secure physician-patient e-mail and online consultation, as well as automated disease management via medication or condition-specific “adherence” messages sent from the physician to the patient.

The AAP is now developing standards for PHRs. Dr. Simonian said that basic features should include information on foster care, birth history, and family history; insurance information; a list of allergies; and a record of medications, immunizations, and lab, image, and other studies.

“That is absolutely essential,” said Dr. Simonian, who practices pediatrics in Clovis, Calif.

PHRs can be either standalone (portable) or tethered (not transferable from one provider or insurer to another). Several free standalone PHR tools exist, such as Microsoft HealthVault (www.healthvault.comwww.google.com/healthwww.healthbutler.com

He said that he currently offers his patients a tethered PHR “that is only active as long as they're part of my practice. I'm talking to my vendor about allowing patients to access their PHR, even if they move to another provider.”

While he noted that he expects increasing numbers of physicians to offer PHRs to their patients in the coming years, Dr. Simonian acknowledged certain obstacles to their widespread use, including the fact that not all patients and their families have ready access to the Internet. Then there's the challenge of meeting the needs of patients who do not speak English. “There's no interpreter built into the PHR,” he said.

Other concerns include compliance with the Health Insurance Portability and Accountability Act and the potential for patients to alter the information the physician enters into the PHR. “If you can't trust what's in the record, how valuable is it?” he asked.

Dr. Simonian said he had no conflicts of interest to disclose.

Dr. Mark M. Simonian shows an example of an electronic personal health record. Courtesy Dr. Mark M. Simonian

SAN DIEGO — If you think that providing your patients with their own electronic personal health record is a waste of time and money, think again.

“If you can communicate more effectively with an online personal health record, then you're enhancing that physician-patient relationship to make sure that patients have the care that they need,” Dr. Mark M. Simonian said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Dr. Simonian, executive member and past chair of the AAP's Council on Clinical Information Technology, explained that a personal health record (PHR) is accessed through the Internet and may be affiliated with the patient's physician, but it's under the primary control of the patient. “It's not a practice-based electronic medical record, but it's capable of being integrated with the electronic medical record,” he noted.

The goal is to provide an Internet-based health record that coordinates lifelong health information and is accessible and portable. PHRs also may include integrated, secure physician-patient e-mail and online consultation, as well as automated disease management via medication or condition-specific “adherence” messages sent from the physician to the patient.

The AAP is now developing standards for PHRs. Dr. Simonian said that basic features should include information on foster care, birth history, and family history; insurance information; a list of allergies; and a record of medications, immunizations, and lab, image, and other studies.

“That is absolutely essential,” said Dr. Simonian, who practices pediatrics in Clovis, Calif.

PHRs can be either standalone (portable) or tethered (not transferable from one provider or insurer to another). Several free standalone PHR tools exist, such as Microsoft HealthVault (www.healthvault.comwww.google.com/healthwww.healthbutler.com

He said that he currently offers his patients a tethered PHR “that is only active as long as they're part of my practice. I'm talking to my vendor about allowing patients to access their PHR, even if they move to another provider.”

While he noted that he expects increasing numbers of physicians to offer PHRs to their patients in the coming years, Dr. Simonian acknowledged certain obstacles to their widespread use, including the fact that not all patients and their families have ready access to the Internet. Then there's the challenge of meeting the needs of patients who do not speak English. “There's no interpreter built into the PHR,” he said.

Other concerns include compliance with the Health Insurance Portability and Accountability Act and the potential for patients to alter the information the physician enters into the PHR. “If you can't trust what's in the record, how valuable is it?” he asked.

Dr. Simonian said he had no conflicts of interest to disclose.

Dr. Mark M. Simonian shows an example of an electronic personal health record. Courtesy Dr. Mark M. Simonian

SAN DIEGO — If you think that providing your patients with their own electronic personal health record is a waste of time and money, think again.

“If you can communicate more effectively with an online personal health record, then you're enhancing that physician-patient relationship to make sure that patients have the care that they need,” Dr. Mark M. Simonian said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics.

Dr. Simonian, executive member and past chair of the AAP's Council on Clinical Information Technology, explained that a personal health record (PHR) is accessed through the Internet and may be affiliated with the patient's physician, but it's under the primary control of the patient. “It's not a practice-based electronic medical record, but it's capable of being integrated with the electronic medical record,” he noted.

The goal is to provide an Internet-based health record that coordinates lifelong health information and is accessible and portable. PHRs also may include integrated, secure physician-patient e-mail and online consultation, as well as automated disease management via medication or condition-specific “adherence” messages sent from the physician to the patient.

The AAP is now developing standards for PHRs. Dr. Simonian said that basic features should include information on foster care, birth history, and family history; insurance information; a list of allergies; and a record of medications, immunizations, and lab, image, and other studies.

“That is absolutely essential,” said Dr. Simonian, who practices pediatrics in Clovis, Calif.

PHRs can be either standalone (portable) or tethered (not transferable from one provider or insurer to another). Several free standalone PHR tools exist, such as Microsoft HealthVault (www.healthvault.comwww.google.com/healthwww.healthbutler.com

He said that he currently offers his patients a tethered PHR “that is only active as long as they're part of my practice. I'm talking to my vendor about allowing patients to access their PHR, even if they move to another provider.”

While he noted that he expects increasing numbers of physicians to offer PHRs to their patients in the coming years, Dr. Simonian acknowledged certain obstacles to their widespread use, including the fact that not all patients and their families have ready access to the Internet. Then there's the challenge of meeting the needs of patients who do not speak English. “There's no interpreter built into the PHR,” he said.

Other concerns include compliance with the Health Insurance Portability and Accountability Act and the potential for patients to alter the information the physician enters into the PHR. “If you can't trust what's in the record, how valuable is it?” he asked.

Dr. Simonian said he had no conflicts of interest to disclose.

Dr. Mark M. Simonian shows an example of an electronic personal health record. Courtesy Dr. Mark M. Simonian

A simple scoring system for identifying patients with acute pancreatitis who do not require intensive care was 98% accurate and took about 30 minutes to complete, according to Dr. Paul Georg Lankisch and his colleagues.

The tool, known as the harmless acute pancreatitis score (HAPS), combines parameters that suggest a patient has a mild form of the disease: absence of rebound tenderness/guarding, normal levels of serum creatinine, and normal hematocrit.

“A physical examination of a patient with acute pancreatitis takes only minutes to find out whether he or she has rebound tenderness and/or guarding,” wrote Dr. Lankisch of the University of Göttingen (Germany) and his colleagues (Clin. Gastroenterol. Hepatol. 2009 [doi:10.1016/j.cgh.2009.02.020]). Hematocrit and serum creatinine are laboratory investigations available in every hospital at all times, and the findings are reported in about 30 minutes. Therefore, the HAPS yields a result in about a half-hour.

The authors pointed out that current tests used to determine the severity of pancreatitis “are insufficiently sensitive, too complicated, too expensive, and not available soon enough or not available at all outside specialized centers.”

Dr. Lankisch and his colleagues reported on findings from two prospective studies. In an effort to develop an easier way to identify patients with a first attack of acute pancreatitis who do not require intensive care, the researchers studied 394 patients with the condition who were admitted to the department of internal medicine at the Municipal Clinic in Luneburg, Germany, between 1987 and 2003.

A severe disease course was defined as presence of necrosis by contrast-enhanced CT (a Balthazar score of 5 or more points), while a nonsevere, “harmless” course was defined as having no necrosis (a Balthazar score of 0–4), no need for artificial ventilation or dialysis at any time during the hospital stay, and no fatal outcome.

Of the 394 patients, 143 had rebound tenderness and/or guarding and 251 did not. Baseline characteristics of all patients revealed that absence of rebound tenderness/guarding and normal serum creatinine levels were two strong predictors of a mild disease course. However, 23 of the 251 patients (9%) with no rebound tenderness/guarding and a normal serum creatinine level had a severe course.

The researchers observed that among these 251 patients, hematocrit levels exceeding 43% for men and 39.6% for women were strongly associated with having a severe course of the disease, so they added normal hematocrit levels as a third predictor to form the HAPS.

When applied to the 394 patients, the specificity of the HAPS was 97%, the sensitivity was 29%, the positive predictive value was 98%, and the negative predictive value was 22%.

Dr. Lankisch and his associates then sought to validate the HAPS in a multicenter study of 452 patients with a first attack of pancreatitis seen at one of three clinics between January 2004 and December 2006. These patients were similar to the initial set of patients in terms of pancreatic necrosis, and need for dialysis.

When applied to these patients, the specificity of the HAPS was 97%, the sensitivity was 28%, the positive predictive value was 98%, and the negative predictive value was 18%.

Combining results from the initial and validation sets of patients revealed that a severe course of disease was seen in only 4 of 204 patients (2%) whose pancreatitis was classified as harmless. “In two patients from the initial set and one from the validation set, the clinical condition deteriorated and for a short time, contrast-enhanced CT demonstrated small but definite areas of necrosis (Balthazar score 6 points),” the researchers reported.

“In the fourth patient, from the validation set, the acute pancreatitis healed without complications, but the patient died of methicillin-resistant Staphylococcus aureus pneumonia contracted during his hospital stay. Although the cause of death was unconnected with the pancreatitis, he was assigned to the 'not harmless' group because the fatal infection was acquired during his hospital stay for pancreatitis treatment.”

HAPS decides with great accuracy which patients' acute pancreatitis will run a mild course or who will have only interstitial pancreatitis, they concluded.

“Moreover, the score helps to decide which patients do not require intensive management and therapy and expensive imaging procedures, such as contrast-enhanced CT.”

A simple scoring system for identifying patients with acute pancreatitis who do not require intensive care was 98% accurate and took about 30 minutes to complete, according to Dr. Paul Georg Lankisch and his colleagues.

The tool, known as the harmless acute pancreatitis score (HAPS), combines parameters that suggest a patient has a mild form of the disease: absence of rebound tenderness/guarding, normal levels of serum creatinine, and normal hematocrit.

“A physical examination of a patient with acute pancreatitis takes only minutes to find out whether he or she has rebound tenderness and/or guarding,” wrote Dr. Lankisch of the University of Göttingen (Germany) and his colleagues (Clin. Gastroenterol. Hepatol. 2009 [doi:10.1016/j.cgh.2009.02.020]). Hematocrit and serum creatinine are laboratory investigations available in every hospital at all times, and the findings are reported in about 30 minutes. Therefore, the HAPS yields a result in about a half-hour.

The authors pointed out that current tests used to determine the severity of pancreatitis “are insufficiently sensitive, too complicated, too expensive, and not available soon enough or not available at all outside specialized centers.”

Dr. Lankisch and his colleagues reported on findings from two prospective studies. In an effort to develop an easier way to identify patients with a first attack of acute pancreatitis who do not require intensive care, the researchers studied 394 patients with the condition who were admitted to the department of internal medicine at the Municipal Clinic in Luneburg, Germany, between 1987 and 2003.

A severe disease course was defined as presence of necrosis by contrast-enhanced CT (a Balthazar score of 5 or more points), while a nonsevere, “harmless” course was defined as having no necrosis (a Balthazar score of 0–4), no need for artificial ventilation or dialysis at any time during the hospital stay, and no fatal outcome.

Of the 394 patients, 143 had rebound tenderness and/or guarding and 251 did not. Baseline characteristics of all patients revealed that absence of rebound tenderness/guarding and normal serum creatinine levels were two strong predictors of a mild disease course. However, 23 of the 251 patients (9%) with no rebound tenderness/guarding and a normal serum creatinine level had a severe course.

The researchers observed that among these 251 patients, hematocrit levels exceeding 43% for men and 39.6% for women were strongly associated with having a severe course of the disease, so they added normal hematocrit levels as a third predictor to form the HAPS.

When applied to the 394 patients, the specificity of the HAPS was 97%, the sensitivity was 29%, the positive predictive value was 98%, and the negative predictive value was 22%.

Dr. Lankisch and his associates then sought to validate the HAPS in a multicenter study of 452 patients with a first attack of pancreatitis seen at one of three clinics between January 2004 and December 2006. These patients were similar to the initial set of patients in terms of pancreatic necrosis, and need for dialysis.

When applied to these patients, the specificity of the HAPS was 97%, the sensitivity was 28%, the positive predictive value was 98%, and the negative predictive value was 18%.

Combining results from the initial and validation sets of patients revealed that a severe course of disease was seen in only 4 of 204 patients (2%) whose pancreatitis was classified as harmless. “In two patients from the initial set and one from the validation set, the clinical condition deteriorated and for a short time, contrast-enhanced CT demonstrated small but definite areas of necrosis (Balthazar score 6 points),” the researchers reported.

“In the fourth patient, from the validation set, the acute pancreatitis healed without complications, but the patient died of methicillin-resistant Staphylococcus aureus pneumonia contracted during his hospital stay. Although the cause of death was unconnected with the pancreatitis, he was assigned to the 'not harmless' group because the fatal infection was acquired during his hospital stay for pancreatitis treatment.”

HAPS decides with great accuracy which patients' acute pancreatitis will run a mild course or who will have only interstitial pancreatitis, they concluded.

“Moreover, the score helps to decide which patients do not require intensive management and therapy and expensive imaging procedures, such as contrast-enhanced CT.”

A simple scoring system for identifying patients with acute pancreatitis who do not require intensive care was 98% accurate and took about 30 minutes to complete, according to Dr. Paul Georg Lankisch and his colleagues.

The tool, known as the harmless acute pancreatitis score (HAPS), combines parameters that suggest a patient has a mild form of the disease: absence of rebound tenderness/guarding, normal levels of serum creatinine, and normal hematocrit.

“A physical examination of a patient with acute pancreatitis takes only minutes to find out whether he or she has rebound tenderness and/or guarding,” wrote Dr. Lankisch of the University of Göttingen (Germany) and his colleagues (Clin. Gastroenterol. Hepatol. 2009 [doi:10.1016/j.cgh.2009.02.020]). Hematocrit and serum creatinine are laboratory investigations available in every hospital at all times, and the findings are reported in about 30 minutes. Therefore, the HAPS yields a result in about a half-hour.

The authors pointed out that current tests used to determine the severity of pancreatitis “are insufficiently sensitive, too complicated, too expensive, and not available soon enough or not available at all outside specialized centers.”

Dr. Lankisch and his colleagues reported on findings from two prospective studies. In an effort to develop an easier way to identify patients with a first attack of acute pancreatitis who do not require intensive care, the researchers studied 394 patients with the condition who were admitted to the department of internal medicine at the Municipal Clinic in Luneburg, Germany, between 1987 and 2003.

A severe disease course was defined as presence of necrosis by contrast-enhanced CT (a Balthazar score of 5 or more points), while a nonsevere, “harmless” course was defined as having no necrosis (a Balthazar score of 0–4), no need for artificial ventilation or dialysis at any time during the hospital stay, and no fatal outcome.

Of the 394 patients, 143 had rebound tenderness and/or guarding and 251 did not. Baseline characteristics of all patients revealed that absence of rebound tenderness/guarding and normal serum creatinine levels were two strong predictors of a mild disease course. However, 23 of the 251 patients (9%) with no rebound tenderness/guarding and a normal serum creatinine level had a severe course.

The researchers observed that among these 251 patients, hematocrit levels exceeding 43% for men and 39.6% for women were strongly associated with having a severe course of the disease, so they added normal hematocrit levels as a third predictor to form the HAPS.

When applied to the 394 patients, the specificity of the HAPS was 97%, the sensitivity was 29%, the positive predictive value was 98%, and the negative predictive value was 22%.

Dr. Lankisch and his associates then sought to validate the HAPS in a multicenter study of 452 patients with a first attack of pancreatitis seen at one of three clinics between January 2004 and December 2006. These patients were similar to the initial set of patients in terms of pancreatic necrosis, and need for dialysis.

When applied to these patients, the specificity of the HAPS was 97%, the sensitivity was 28%, the positive predictive value was 98%, and the negative predictive value was 18%.

Combining results from the initial and validation sets of patients revealed that a severe course of disease was seen in only 4 of 204 patients (2%) whose pancreatitis was classified as harmless. “In two patients from the initial set and one from the validation set, the clinical condition deteriorated and for a short time, contrast-enhanced CT demonstrated small but definite areas of necrosis (Balthazar score 6 points),” the researchers reported.

“In the fourth patient, from the validation set, the acute pancreatitis healed without complications, but the patient died of methicillin-resistant Staphylococcus aureus pneumonia contracted during his hospital stay. Although the cause of death was unconnected with the pancreatitis, he was assigned to the 'not harmless' group because the fatal infection was acquired during his hospital stay for pancreatitis treatment.”

HAPS decides with great accuracy which patients' acute pancreatitis will run a mild course or who will have only interstitial pancreatitis, they concluded.

“Moreover, the score helps to decide which patients do not require intensive management and therapy and expensive imaging procedures, such as contrast-enhanced CT.”

The prevalence of elevated hemoglobin A_1c levels in adults without a history of diabetes is 3.8%, based on an analysis of data from the National Health and Nutrition Examination Survey.

This indication of a significant prevalence of undiagnosed diabetes was seen in an evaluation of data from 15,934 men and women aged 20 years and older. All had HbA_1c measured during their participation in NHANES 1999–2006. Elevated HbA_1c was defined as a level higher than 6%, and normal fasting glucose was defined as a level below 100 mg/dL.

The 3.8% overall prevalence of elevated HbA_1c levels seen in this population translates into 7.1 million American adults. About 90% of the individuals with high HbA_1c values also had fasting glucose levels that were 100 mg/dL or higher.

Elevated HbA_1c values were significantly associated with male sex, advanced age, nonwhite race/ethnicity, hypercholesterolemia, a high body mass index, and a low level of education. The associations remained even for study participants with elevated HbA_1c levels and normal fasting glucose values, according to Elizabeth Selvin, Ph.D., of the department of epidemiology at the Johns Hopkins University, Baltimore, and her associates.

Non-Hispanic blacks had higher rates of elevated HbA_1c values, compared with other ethnic groups; however, the explanation for this association remains unclear. “Further research should be conducted to determine whether this disparity stems from racial differences in postprandial glycemia or from racial differences in the tendency of hemoglobin to undergo glycosylation,” the researchers stated (Diabetes Care 2009;32:828–33).

Dr. Selvin and her associates acknowledged the study's limitations, including its cross-sectional design and the fact that only one measurement of fasting glucose was taken. (The American Diabetes Association recommends repeating an elevated fasting glucose result.)

HbA_1c values have been proposed for the screening and diagnosis of diabetes. The advantages of using HbA_1c rather than glucose measures include the test's widespread availability and the fact that patients do not need to fast, as well as the “high repeatability of the measurement and the high specificity of elevated values,” the researchers wrote.

Although it “seems reasonable to adopt a single elevated A_1c value as being diagnostic for diabetes … the real test of utility for A_1c as a screening or diagnostic test of diabetes is its association with long-term clinical outcomes in an initially nondiabetic population specifically in comparison with fasting glucose levels,” they said.

The study was supported by grants from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

The authors disclosed no conflicts.

The prevalence of elevated hemoglobin A_1c levels in adults without a history of diabetes is 3.8%, based on an analysis of data from the National Health and Nutrition Examination Survey.

This indication of a significant prevalence of undiagnosed diabetes was seen in an evaluation of data from 15,934 men and women aged 20 years and older. All had HbA_1c measured during their participation in NHANES 1999–2006. Elevated HbA_1c was defined as a level higher than 6%, and normal fasting glucose was defined as a level below 100 mg/dL.

The 3.8% overall prevalence of elevated HbA_1c levels seen in this population translates into 7.1 million American adults. About 90% of the individuals with high HbA_1c values also had fasting glucose levels that were 100 mg/dL or higher.

Elevated HbA_1c values were significantly associated with male sex, advanced age, nonwhite race/ethnicity, hypercholesterolemia, a high body mass index, and a low level of education. The associations remained even for study participants with elevated HbA_1c levels and normal fasting glucose values, according to Elizabeth Selvin, Ph.D., of the department of epidemiology at the Johns Hopkins University, Baltimore, and her associates.

Non-Hispanic blacks had higher rates of elevated HbA_1c values, compared with other ethnic groups; however, the explanation for this association remains unclear. “Further research should be conducted to determine whether this disparity stems from racial differences in postprandial glycemia or from racial differences in the tendency of hemoglobin to undergo glycosylation,” the researchers stated (Diabetes Care 2009;32:828–33).

Dr. Selvin and her associates acknowledged the study's limitations, including its cross-sectional design and the fact that only one measurement of fasting glucose was taken. (The American Diabetes Association recommends repeating an elevated fasting glucose result.)

HbA_1c values have been proposed for the screening and diagnosis of diabetes. The advantages of using HbA_1c rather than glucose measures include the test's widespread availability and the fact that patients do not need to fast, as well as the “high repeatability of the measurement and the high specificity of elevated values,” the researchers wrote.

Although it “seems reasonable to adopt a single elevated A_1c value as being diagnostic for diabetes … the real test of utility for A_1c as a screening or diagnostic test of diabetes is its association with long-term clinical outcomes in an initially nondiabetic population specifically in comparison with fasting glucose levels,” they said.

The study was supported by grants from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

The authors disclosed no conflicts.

The prevalence of elevated hemoglobin A_1c levels in adults without a history of diabetes is 3.8%, based on an analysis of data from the National Health and Nutrition Examination Survey.

This indication of a significant prevalence of undiagnosed diabetes was seen in an evaluation of data from 15,934 men and women aged 20 years and older. All had HbA_1c measured during their participation in NHANES 1999–2006. Elevated HbA_1c was defined as a level higher than 6%, and normal fasting glucose was defined as a level below 100 mg/dL.

The 3.8% overall prevalence of elevated HbA_1c levels seen in this population translates into 7.1 million American adults. About 90% of the individuals with high HbA_1c values also had fasting glucose levels that were 100 mg/dL or higher.

Elevated HbA_1c values were significantly associated with male sex, advanced age, nonwhite race/ethnicity, hypercholesterolemia, a high body mass index, and a low level of education. The associations remained even for study participants with elevated HbA_1c levels and normal fasting glucose values, according to Elizabeth Selvin, Ph.D., of the department of epidemiology at the Johns Hopkins University, Baltimore, and her associates.

Non-Hispanic blacks had higher rates of elevated HbA_1c values, compared with other ethnic groups; however, the explanation for this association remains unclear. “Further research should be conducted to determine whether this disparity stems from racial differences in postprandial glycemia or from racial differences in the tendency of hemoglobin to undergo glycosylation,” the researchers stated (Diabetes Care 2009;32:828–33).

Dr. Selvin and her associates acknowledged the study's limitations, including its cross-sectional design and the fact that only one measurement of fasting glucose was taken. (The American Diabetes Association recommends repeating an elevated fasting glucose result.)

HbA_1c values have been proposed for the screening and diagnosis of diabetes. The advantages of using HbA_1c rather than glucose measures include the test's widespread availability and the fact that patients do not need to fast, as well as the “high repeatability of the measurement and the high specificity of elevated values,” the researchers wrote.

Although it “seems reasonable to adopt a single elevated A_1c value as being diagnostic for diabetes … the real test of utility for A_1c as a screening or diagnostic test of diabetes is its association with long-term clinical outcomes in an initially nondiabetic population specifically in comparison with fasting glucose levels,” they said.

The study was supported by grants from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

The authors disclosed no conflicts.

SAN DIEGO — Health care worker influenza vaccination programs with high coverage rates emphasized accountability to the highest levels of the organization, provided weekend access to the vaccine, and used train-the-trainer programs, a survey of 50 hospitals showed.

The researchers found surprising variation from hospital to hospital in the definition of heath care worker. “A uniform definition of health care worker is essential if and when health care worker vaccination rates are reported publicly,” lead investigator Dr. Thomas R. Talbot said at the annual meeting of the Society for Healthcare Epidemiology of America.

In August and September of 2008, he and his associates sent a 45-question survey about health care worker vaccination practices to 50 hospitals in 33 states that were members of the University HealthSystem Consortium, a group of academic medical centers that conducts multiple benchmarking studies each year. The 50 hospitals ranged in size from 2,603 to 26,000 health care workers and represented a total of 368,969 health care workers, said Dr. Talbot, chief hospital epidemiologist at Vanderbilt University, Nashville, Tenn.

Nearly all vaccination programs (98%) included nursing staff, but only 68% targeted attending and faculty physicians, 54% included volunteers, 46% included agency staff, and 34% included medical students. Although 94% of hospitals tracked health care worker vaccination rates, the remainder tracked the number of doses of vaccine administered.

Of all health care workers at the hospitals surveyed, 57% were vaccinated during the 2007–2008 influenza season. The rate per facility ranged from 26% to 81%.

The vaccine was provided free of charge to all employees at all sites. It was also provided at no charge to 96% of volunteers, 62% of students, 60% of visiting health care workers, and 14% of employee family members.

Reported times and locations where the influenza vaccine was provided included clinical units (96%), satellite facilities (92%), at group meetings (92%), on night shifts (90%), and on weekends (78%). In addition, 76% of the hospitals used mobile carts, 70% had a train-the-trainer program, 34% provided incentives or raffles for prizes, and 18% rewarded units or areas with high vaccination rates.

More than one-third of hospitals (38%) require health care workers who refuse vaccination to formally decline vaccination. Of those, 79% require a signed declination form.

The majority of hospitals (82%) report their vaccination rates to facility administrators, and 62% provide them to department chairs or service chiefs, but only 20% provide them to the hospital board of trustees.

None of the hospitals reported that they had ever dismissed an employee because of failure to follow the facility's influenza vaccination policy.

Two-thirds of hospitals (66%) reported that administrators send a letter or communication to their health care workers emphasizing the importance of the influenza vaccination campaign.

Certain vaccination program components were associated with significantly higher vaccination rates when compared with hospitals that did not use such components. These included provision of vaccine on weekends (59% vs. 44%), use of train-the-trainer programs (60% vs. 47%), report of vaccination coverage rates to the hospital board of trustees (64% vs. 53%), and visible support from hospital administrators (58% vs. 37%), such as administration sending a letter to health care workers emphasizing the importance of influenza vaccination.

Dr. Talbot disclosed that he has received research funding from Sanofi Pasteur.

At the hospitals surveyed, 57% of health care workers were vaccinated during the 2007–2008 influenza season. DR. TALBOT

SAN DIEGO — Health care worker influenza vaccination programs with high coverage rates emphasized accountability to the highest levels of the organization, provided weekend access to the vaccine, and used train-the-trainer programs, a survey of 50 hospitals showed.

The researchers found surprising variation from hospital to hospital in the definition of heath care worker. “A uniform definition of health care worker is essential if and when health care worker vaccination rates are reported publicly,” lead investigator Dr. Thomas R. Talbot said at the annual meeting of the Society for Healthcare Epidemiology of America.

In August and September of 2008, he and his associates sent a 45-question survey about health care worker vaccination practices to 50 hospitals in 33 states that were members of the University HealthSystem Consortium, a group of academic medical centers that conducts multiple benchmarking studies each year. The 50 hospitals ranged in size from 2,603 to 26,000 health care workers and represented a total of 368,969 health care workers, said Dr. Talbot, chief hospital epidemiologist at Vanderbilt University, Nashville, Tenn.

Nearly all vaccination programs (98%) included nursing staff, but only 68% targeted attending and faculty physicians, 54% included volunteers, 46% included agency staff, and 34% included medical students. Although 94% of hospitals tracked health care worker vaccination rates, the remainder tracked the number of doses of vaccine administered.

Of all health care workers at the hospitals surveyed, 57% were vaccinated during the 2007–2008 influenza season. The rate per facility ranged from 26% to 81%.

The vaccine was provided free of charge to all employees at all sites. It was also provided at no charge to 96% of volunteers, 62% of students, 60% of visiting health care workers, and 14% of employee family members.

Reported times and locations where the influenza vaccine was provided included clinical units (96%), satellite facilities (92%), at group meetings (92%), on night shifts (90%), and on weekends (78%). In addition, 76% of the hospitals used mobile carts, 70% had a train-the-trainer program, 34% provided incentives or raffles for prizes, and 18% rewarded units or areas with high vaccination rates.

More than one-third of hospitals (38%) require health care workers who refuse vaccination to formally decline vaccination. Of those, 79% require a signed declination form.

The majority of hospitals (82%) report their vaccination rates to facility administrators, and 62% provide them to department chairs or service chiefs, but only 20% provide them to the hospital board of trustees.

None of the hospitals reported that they had ever dismissed an employee because of failure to follow the facility's influenza vaccination policy.

Two-thirds of hospitals (66%) reported that administrators send a letter or communication to their health care workers emphasizing the importance of the influenza vaccination campaign.

Certain vaccination program components were associated with significantly higher vaccination rates when compared with hospitals that did not use such components. These included provision of vaccine on weekends (59% vs. 44%), use of train-the-trainer programs (60% vs. 47%), report of vaccination coverage rates to the hospital board of trustees (64% vs. 53%), and visible support from hospital administrators (58% vs. 37%), such as administration sending a letter to health care workers emphasizing the importance of influenza vaccination.

Dr. Talbot disclosed that he has received research funding from Sanofi Pasteur.

At the hospitals surveyed, 57% of health care workers were vaccinated during the 2007–2008 influenza season. DR. TALBOT

SAN DIEGO — Health care worker influenza vaccination programs with high coverage rates emphasized accountability to the highest levels of the organization, provided weekend access to the vaccine, and used train-the-trainer programs, a survey of 50 hospitals showed.

The researchers found surprising variation from hospital to hospital in the definition of heath care worker. “A uniform definition of health care worker is essential if and when health care worker vaccination rates are reported publicly,” lead investigator Dr. Thomas R. Talbot said at the annual meeting of the Society for Healthcare Epidemiology of America.

In August and September of 2008, he and his associates sent a 45-question survey about health care worker vaccination practices to 50 hospitals in 33 states that were members of the University HealthSystem Consortium, a group of academic medical centers that conducts multiple benchmarking studies each year. The 50 hospitals ranged in size from 2,603 to 26,000 health care workers and represented a total of 368,969 health care workers, said Dr. Talbot, chief hospital epidemiologist at Vanderbilt University, Nashville, Tenn.

Nearly all vaccination programs (98%) included nursing staff, but only 68% targeted attending and faculty physicians, 54% included volunteers, 46% included agency staff, and 34% included medical students. Although 94% of hospitals tracked health care worker vaccination rates, the remainder tracked the number of doses of vaccine administered.

Of all health care workers at the hospitals surveyed, 57% were vaccinated during the 2007–2008 influenza season. The rate per facility ranged from 26% to 81%.

The vaccine was provided free of charge to all employees at all sites. It was also provided at no charge to 96% of volunteers, 62% of students, 60% of visiting health care workers, and 14% of employee family members.

Reported times and locations where the influenza vaccine was provided included clinical units (96%), satellite facilities (92%), at group meetings (92%), on night shifts (90%), and on weekends (78%). In addition, 76% of the hospitals used mobile carts, 70% had a train-the-trainer program, 34% provided incentives or raffles for prizes, and 18% rewarded units or areas with high vaccination rates.

More than one-third of hospitals (38%) require health care workers who refuse vaccination to formally decline vaccination. Of those, 79% require a signed declination form.

The majority of hospitals (82%) report their vaccination rates to facility administrators, and 62% provide them to department chairs or service chiefs, but only 20% provide them to the hospital board of trustees.

None of the hospitals reported that they had ever dismissed an employee because of failure to follow the facility's influenza vaccination policy.

Two-thirds of hospitals (66%) reported that administrators send a letter or communication to their health care workers emphasizing the importance of the influenza vaccination campaign.

Certain vaccination program components were associated with significantly higher vaccination rates when compared with hospitals that did not use such components. These included provision of vaccine on weekends (59% vs. 44%), use of train-the-trainer programs (60% vs. 47%), report of vaccination coverage rates to the hospital board of trustees (64% vs. 53%), and visible support from hospital administrators (58% vs. 37%), such as administration sending a letter to health care workers emphasizing the importance of influenza vaccination.

Dr. Talbot disclosed that he has received research funding from Sanofi Pasteur.

At the hospitals surveyed, 57% of health care workers were vaccinated during the 2007–2008 influenza season. DR. TALBOT

SAN DIEGO — Treating nonalcoholic steatohepatitis is difficult territory for clinicians because no therapy has been proved effective, Dr. Arthur J. McCullough said at a meeting on chronic liver disease sponsored by Scripps Clinic.

“All therapies I consider emerging, because, at present, there are no proven therapies for this,” said Dr. McCullough, chairman of the department of gastroenterology and hepatology at the Cleveland Clinic. “Not everyone with NASH [nonalcoholic steatohepatitis] progresses, but our current management is not adequate.”

One practical approach is to advise patients to follow a Mediterranean diet, which has been shown to improve insulin resistance, compared with other diets. “There are controversies with whatever diet you use,” he said. “Most of the studies say a high-fat diet is bad. For my patients, I recommend a low-fat diet emphasizing polyunsaturated fatty acids and a low glycemic diet, which means a fiber bread instead of white bread, fish and chicken, fruits and vegetables, no fructose, and no trans fat.”

At least one study has demonstrated that use of polyunsaturated fatty acids (PUFAs) by NASH patients improved their alanine transaminase (ALT) and triglyceride levels (Aliment. Pharmacol. Ther. 2006;23:1143–51). PUFAs “work like fibrates,” Dr. McCullough explained. “They upregulate peroxisome proliferator-activated receptor-alpha, which increases fatty acid oxidation from peroxisomes and mitochondria. But they also suppress a number of genes in the triglyceride synthesis pathway.”

Another treatment approach involves weight loss and exercise. Between 2002 and 2007, there were 26 published studies on weight loss and exercise in patients with NASH, but the evidence is incomplete because only 3 of the trials were controlled and only 4 included liver biopsies before and after treatment. “Most of the trials were short term, so the intervention was mainly prescriptive,” he said. “Only four included behavior therapy according to current guidelines.”

Despite the paucity of robust studies, Dr. McCullough maintained that patients with NASH can improve their disease with small improvements in their body mass index. “It can be discouraging to tell people to lose 20% of their body weight, but I think you can achieve significant decreases in ALT and steatosis with as little as a 5% drop in body weight,” he said. “We set targets of 5% at 3 months and 10% at 6 months.”

Even so, only about 30% of patients at the Cleveland Clinic are able to sustain a weight loss of 10% over the long term, “and this is with behavior modification and counseling. We do the best we can, but this is very difficult to achieve.”

Bariatric surgery is another treatment option. Dr. McCullough recommends this for patients with a body mass index (BMI) of 35 kg/m

Some clinicians have advocated the use of metformin in patients with NASH, but this is “a controversial area,” Dr. McCullough said. The investigators looked at 200 patients, but only one of the studies was a controlled trial. That has prompted a movement toward use of the glitazones. “But the problem is, once you stop therapy with glitazones, the NASH comes back. If you're going to start people on this, it's lifelong therapy. Also, there is significant weight gain with the glitazones, an average of at least 3 kg.”

Dr. McCullough prefers to use metformin because “it has [a] more direct effect on the liver,” compared with the glitazones. For now, he said, clinicians should ask themselves two questions before recommending a specific therapy for NASH: “Once you start treatment, what then?” and “Do you feel good about using the treatment long term?”

Dr. McCullough had no conflicts to disclose.

SAN DIEGO — Treating nonalcoholic steatohepatitis is difficult territory for clinicians because no therapy has been proved effective, Dr. Arthur J. McCullough said at a meeting on chronic liver disease sponsored by Scripps Clinic.

“All therapies I consider emerging, because, at present, there are no proven therapies for this,” said Dr. McCullough, chairman of the department of gastroenterology and hepatology at the Cleveland Clinic. “Not everyone with NASH [nonalcoholic steatohepatitis] progresses, but our current management is not adequate.”

One practical approach is to advise patients to follow a Mediterranean diet, which has been shown to improve insulin resistance, compared with other diets. “There are controversies with whatever diet you use,” he said. “Most of the studies say a high-fat diet is bad. For my patients, I recommend a low-fat diet emphasizing polyunsaturated fatty acids and a low glycemic diet, which means a fiber bread instead of white bread, fish and chicken, fruits and vegetables, no fructose, and no trans fat.”

At least one study has demonstrated that use of polyunsaturated fatty acids (PUFAs) by NASH patients improved their alanine transaminase (ALT) and triglyceride levels (Aliment. Pharmacol. Ther. 2006;23:1143–51). PUFAs “work like fibrates,” Dr. McCullough explained. “They upregulate peroxisome proliferator-activated receptor-alpha, which increases fatty acid oxidation from peroxisomes and mitochondria. But they also suppress a number of genes in the triglyceride synthesis pathway.”

Another treatment approach involves weight loss and exercise. Between 2002 and 2007, there were 26 published studies on weight loss and exercise in patients with NASH, but the evidence is incomplete because only 3 of the trials were controlled and only 4 included liver biopsies before and after treatment. “Most of the trials were short term, so the intervention was mainly prescriptive,” he said. “Only four included behavior therapy according to current guidelines.”

Despite the paucity of robust studies, Dr. McCullough maintained that patients with NASH can improve their disease with small improvements in their body mass index. “It can be discouraging to tell people to lose 20% of their body weight, but I think you can achieve significant decreases in ALT and steatosis with as little as a 5% drop in body weight,” he said. “We set targets of 5% at 3 months and 10% at 6 months.”

Even so, only about 30% of patients at the Cleveland Clinic are able to sustain a weight loss of 10% over the long term, “and this is with behavior modification and counseling. We do the best we can, but this is very difficult to achieve.”

Bariatric surgery is another treatment option. Dr. McCullough recommends this for patients with a body mass index (BMI) of 35 kg/m

Some clinicians have advocated the use of metformin in patients with NASH, but this is “a controversial area,” Dr. McCullough said. The investigators looked at 200 patients, but only one of the studies was a controlled trial. That has prompted a movement toward use of the glitazones. “But the problem is, once you stop therapy with glitazones, the NASH comes back. If you're going to start people on this, it's lifelong therapy. Also, there is significant weight gain with the glitazones, an average of at least 3 kg.”

Dr. McCullough prefers to use metformin because “it has [a] more direct effect on the liver,” compared with the glitazones. For now, he said, clinicians should ask themselves two questions before recommending a specific therapy for NASH: “Once you start treatment, what then?” and “Do you feel good about using the treatment long term?”

Dr. McCullough had no conflicts to disclose.

SAN DIEGO — Treating nonalcoholic steatohepatitis is difficult territory for clinicians because no therapy has been proved effective, Dr. Arthur J. McCullough said at a meeting on chronic liver disease sponsored by Scripps Clinic.

“All therapies I consider emerging, because, at present, there are no proven therapies for this,” said Dr. McCullough, chairman of the department of gastroenterology and hepatology at the Cleveland Clinic. “Not everyone with NASH [nonalcoholic steatohepatitis] progresses, but our current management is not adequate.”

One practical approach is to advise patients to follow a Mediterranean diet, which has been shown to improve insulin resistance, compared with other diets. “There are controversies with whatever diet you use,” he said. “Most of the studies say a high-fat diet is bad. For my patients, I recommend a low-fat diet emphasizing polyunsaturated fatty acids and a low glycemic diet, which means a fiber bread instead of white bread, fish and chicken, fruits and vegetables, no fructose, and no trans fat.”

At least one study has demonstrated that use of polyunsaturated fatty acids (PUFAs) by NASH patients improved their alanine transaminase (ALT) and triglyceride levels (Aliment. Pharmacol. Ther. 2006;23:1143–51). PUFAs “work like fibrates,” Dr. McCullough explained. “They upregulate peroxisome proliferator-activated receptor-alpha, which increases fatty acid oxidation from peroxisomes and mitochondria. But they also suppress a number of genes in the triglyceride synthesis pathway.”

Another treatment approach involves weight loss and exercise. Between 2002 and 2007, there were 26 published studies on weight loss and exercise in patients with NASH, but the evidence is incomplete because only 3 of the trials were controlled and only 4 included liver biopsies before and after treatment. “Most of the trials were short term, so the intervention was mainly prescriptive,” he said. “Only four included behavior therapy according to current guidelines.”

Despite the paucity of robust studies, Dr. McCullough maintained that patients with NASH can improve their disease with small improvements in their body mass index. “It can be discouraging to tell people to lose 20% of their body weight, but I think you can achieve significant decreases in ALT and steatosis with as little as a 5% drop in body weight,” he said. “We set targets of 5% at 3 months and 10% at 6 months.”

Even so, only about 30% of patients at the Cleveland Clinic are able to sustain a weight loss of 10% over the long term, “and this is with behavior modification and counseling. We do the best we can, but this is very difficult to achieve.”

Bariatric surgery is another treatment option. Dr. McCullough recommends this for patients with a body mass index (BMI) of 35 kg/m

Some clinicians have advocated the use of metformin in patients with NASH, but this is “a controversial area,” Dr. McCullough said. The investigators looked at 200 patients, but only one of the studies was a controlled trial. That has prompted a movement toward use of the glitazones. “But the problem is, once you stop therapy with glitazones, the NASH comes back. If you're going to start people on this, it's lifelong therapy. Also, there is significant weight gain with the glitazones, an average of at least 3 kg.”

Dr. McCullough prefers to use metformin because “it has [a] more direct effect on the liver,” compared with the glitazones. For now, he said, clinicians should ask themselves two questions before recommending a specific therapy for NASH: “Once you start treatment, what then?” and “Do you feel good about using the treatment long term?”

Dr. McCullough had no conflicts to disclose.

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with "keeping him sane."

"I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense," recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. "My wife used to tell me: 'You are so tense. What's the matter with you?' "

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. "I've always had a studio in the house," he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. "I went to Birmingham about 3 years ago to see that mural," he said. "They keep it in very good shape."

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. "I'm going to do that; I'm going to get busy again," he said, estimating that the portrait will take him 2–3 weeks to complete. "I don't paint for money," he added. "It's absolutely a hobby."

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

"You have to have an inspiration for something to paint," he said. "Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in."

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. "I don't like this modern stuff," he said. "All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic."

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. "It's like a small museum there," he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. "I think I'm a workaholic," he admitted.

Asked what it takes to be vital at age 92, he replied: "Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else]."

Dr. Robert R. Canas still paints 1–2 hours each day before going to work. Courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with "keeping him sane."

"I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense," recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. "My wife used to tell me: 'You are so tense. What's the matter with you?' "

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. "I've always had a studio in the house," he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. "I went to Birmingham about 3 years ago to see that mural," he said. "They keep it in very good shape."

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. "I'm going to do that; I'm going to get busy again," he said, estimating that the portrait will take him 2–3 weeks to complete. "I don't paint for money," he added. "It's absolutely a hobby."

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

"You have to have an inspiration for something to paint," he said. "Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in."

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. "I don't like this modern stuff," he said. "All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic."

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. "It's like a small museum there," he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. "I think I'm a workaholic," he admitted.

Asked what it takes to be vital at age 92, he replied: "Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else]."

Dr. Robert R. Canas still paints 1–2 hours each day before going to work. Courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with "keeping him sane."

"I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense," recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. "My wife used to tell me: 'You are so tense. What's the matter with you?' "

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. "I've always had a studio in the house," he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. "I went to Birmingham about 3 years ago to see that mural," he said. "They keep it in very good shape."

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. "I'm going to do that; I'm going to get busy again," he said, estimating that the portrait will take him 2–3 weeks to complete. "I don't paint for money," he added. "It's absolutely a hobby."

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

"You have to have an inspiration for something to paint," he said. "Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in."

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velázquez. "I don't like this modern stuff," he said. "All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic."

On most days Dr. Canas paints for 1–2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. "It's like a small museum there," he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. "I think I'm a workaholic," he admitted.

Asked what it takes to be vital at age 92, he replied: "Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else]."

Dr. Robert R. Canas still paints 1–2 hours each day before going to work. Courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. “My wife used to tell me: 'You are so tense. What's the matter with you?'”

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2-3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

“You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velàzquez. “I don't like this modern stuff,” he said.

“All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1-2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He considers his wife, Norma Gail, a “good critic” of his work. “When I call her in to look at a painting, she'll say, 'I hate to tell you this, but there is something wrong there,' and the majority of [the] time she is right. She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

Dr. Robert R. Canas still paints 1-2 hours each day before heading into work at a medical clinic in Durand, Mich.

He painted this large mural of religious scenes on the sanctuary walls of a church in Birmingham, Ala. Photos courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. “My wife used to tell me: 'You are so tense. What's the matter with you?'”

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2-3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

“You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velàzquez. “I don't like this modern stuff,” he said.

“All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1-2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He considers his wife, Norma Gail, a “good critic” of his work. “When I call her in to look at a painting, she'll say, 'I hate to tell you this, but there is something wrong there,' and the majority of [the] time she is right. She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

Dr. Robert R. Canas still paints 1-2 hours each day before heading into work at a medical clinic in Durand, Mich.

He painted this large mural of religious scenes on the sanctuary walls of a church in Birmingham, Ala. Photos courtesy Dr. Robert R. Canas

Practicing medicine since 1942, Dr. Robert R. Canas credits his painting and sculpture hobbies with “keeping him sane.”

“I was a general surgeon for many years, and after the pressure in the operating room I would come home and be very tense,” recalls Dr. Canas, who is 92 years old and now practices general medicine in Durand, Mich. “My wife used to tell me: 'You are so tense. What's the matter with you?'”

As a young surgeon in Panama, Dr. Canas transformed a room in his house into an art studio, where he went to unwind by creating works of art in various media, from acrylic paints and oils to watercolors, ink, charcoal, clay, and bronze. It became his refuge, and he created other studios when his career path led to stops in Birmingham, Ala., and Durand, where he's lived since 1966. “I've always had a studio in the house,” he said.

His creations over the years have ranged widely in medium and in size, and have included a life-sized bronze statue of a railroad worker displayed in downtown Durand (an area rich in railroad history), a life-sized stone statue of Saint Patrick that stands on the grounds of a church in downtown Birmingham, and a large mural of religious scenes he painted on the sanctuary walls of another church in Birmingham. “I went to Birmingham about 3 years ago to see that mural,” he said. “They keep it in very good shape.”

He painted another mural of religious imagery for a church in Durand that was torn down a few years ago, but he salvaged the mural and hopes to find another home for it.

Dr. Canas also creates works of art on request from family members, friends, and patients. Recently one of his patients brought in a photo of her granddaughter and asked Dr. Canas if he would paint a portrait of her on 24-inch by 18-inch canvas. “I'm going to do that; I'm going to get busy again,” he said, estimating that the portrait will take him 2-3 weeks to complete. “I don't paint for money,” he added. “It's absolutely a hobby.”

Raised in El Salvador, Dr. Canas began painting and sculpting when he was about 10 years old. He recalls no specific personal influence in pursuing art, just inspiration.

“You have to have an inspiration for something to paint,” he said. “Sometimes I get inspired by horses or other animals. I've also painted a lot of portraits. It depends [on] what mood I'm in.”

He describes himself as a realist inspired by Michelangelo, Rembrandt, and Velàzquez. “I don't like this modern stuff,” he said.

“All of my paintings are realistic; they're not something that you have to interpret, and say 'well, that looks like a horse or that looks like a parrot.' I want people to see that's what it is. It's realistic.”

On most days Dr. Canas paints for 1-2 hours in the morning before heading to the medical clinic to see patients, where several of his paintings adorn the walls. “It's like a small museum there,” he said.

The clinic also features a dedicated room where he can paint when it is a slow day or when there is a time gap in the schedule. “I think I'm a workaholic,” he admitted.

He considers his wife, Norma Gail, a “good critic” of his work. “When I call her in to look at a painting, she'll say, 'I hate to tell you this, but there is something wrong there,' and the majority of [the] time she is right. She's my backup.”

Asked what it takes to be vital at age 92, he replied: “Find something to help you relax. If you cannot paint, go play golf. If you don't play golf, go hunting or fishing, or do something [else].”

Dr. Robert R. Canas still paints 1-2 hours each day before heading into work at a medical clinic in Durand, Mich.

He painted this large mural of religious scenes on the sanctuary walls of a church in Birmingham, Ala. Photos courtesy Dr. Robert R. Canas

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL. Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The mean age was 10 years, 60% were boys, and 78% were white. Fourteen had definite LM, 6 had possible LM, and 30 had aseptic meningitis.

Probability percentage ranges were used to categorize risk. Calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%–50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

If a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%. “We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons.

Funding was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL. Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The mean age was 10 years, 60% were boys, and 78% were white. Fourteen had definite LM, 6 had possible LM, and 30 had aseptic meningitis.

Probability percentage ranges were used to categorize risk. Calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%–50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

If a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%. “We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons.

Funding was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL. Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The mean age was 10 years, 60% were boys, and 78% were white. Fourteen had definite LM, 6 had possible LM, and 30 had aseptic meningitis.

Probability percentage ranges were used to categorize risk. Calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%–50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

If a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%. “We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons.

Funding was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

For Dr. Christiane Stahl, bicycling is not so much a hobby as a way of life. She's been commuting by bike to school or work since she was 8 years old.

“I use public transportation, but the nice thing about a bike is you're kind of out there on your own,” said Dr. Stahl of the department of pediatrics at the University of Illinois at Chicago. “It's a little more individual and gives you more time for reflection. You're not distracted by all the social interactions that are going on when you take public transportation.”

She bikes 5 miles to work “if it's not actively precipitating and the wind is not more than 20 miles an hour against me.”

Even Chicago's harsh winter days don't stop her. “I have little booties that I put over my bike shoes and big puffy bike gloves and hats to wear under my helmet,” she said.

No special tires are required during her winter commutes because the route she takes includes a network of bike lanes that “get cleared out pretty well” by the city's snowplows. However, degradation of the bike chain from road salt is an ongoing issue.

Among her favorite vacations are bike trips she's taken through Germany, Wisconsin, and South Carolina. Her easiest and most spontaneous trip “was on the back of a tandem bicycle around the Chicago area—taking advantage of the great trail system, the outdoor concert area of Ravinia Park, and views of Lake Michigan,” she said. “Plus, I was in beeper range the whole time, and it's easy to make callbacks from the back of a tandem so no cross-coverage arrangements were required.”

An advocate for bike safety, Dr. Stahl has served as a medical volunteer for Bank of America's Bike the Drive, an annual bike ride along scenic Lake Shore Drive that benefits the Active Transportation Alliance (formerly the Chicagoland Bicycle Federation), a not-for-profit biking, walking, and transit advocacy organization. She noted that as more people take up bicycling as an inexpensive and environmentally friendly commuting tactic, upgrades in the separation of auto and bicycle traffic will be needed.

“Until we do that, we're going to see rising rates of injury, because I think more people will turn to bicycling as a way of getting around,” she said. “Compared with Europe, we have so far to go in terms of creating safer bikeways.”

A devoted helmet wearer, Dr. Stahl had one serious biking injury: a low-speed face plant when she dropped a wheel into a sidewalk grate. “Fortunately, I was just outside the hospital emergency room,” she said. “I got a fair number of facial lacerations, but I didn't have any head injury.”

Although she knows bicyclists who set goals to improve their speed or endurance, Dr. Stahl just enjoys the ride.

“For me, biking is not goal oriented,” she said. “That's one of the chief joys of riding my bike: to explore, look around, and see things.”

Dr. Christiane Stahl bikes 5 miles to work every day in Chicago. COURTESY DR. CHRISTIANE STAHL

For Dr. Christiane Stahl, bicycling is not so much a hobby as a way of life. She's been commuting by bike to school or work since she was 8 years old.

“I use public transportation, but the nice thing about a bike is you're kind of out there on your own,” said Dr. Stahl of the department of pediatrics at the University of Illinois at Chicago. “It's a little more individual and gives you more time for reflection. You're not distracted by all the social interactions that are going on when you take public transportation.”

She bikes 5 miles to work “if it's not actively precipitating and the wind is not more than 20 miles an hour against me.”

Even Chicago's harsh winter days don't stop her. “I have little booties that I put over my bike shoes and big puffy bike gloves and hats to wear under my helmet,” she said.

No special tires are required during her winter commutes because the route she takes includes a network of bike lanes that “get cleared out pretty well” by the city's snowplows. However, degradation of the bike chain from road salt is an ongoing issue.

Among her favorite vacations are bike trips she's taken through Germany, Wisconsin, and South Carolina. Her easiest and most spontaneous trip “was on the back of a tandem bicycle around the Chicago area—taking advantage of the great trail system, the outdoor concert area of Ravinia Park, and views of Lake Michigan,” she said. “Plus, I was in beeper range the whole time, and it's easy to make callbacks from the back of a tandem so no cross-coverage arrangements were required.”

An advocate for bike safety, Dr. Stahl has served as a medical volunteer for Bank of America's Bike the Drive, an annual bike ride along scenic Lake Shore Drive that benefits the Active Transportation Alliance (formerly the Chicagoland Bicycle Federation), a not-for-profit biking, walking, and transit advocacy organization. She noted that as more people take up bicycling as an inexpensive and environmentally friendly commuting tactic, upgrades in the separation of auto and bicycle traffic will be needed.

“Until we do that, we're going to see rising rates of injury, because I think more people will turn to bicycling as a way of getting around,” she said. “Compared with Europe, we have so far to go in terms of creating safer bikeways.”

A devoted helmet wearer, Dr. Stahl had one serious biking injury: a low-speed face plant when she dropped a wheel into a sidewalk grate. “Fortunately, I was just outside the hospital emergency room,” she said. “I got a fair number of facial lacerations, but I didn't have any head injury.”

Although she knows bicyclists who set goals to improve their speed or endurance, Dr. Stahl just enjoys the ride.

“For me, biking is not goal oriented,” she said. “That's one of the chief joys of riding my bike: to explore, look around, and see things.”

Dr. Christiane Stahl bikes 5 miles to work every day in Chicago. COURTESY DR. CHRISTIANE STAHL

For Dr. Christiane Stahl, bicycling is not so much a hobby as a way of life. She's been commuting by bike to school or work since she was 8 years old.

“I use public transportation, but the nice thing about a bike is you're kind of out there on your own,” said Dr. Stahl of the department of pediatrics at the University of Illinois at Chicago. “It's a little more individual and gives you more time for reflection. You're not distracted by all the social interactions that are going on when you take public transportation.”

She bikes 5 miles to work “if it's not actively precipitating and the wind is not more than 20 miles an hour against me.”

Even Chicago's harsh winter days don't stop her. “I have little booties that I put over my bike shoes and big puffy bike gloves and hats to wear under my helmet,” she said.

No special tires are required during her winter commutes because the route she takes includes a network of bike lanes that “get cleared out pretty well” by the city's snowplows. However, degradation of the bike chain from road salt is an ongoing issue.

Among her favorite vacations are bike trips she's taken through Germany, Wisconsin, and South Carolina. Her easiest and most spontaneous trip “was on the back of a tandem bicycle around the Chicago area—taking advantage of the great trail system, the outdoor concert area of Ravinia Park, and views of Lake Michigan,” she said. “Plus, I was in beeper range the whole time, and it's easy to make callbacks from the back of a tandem so no cross-coverage arrangements were required.”

An advocate for bike safety, Dr. Stahl has served as a medical volunteer for Bank of America's Bike the Drive, an annual bike ride along scenic Lake Shore Drive that benefits the Active Transportation Alliance (formerly the Chicagoland Bicycle Federation), a not-for-profit biking, walking, and transit advocacy organization. She noted that as more people take up bicycling as an inexpensive and environmentally friendly commuting tactic, upgrades in the separation of auto and bicycle traffic will be needed.

“Until we do that, we're going to see rising rates of injury, because I think more people will turn to bicycling as a way of getting around,” she said. “Compared with Europe, we have so far to go in terms of creating safer bikeways.”

A devoted helmet wearer, Dr. Stahl had one serious biking injury: a low-speed face plant when she dropped a wheel into a sidewalk grate. “Fortunately, I was just outside the hospital emergency room,” she said. “I got a fair number of facial lacerations, but I didn't have any head injury.”

Although she knows bicyclists who set goals to improve their speed or endurance, Dr. Stahl just enjoys the ride.

“For me, biking is not goal oriented,” she said. “That's one of the chief joys of riding my bike: to explore, look around, and see things.”

Dr. Christiane Stahl bikes 5 miles to work every day in Chicago. COURTESY DR. CHRISTIANE STAHL

LA JOLLA, CALIF. — The estimated prevalence of nonalcoholic fatty liver disease in the United States is 10%-33%, and is likely to climb even higher unless Americans start to lose weight.

“Our high body mass index is the main driving force of nonalcoholic fatty liver disease [NAFLD],” Dr. Paul J. Pockros said at a meeting on chronic liver disease sponsored by Scripps Clinic. “The reason we're in trouble is that too many people are eating 2,500 calories at each meal and are not exercising.”

The presence of metabolic syndrome or its manifestations can be associated with nonalcoholic steatohepatitis (NASH). In a study of 212 morbidly obese patients who underwent bariatric surgery, 93% had NAFLD, 26% had NASH, and 9% had advanced fibrosis at the time of their surgery (Obes. Surg. 2005;15:310-5). Independent predictors of NASH were high aspartate aminotransferase (AST) level, diabetes, and male sex. Independent predictors of advanced fibrosis were high AST, central obesity, and hepatocyte necrosis, said Dr. Pockros, head of the division of gastroenterology and hepatology at Scripps Clinic, La Jolla.

Another study found that patients with NAFLD plus diabetes had higher rates of cirrhosis than did patients who had NAFLD alone (25% vs. 10%, respectively). Overall mortality (risk ratio of 3.3) and mortality related to liver disease (risk ratio of 22.83) were greater in diabetic patients with NAFLD (Clin. Gastroenterol. Hepatol. 2004;2:262-5).

Dr. Pockros prescribes a low-fat, Mediterranean-type diet and exercise for his obese patients with NAFLD and NASH. “No single intervention has convincingly improved all important outcomes in NAFLD,” he said. “Our best approach is with diet and exercise.”

Dr. Pockros said he has received research support from, and is an adviser to, Roche, Vertex, and Gilead, and is an adviser to Amgen.

LA JOLLA, CALIF. — The estimated prevalence of nonalcoholic fatty liver disease in the United States is 10%-33%, and is likely to climb even higher unless Americans start to lose weight.

“Our high body mass index is the main driving force of nonalcoholic fatty liver disease [NAFLD],” Dr. Paul J. Pockros said at a meeting on chronic liver disease sponsored by Scripps Clinic. “The reason we're in trouble is that too many people are eating 2,500 calories at each meal and are not exercising.”

The presence of metabolic syndrome or its manifestations can be associated with nonalcoholic steatohepatitis (NASH). In a study of 212 morbidly obese patients who underwent bariatric surgery, 93% had NAFLD, 26% had NASH, and 9% had advanced fibrosis at the time of their surgery (Obes. Surg. 2005;15:310-5). Independent predictors of NASH were high aspartate aminotransferase (AST) level, diabetes, and male sex. Independent predictors of advanced fibrosis were high AST, central obesity, and hepatocyte necrosis, said Dr. Pockros, head of the division of gastroenterology and hepatology at Scripps Clinic, La Jolla.

Another study found that patients with NAFLD plus diabetes had higher rates of cirrhosis than did patients who had NAFLD alone (25% vs. 10%, respectively). Overall mortality (risk ratio of 3.3) and mortality related to liver disease (risk ratio of 22.83) were greater in diabetic patients with NAFLD (Clin. Gastroenterol. Hepatol. 2004;2:262-5).

Dr. Pockros prescribes a low-fat, Mediterranean-type diet and exercise for his obese patients with NAFLD and NASH. “No single intervention has convincingly improved all important outcomes in NAFLD,” he said. “Our best approach is with diet and exercise.”

Dr. Pockros said he has received research support from, and is an adviser to, Roche, Vertex, and Gilead, and is an adviser to Amgen.

LA JOLLA, CALIF. — The estimated prevalence of nonalcoholic fatty liver disease in the United States is 10%-33%, and is likely to climb even higher unless Americans start to lose weight.

“Our high body mass index is the main driving force of nonalcoholic fatty liver disease [NAFLD],” Dr. Paul J. Pockros said at a meeting on chronic liver disease sponsored by Scripps Clinic. “The reason we're in trouble is that too many people are eating 2,500 calories at each meal and are not exercising.”

The presence of metabolic syndrome or its manifestations can be associated with nonalcoholic steatohepatitis (NASH). In a study of 212 morbidly obese patients who underwent bariatric surgery, 93% had NAFLD, 26% had NASH, and 9% had advanced fibrosis at the time of their surgery (Obes. Surg. 2005;15:310-5). Independent predictors of NASH were high aspartate aminotransferase (AST) level, diabetes, and male sex. Independent predictors of advanced fibrosis were high AST, central obesity, and hepatocyte necrosis, said Dr. Pockros, head of the division of gastroenterology and hepatology at Scripps Clinic, La Jolla.

Another study found that patients with NAFLD plus diabetes had higher rates of cirrhosis than did patients who had NAFLD alone (25% vs. 10%, respectively). Overall mortality (risk ratio of 3.3) and mortality related to liver disease (risk ratio of 22.83) were greater in diabetic patients with NAFLD (Clin. Gastroenterol. Hepatol. 2004;2:262-5).

Dr. Pockros prescribes a low-fat, Mediterranean-type diet and exercise for his obese patients with NAFLD and NASH. “No single intervention has convincingly improved all important outcomes in NAFLD,” he said. “Our best approach is with diet and exercise.”

Dr. Pockros said he has received research support from, and is an adviser to, Roche, Vertex, and Gilead, and is an adviser to Amgen.