Commentary

 

Recently, the hospital I take call at switched to Epic as its electronic health record system.

Overall, I don’t have too many complaints about it. It does some things better and some things worse than other systems I’ve used. That’s to be expected.

But with Epic has come an alarming new trend: the monster note.

The feature that automatically pastes radiology and lab results in a note has become horribly misused. I’m sure it looks good for legal purposes (“Hey, of course I read it. It’s in my note”). But what it really does is fill up a note with drivel: test results that take up space, followed by an exam that’s likely been cut and pasted from the previous day, and an impression that’s usually almost meaningless. Typically the last is along the lines of “continue current treatment” or “cardiology to see.”

Rarely does it ever give you a hint into the thought process or what’s going on that (at least to me) is so critical to medicine.

In a recent example of the insanity, one of my office patients was in the hospital overnight for a transient ischemic attack. When I went to get the discharge summary, it was 97 pages long! (Really, it was.) All of it was auto-filled in with test results, vital signs, MRI screening forms, medication administration records, and nurse, therapy, and respiratory notes. Most of it was far from the stuff that discharge summaries are supposed to contain. What part of “summary” are people not understanding anymore?

Of course, this isn’t Epic’s fault. It’s just a tool. It’s how humans use it that becomes the problem. This misuse of the system has made routine notes, as Shakespeare’s Macbeth said, “a tale told by an idiot, full of sound and fury, signifying nothing.”

For better or worse, I deliberately don’t do this. I let Epic put in the patient’s name, birthday, and most recent vital signs ... and nothing else. I’ll fill in the test results when needed, in a concise form that I can grasp. (It’s my note, after all.) To me, writing (or typing) the note is part of the thought process. As I enter results, I turn over what they mean, in a way that just seeing five paragraphs auto-pasted in doesn’t do. It also allows me to boil them down to one or two sentences.

After all, brevity is the soul of wit. And while I’m not trying to be witty in my notes, I am trying solve the problem in front of me. Taking the time write it out in my own words is essential to my thought process and letting others understand how I came to my plan. And, as a result, it is what’s best for the patient.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

Recently, the hospital I take call at switched to Epic as its electronic health record system.

Overall, I don’t have too many complaints about it. It does some things better and some things worse than other systems I’ve used. That’s to be expected.

But with Epic has come an alarming new trend: the monster note.

The feature that automatically pastes radiology and lab results in a note has become horribly misused. I’m sure it looks good for legal purposes (“Hey, of course I read it. It’s in my note”). But what it really does is fill up a note with drivel: test results that take up space, followed by an exam that’s likely been cut and pasted from the previous day, and an impression that’s usually almost meaningless. Typically the last is along the lines of “continue current treatment” or “cardiology to see.”

Rarely does it ever give you a hint into the thought process or what’s going on that (at least to me) is so critical to medicine.

In a recent example of the insanity, one of my office patients was in the hospital overnight for a transient ischemic attack. When I went to get the discharge summary, it was 97 pages long! (Really, it was.) All of it was auto-filled in with test results, vital signs, MRI screening forms, medication administration records, and nurse, therapy, and respiratory notes. Most of it was far from the stuff that discharge summaries are supposed to contain. What part of “summary” are people not understanding anymore?

Of course, this isn’t Epic’s fault. It’s just a tool. It’s how humans use it that becomes the problem. This misuse of the system has made routine notes, as Shakespeare’s Macbeth said, “a tale told by an idiot, full of sound and fury, signifying nothing.”

For better or worse, I deliberately don’t do this. I let Epic put in the patient’s name, birthday, and most recent vital signs ... and nothing else. I’ll fill in the test results when needed, in a concise form that I can grasp. (It’s my note, after all.) To me, writing (or typing) the note is part of the thought process. As I enter results, I turn over what they mean, in a way that just seeing five paragraphs auto-pasted in doesn’t do. It also allows me to boil them down to one or two sentences.

After all, brevity is the soul of wit. And while I’m not trying to be witty in my notes, I am trying solve the problem in front of me. Taking the time write it out in my own words is essential to my thought process and letting others understand how I came to my plan. And, as a result, it is what’s best for the patient.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

Recently, the hospital I take call at switched to Epic as its electronic health record system.

Overall, I don’t have too many complaints about it. It does some things better and some things worse than other systems I’ve used. That’s to be expected.

But with Epic has come an alarming new trend: the monster note.

The feature that automatically pastes radiology and lab results in a note has become horribly misused. I’m sure it looks good for legal purposes (“Hey, of course I read it. It’s in my note”). But what it really does is fill up a note with drivel: test results that take up space, followed by an exam that’s likely been cut and pasted from the previous day, and an impression that’s usually almost meaningless. Typically the last is along the lines of “continue current treatment” or “cardiology to see.”

Rarely does it ever give you a hint into the thought process or what’s going on that (at least to me) is so critical to medicine.

In a recent example of the insanity, one of my office patients was in the hospital overnight for a transient ischemic attack. When I went to get the discharge summary, it was 97 pages long! (Really, it was.) All of it was auto-filled in with test results, vital signs, MRI screening forms, medication administration records, and nurse, therapy, and respiratory notes. Most of it was far from the stuff that discharge summaries are supposed to contain. What part of “summary” are people not understanding anymore?

Of course, this isn’t Epic’s fault. It’s just a tool. It’s how humans use it that becomes the problem. This misuse of the system has made routine notes, as Shakespeare’s Macbeth said, “a tale told by an idiot, full of sound and fury, signifying nothing.”

For better or worse, I deliberately don’t do this. I let Epic put in the patient’s name, birthday, and most recent vital signs ... and nothing else. I’ll fill in the test results when needed, in a concise form that I can grasp. (It’s my note, after all.) To me, writing (or typing) the note is part of the thought process. As I enter results, I turn over what they mean, in a way that just seeing five paragraphs auto-pasted in doesn’t do. It also allows me to boil them down to one or two sentences.

After all, brevity is the soul of wit. And while I’m not trying to be witty in my notes, I am trying solve the problem in front of me. Taking the time write it out in my own words is essential to my thought process and letting others understand how I came to my plan. And, as a result, it is what’s best for the patient.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

Infections resulting from Clostridium difficile are a major clinical challenge. In hematology and oncology, the widespread use of broad-spectrum antibiotics is essential for patients with profound neutropenia and infectious complications, which are a high-risk factor for C. difficile enteritis.

C. difficile enteritis occurs in 5%-20% of cancer patients.¹ With standard of care antibiotics, oral metronidazole or oral vancomycin, high C. difficile cure rates are possible, but up to 25% of these infections recur. Recently, oral fidaxomicin was approved for treatment of C. difficile enteritis and was associated with high cure rates and, more importantly, with significantly lower recurrence rates.²

About 40 years ago, the pathogenesis of C. difficile enteritis was described when toxin A (enterotoxin) and toxin B (cytotoxin) were identified.³ There is good evidence that, among both toxins, toxin B plays the essential role in virulence of C. difficile.⁴C. difficile toxin B uses eukaryotic signals for induced autoproteolysis to deliver its toxic products into the cytosol of target cells. Toxin B binds to the surface of intestinal epithelial cells, where it is internalized and catalyzes the glucosylation of cytoplasmic-rho proteins, leading to disaggregation of the cytoskeleton and cell death.⁵ Toxin B must be neutralized to protect against recurrent infection.⁶

Bezlotoxumab, a fully humanized monoclonal antibody against C. difficile toxin B, has been shown by x-ray crystallography to neutralize toxin B by blocking its ability to bind to host cells.⁷ Most recently, this new therapeutic approach was investigated in humans.⁸

Wilcox et al. used pooled data of 2655 adults treated in two double-blind, randomized, placebo-controlled phase III clinical trials (MODIFY I and MODIFY II) for primary or recurrent C. difficile enteritis. This industry-sponsored trial was conducted at 322 sites in 30 countries.

In one treatment group, patients received a single infusion of bezlotoxumab (781 patients) or placebo (773 patients) and one of the three oral standard-of-care C. difficile antibiotics. Importantly, the primary end point of this trial was recurrent infection within 12 weeks. About 28% of the patients in both the bezlotoxumab group and the placebo group previously had at least one episode of C. difficile enteritis. About 20% of the patients in both groups were immunocompromised.

Pooled data showed that recurrent infection was significantly lower (P less than 0.001) in the bezlotoxumab group (17%), compared with the placebo group (27%). The difference in recurrence rate (25% vs. 41%) was even more pronounced in patients with one or more episodes of recurrent C. difficile enteritis in the past 6 months. Furthermore, a benefit for bezlotoxumab was seen in immunocompromised patients, whose recurrence rates were 15% with bezlotoxumab, vs. 28% with placebo. After the 12 weeks of follow-up, the absolute difference in the Kaplan-Meier rates of recurrent infection was 13% (absolute rate, 21% in bezlotoxumab group vs. 34% in placebo group; P less than 0.001).

The results indicate that bezlotoxumab, which was approved in 2016 by the U.S. Food and Drug Administration, might improve the outcome of patients with C. difficile enteritis. However, bezlotoxumab is not a “magic bullet.” The number needed to treat to prevent one episode of C. difficile enteritis is 10.

It is conceivable that bezlotoxumab may find its role in high-risk patients – those older than 65 years or patients with recurrent C. difficile enteritis – since the number needed to treat is only 6 in these subgroups.⁸

This new agent could be an important treatment option for our high-risk patients in hematology. However, more studies concerning costs and real-life efficacy are needed.

The new approach of passive immunization for prevention of recurrent C. difficile enteritis shows the importance and the role of toxin B – not only the bacterium per se – in pathogenesis and virulence of C. difficile. This could mean that we have to renew our view on the role of antibiotics against C. difficile. However, in contrast, bezlotoxumab does not affect the efficacy of standard of care antibiotics since the initial cure rates were 80% for both the antibody and the placebo groups.⁸ Toxin B levels are not detectable in stool samples between days 4 and 10 of standard of care antibiotic treatment. Afterward, however, they increase again.⁹ Most of the patients had received bezlotoxumab 3 or more days after they began standard-of-care antibiotic treatment – in the time period when toxin B is undetectable in stool – which underlines the importance of toxin B in the pathogenesis of recurrent C. difficile enteritis.⁸

In summary, the introduction of bezlotoxumab in clinical care gives new and important insights and solutions not only for treatment options but also for our understanding of C. difficile pathogenesis.

 

Dr. Schalk is consultant of internal medicine at the department of hematology and oncology, Magdeburg University Hospital, Germany, with clinical and research focus on infectious diseases in hematology and oncology.

Dr. Fischer is professor of internal medicine, hematology and oncology, at the Otto-von-Guericke University Hospital Magdeburg, Germany. He is head of the department of hematology and oncology and a clinical/molecular researcher in myeloid neoplasms. He is a member of the editorial advisory board of Hematology News.

Contact Dr. Schalk at enrico.schalk@med.ovgu.de.

References

1. Vehreschild, MJ et al. Diagnosis and management of gastrointestinal complications in adult cancer patients: Wvidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Oncol. 2013;24:1189-202

2. Cornely, OA. Current and emerging management options for Clostridium difficile infection: What is the role of fidaxomicin? Clin Microbiol Infect. 2012;18(Suppl 6):28-35.

3. Bartlett, JG et al. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med. 1978;298(10):531-4.

4. Lyras, D et al. Toxin B is essential for virulence of Clostridium difficile. Nature. 2009;458:1176-9.

5. Reineke, J et al. Autocatalytic cleavage of Clostridium difficile toxin B. Nature. 2007;446:415-9.

6. Leav, BA et al. Serum anti-toxin B antibody correlates with protection from recurrent Clostridium difficile infection (CDI). Vaccine. 2010;28:965-9.

7. Orth, P et al. Mechanism of action and epitopes of Clostridium difficile toxin B-neutralizing antibody bezlotoxumab revealed by X-ray crystallography. J Biol Chem. 2014;289:18008-21.

8. Wilcox, MH et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017;376:305-17.

9. Louie, TJ et al. Fidaxomicin preserves the intestinal microbiome during and after treatment of Clostridium difficile infection (CDI) and reduces both toxin reexpression and recurrence of CDI. Clin Infect Dis. 2012;5(Suppl 2):S132-42.

 

Infections resulting from Clostridium difficile are a major clinical challenge. In hematology and oncology, the widespread use of broad-spectrum antibiotics is essential for patients with profound neutropenia and infectious complications, which are a high-risk factor for C. difficile enteritis.

C. difficile enteritis occurs in 5%-20% of cancer patients.¹ With standard of care antibiotics, oral metronidazole or oral vancomycin, high C. difficile cure rates are possible, but up to 25% of these infections recur. Recently, oral fidaxomicin was approved for treatment of C. difficile enteritis and was associated with high cure rates and, more importantly, with significantly lower recurrence rates.²

About 40 years ago, the pathogenesis of C. difficile enteritis was described when toxin A (enterotoxin) and toxin B (cytotoxin) were identified.³ There is good evidence that, among both toxins, toxin B plays the essential role in virulence of C. difficile.⁴C. difficile toxin B uses eukaryotic signals for induced autoproteolysis to deliver its toxic products into the cytosol of target cells. Toxin B binds to the surface of intestinal epithelial cells, where it is internalized and catalyzes the glucosylation of cytoplasmic-rho proteins, leading to disaggregation of the cytoskeleton and cell death.⁵ Toxin B must be neutralized to protect against recurrent infection.⁶

Bezlotoxumab, a fully humanized monoclonal antibody against C. difficile toxin B, has been shown by x-ray crystallography to neutralize toxin B by blocking its ability to bind to host cells.⁷ Most recently, this new therapeutic approach was investigated in humans.⁸

Wilcox et al. used pooled data of 2655 adults treated in two double-blind, randomized, placebo-controlled phase III clinical trials (MODIFY I and MODIFY II) for primary or recurrent C. difficile enteritis. This industry-sponsored trial was conducted at 322 sites in 30 countries.

In one treatment group, patients received a single infusion of bezlotoxumab (781 patients) or placebo (773 patients) and one of the three oral standard-of-care C. difficile antibiotics. Importantly, the primary end point of this trial was recurrent infection within 12 weeks. About 28% of the patients in both the bezlotoxumab group and the placebo group previously had at least one episode of C. difficile enteritis. About 20% of the patients in both groups were immunocompromised.

Pooled data showed that recurrent infection was significantly lower (P less than 0.001) in the bezlotoxumab group (17%), compared with the placebo group (27%). The difference in recurrence rate (25% vs. 41%) was even more pronounced in patients with one or more episodes of recurrent C. difficile enteritis in the past 6 months. Furthermore, a benefit for bezlotoxumab was seen in immunocompromised patients, whose recurrence rates were 15% with bezlotoxumab, vs. 28% with placebo. After the 12 weeks of follow-up, the absolute difference in the Kaplan-Meier rates of recurrent infection was 13% (absolute rate, 21% in bezlotoxumab group vs. 34% in placebo group; P less than 0.001).

The results indicate that bezlotoxumab, which was approved in 2016 by the U.S. Food and Drug Administration, might improve the outcome of patients with C. difficile enteritis. However, bezlotoxumab is not a “magic bullet.” The number needed to treat to prevent one episode of C. difficile enteritis is 10.

It is conceivable that bezlotoxumab may find its role in high-risk patients – those older than 65 years or patients with recurrent C. difficile enteritis – since the number needed to treat is only 6 in these subgroups.⁸

This new agent could be an important treatment option for our high-risk patients in hematology. However, more studies concerning costs and real-life efficacy are needed.

The new approach of passive immunization for prevention of recurrent C. difficile enteritis shows the importance and the role of toxin B – not only the bacterium per se – in pathogenesis and virulence of C. difficile. This could mean that we have to renew our view on the role of antibiotics against C. difficile. However, in contrast, bezlotoxumab does not affect the efficacy of standard of care antibiotics since the initial cure rates were 80% for both the antibody and the placebo groups.⁸ Toxin B levels are not detectable in stool samples between days 4 and 10 of standard of care antibiotic treatment. Afterward, however, they increase again.⁹ Most of the patients had received bezlotoxumab 3 or more days after they began standard-of-care antibiotic treatment – in the time period when toxin B is undetectable in stool – which underlines the importance of toxin B in the pathogenesis of recurrent C. difficile enteritis.⁸

In summary, the introduction of bezlotoxumab in clinical care gives new and important insights and solutions not only for treatment options but also for our understanding of C. difficile pathogenesis.

 

Dr. Schalk is consultant of internal medicine at the department of hematology and oncology, Magdeburg University Hospital, Germany, with clinical and research focus on infectious diseases in hematology and oncology.

Dr. Fischer is professor of internal medicine, hematology and oncology, at the Otto-von-Guericke University Hospital Magdeburg, Germany. He is head of the department of hematology and oncology and a clinical/molecular researcher in myeloid neoplasms. He is a member of the editorial advisory board of Hematology News.

Contact Dr. Schalk at enrico.schalk@med.ovgu.de.

References

1. Vehreschild, MJ et al. Diagnosis and management of gastrointestinal complications in adult cancer patients: Wvidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Oncol. 2013;24:1189-202

2. Cornely, OA. Current and emerging management options for Clostridium difficile infection: What is the role of fidaxomicin? Clin Microbiol Infect. 2012;18(Suppl 6):28-35.

3. Bartlett, JG et al. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med. 1978;298(10):531-4.

4. Lyras, D et al. Toxin B is essential for virulence of Clostridium difficile. Nature. 2009;458:1176-9.

5. Reineke, J et al. Autocatalytic cleavage of Clostridium difficile toxin B. Nature. 2007;446:415-9.

6. Leav, BA et al. Serum anti-toxin B antibody correlates with protection from recurrent Clostridium difficile infection (CDI). Vaccine. 2010;28:965-9.

7. Orth, P et al. Mechanism of action and epitopes of Clostridium difficile toxin B-neutralizing antibody bezlotoxumab revealed by X-ray crystallography. J Biol Chem. 2014;289:18008-21.

8. Wilcox, MH et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017;376:305-17.

9. Louie, TJ et al. Fidaxomicin preserves the intestinal microbiome during and after treatment of Clostridium difficile infection (CDI) and reduces both toxin reexpression and recurrence of CDI. Clin Infect Dis. 2012;5(Suppl 2):S132-42.

 

Infections resulting from Clostridium difficile are a major clinical challenge. In hematology and oncology, the widespread use of broad-spectrum antibiotics is essential for patients with profound neutropenia and infectious complications, which are a high-risk factor for C. difficile enteritis.

C. difficile enteritis occurs in 5%-20% of cancer patients.¹ With standard of care antibiotics, oral metronidazole or oral vancomycin, high C. difficile cure rates are possible, but up to 25% of these infections recur. Recently, oral fidaxomicin was approved for treatment of C. difficile enteritis and was associated with high cure rates and, more importantly, with significantly lower recurrence rates.²

About 40 years ago, the pathogenesis of C. difficile enteritis was described when toxin A (enterotoxin) and toxin B (cytotoxin) were identified.³ There is good evidence that, among both toxins, toxin B plays the essential role in virulence of C. difficile.⁴C. difficile toxin B uses eukaryotic signals for induced autoproteolysis to deliver its toxic products into the cytosol of target cells. Toxin B binds to the surface of intestinal epithelial cells, where it is internalized and catalyzes the glucosylation of cytoplasmic-rho proteins, leading to disaggregation of the cytoskeleton and cell death.⁵ Toxin B must be neutralized to protect against recurrent infection.⁶

Bezlotoxumab, a fully humanized monoclonal antibody against C. difficile toxin B, has been shown by x-ray crystallography to neutralize toxin B by blocking its ability to bind to host cells.⁷ Most recently, this new therapeutic approach was investigated in humans.⁸

Wilcox et al. used pooled data of 2655 adults treated in two double-blind, randomized, placebo-controlled phase III clinical trials (MODIFY I and MODIFY II) for primary or recurrent C. difficile enteritis. This industry-sponsored trial was conducted at 322 sites in 30 countries.

In one treatment group, patients received a single infusion of bezlotoxumab (781 patients) or placebo (773 patients) and one of the three oral standard-of-care C. difficile antibiotics. Importantly, the primary end point of this trial was recurrent infection within 12 weeks. About 28% of the patients in both the bezlotoxumab group and the placebo group previously had at least one episode of C. difficile enteritis. About 20% of the patients in both groups were immunocompromised.

Pooled data showed that recurrent infection was significantly lower (P less than 0.001) in the bezlotoxumab group (17%), compared with the placebo group (27%). The difference in recurrence rate (25% vs. 41%) was even more pronounced in patients with one or more episodes of recurrent C. difficile enteritis in the past 6 months. Furthermore, a benefit for bezlotoxumab was seen in immunocompromised patients, whose recurrence rates were 15% with bezlotoxumab, vs. 28% with placebo. After the 12 weeks of follow-up, the absolute difference in the Kaplan-Meier rates of recurrent infection was 13% (absolute rate, 21% in bezlotoxumab group vs. 34% in placebo group; P less than 0.001).

The results indicate that bezlotoxumab, which was approved in 2016 by the U.S. Food and Drug Administration, might improve the outcome of patients with C. difficile enteritis. However, bezlotoxumab is not a “magic bullet.” The number needed to treat to prevent one episode of C. difficile enteritis is 10.

It is conceivable that bezlotoxumab may find its role in high-risk patients – those older than 65 years or patients with recurrent C. difficile enteritis – since the number needed to treat is only 6 in these subgroups.⁸

This new agent could be an important treatment option for our high-risk patients in hematology. However, more studies concerning costs and real-life efficacy are needed.

The new approach of passive immunization for prevention of recurrent C. difficile enteritis shows the importance and the role of toxin B – not only the bacterium per se – in pathogenesis and virulence of C. difficile. This could mean that we have to renew our view on the role of antibiotics against C. difficile. However, in contrast, bezlotoxumab does not affect the efficacy of standard of care antibiotics since the initial cure rates were 80% for both the antibody and the placebo groups.⁸ Toxin B levels are not detectable in stool samples between days 4 and 10 of standard of care antibiotic treatment. Afterward, however, they increase again.⁹ Most of the patients had received bezlotoxumab 3 or more days after they began standard-of-care antibiotic treatment – in the time period when toxin B is undetectable in stool – which underlines the importance of toxin B in the pathogenesis of recurrent C. difficile enteritis.⁸

In summary, the introduction of bezlotoxumab in clinical care gives new and important insights and solutions not only for treatment options but also for our understanding of C. difficile pathogenesis.

 

Dr. Schalk is consultant of internal medicine at the department of hematology and oncology, Magdeburg University Hospital, Germany, with clinical and research focus on infectious diseases in hematology and oncology.

Dr. Fischer is professor of internal medicine, hematology and oncology, at the Otto-von-Guericke University Hospital Magdeburg, Germany. He is head of the department of hematology and oncology and a clinical/molecular researcher in myeloid neoplasms. He is a member of the editorial advisory board of Hematology News.

Contact Dr. Schalk at enrico.schalk@med.ovgu.de.

References

1. Vehreschild, MJ et al. Diagnosis and management of gastrointestinal complications in adult cancer patients: Wvidence-based guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Oncol. 2013;24:1189-202

2. Cornely, OA. Current and emerging management options for Clostridium difficile infection: What is the role of fidaxomicin? Clin Microbiol Infect. 2012;18(Suppl 6):28-35.

3. Bartlett, JG et al. Antibiotic-associated pseudomembranous colitis due to toxin-producing clostridia. N Engl J Med. 1978;298(10):531-4.

4. Lyras, D et al. Toxin B is essential for virulence of Clostridium difficile. Nature. 2009;458:1176-9.

5. Reineke, J et al. Autocatalytic cleavage of Clostridium difficile toxin B. Nature. 2007;446:415-9.

6. Leav, BA et al. Serum anti-toxin B antibody correlates with protection from recurrent Clostridium difficile infection (CDI). Vaccine. 2010;28:965-9.

7. Orth, P et al. Mechanism of action and epitopes of Clostridium difficile toxin B-neutralizing antibody bezlotoxumab revealed by X-ray crystallography. J Biol Chem. 2014;289:18008-21.

8. Wilcox, MH et al. Bezlotoxumab for prevention of recurrent Clostridium difficile infection. N Engl J Med. 2017;376:305-17.

9. Louie, TJ et al. Fidaxomicin preserves the intestinal microbiome during and after treatment of Clostridium difficile infection (CDI) and reduces both toxin reexpression and recurrence of CDI. Clin Infect Dis. 2012;5(Suppl 2):S132-42.

 

Are foodborne illness outbreaks more common now, or are we simply better at detection? Have the foods and sources associated with foodborne illness changed? Two recent Centers for Disease Control & Prevention reports provide insight.^1,2 In 2016, the Foodborne Diseases Active Surveillance Network (FoodNet) detected 24,029 infections, 5,212 hospitalizations, and 98 fatalities.¹ FoodNet has 10 sites serving 49 million people (15% of the U.S. population). These 2016 numbers changed only modestly from the 3 prior years.

The big two

The most frequent 2016 foodborne pathogens were Campylobacter and Salmonella, at approximately 8,000 illnesses each, detected by traditional cultures or culture-independent diagnostic tests (CIDTs). (See table.) CIDTs are relatively new molecular-based, mostly multiplex assays that test for more than a dozen pathogens in one assay.

Campylobacter-contaminated domestic food in 2016 was mostly raw/undercooked poultry or unpasteurized milk/fruit drinks. Campylobacter can be detected in up to 88% of chicken carcasses at processing plants and approximately 50% of raw chicken at grocery stores. However, Campylobacter from imported food most often came from fresh produce.²

Overall, Salmonella originated from diverse sources (eggs, poultry, meat, unpasteurized milk/juice/cheese, or raw fruits/vegetables/spices/nuts). But, in 2016, U.S. Salmonella outbreaks were from eggs, alfalfa sprouts, poultry, pistachios, and organic shake/meal products.

The runners-up

Most of the remainder of the 2016 foodborne illnesses were caused by Shigella, with nearly 3,000 cases; shigatoxin-producing Escherichia coli (STEC), with nearly 2,000 cases; and Cryptosporidium, also with nearly 2,000 cases. (See table.)

Hemolytic uremic syndrome (HUS)

HUS rates, mostly resulting from E. coli 0157 H7 in meat, did not vary from 2013 to 2016, with a total 62 pediatric HUS cases in FoodNet (0.56 /100,000 population). Slightly over half (56%) occurred in children under 5 years old at 1.18 per 100,000 population.

Does CIDT increase detection rates?

Detection of the “big two” did not change from 2013 to 2016 or over the past 2 decades. That said, Campylobacter detection was actually down 11% if considering only culture-confirmed cases. That is, if we do not count detections made exclusively by CIDT.

This is important because CIDT – now supplanting culture in many laboratories – identifies pathogens not likely detected by standard culture because culture is generally selective and CIDT is more sensitive. CIDT can increase detection rates (solo and multiple pathogens), even if illnesses do not really increase. The CDC suggested that this contributed to increased STEC and Yersinia detection in 2016. Some would not have been detected if only culture had been utilized.

Viable bacterial/viral isolates are not available from CIDT. A replicating pathogen is needed to characterize shifting/emerging pathogen strains (for example, analysis for mutations or new pathogens via sequencing or antimicrobial susceptibility testing).

To compensate, some CIDT-using laboratories perform “reflex cultures.” CIDT positive specimens also are cultured to provide viable isolates. However, this adds cost to an already costly CIDT test.

The role of imported food

Surveillance systems, such as the Foodborne Disease Outbreak Surveillance System, also track imported foodborne illness. Despite an approximately 50% decrease in overall U.S. foodborne outbreaks since 2000, imported food-related outbreaks increased to 195 during 2006-2014 from 54 during 1996-2004, with 10,685 illnesses, 1,017 hospitalizations, and 19 deaths since 2009. Also, imported food-related outbreaks rose from a mean 3 per year pre-2000 to a mean 18 per year during 2009-2014. Most imported food outbreaks (86% of total) had three causes: scombroid toxin (42% of total), Salmonella (33%), and hepatitis A virus (11%).

A foreign origin for approximately 19% of U.S.-consumed food makes it unsurprising that imported foods increasingly cause foodborne outbreaks. Much imported food is “outbreak prone.” Perhaps surprising is that a staggering 97% of fish/shellfish, 50% of fresh fruits, and 20% of fresh vegetables are imported, according to 2016 estimates by the U.S. Department of Agriculture.

Most imported food illnesses were from Salmonella (4,421 from 52 outbreaks), Cyclospora (2,533 from 33 outbreaks), hepatitis A virus (1,150 from 11 outbreaks), and Shigella (625 from 6 outbreaks). While eggs, ice cream, and poultry are notorious origins for Salmonella in domestic food, most imported Salmonella were from produce: fruits (26%), seeded vegetables (20%), sprouts (11%), nuts/seeds (10%), spices (7%), and herbs (2%).

Seafood/fish caused 55% of outbreaks but few illnesses per outbreak (median 3 illnesses/outbreak), so only 11% of total illnesses were caused by seafood/fish. In contrast, fresh produce caused only 33% of outbreaks but 84% of illnesses (median 40 illnesses/outbreak).

Geographic source, outbreak locations

The origin was known in 91% of outbreaks. Latin America and the Caribbean were most common, followed by Asia.³ Main contributing countries were Mexico (42 outbreaks), Indonesia (17) and Canada (11).

 

Contaminated fish/shellfish originated from all regions except Europe, most commonly from Asia (the majority of fish/shellfish outbreaks were from Indonesia, Vietnam, China, Philippines, Taiwan, and Thailand) with smaller contributions from the Bahamas and Ecuador.

Contaminated produce originated from all regions, mostly (64%) from Mexico and the Americas (Chile, Guatemala, and Honduras). All but one dairy outbreak originated in Latin America/the Caribbean.³ Outbreaks occurred in 31 states, most commonly California (30), Florida (25), and New York (16). Additionally, 43 (22%) were multistate outbreaks.

Conclusions

Outbreaks from domestic foods decreased, but those from imported foods increased. This makes sense given recent increases in outbreak-prone food imports, such as seafood/fish and produce.

To reduce overall foodborne illness outbreaks, governmental agencies need to:

• Develop/enforce regulations that promote proper growing, handling, and processing of foods.
• Strengthen surveillance networks and share standard culture and molecular detection/characterization protocols to identify outbreaks as close to real time as possible.
• Ensure rapid traceability not only to country of origin but to an exact farm or seafood/fish harvesting entity.
• Provide rapid public knowledge of outbreaks and origins, plus outbreak-specific recommendations to control/minimize resultant illnesses.

Individuals can help protect themselves by avoiding inadequately washed or incompletely cooked foods or foods of uncertain origin.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

References

1. MMWR. 2017 Apr 21;66(15):397-403.

2. Emerg Infect Dis. 2017 Mar;23(3):525-8.

3. Technical appendix in Emerg Infect Dis. 2017 Mar;23(3):525-8.

 

Are foodborne illness outbreaks more common now, or are we simply better at detection? Have the foods and sources associated with foodborne illness changed? Two recent Centers for Disease Control & Prevention reports provide insight.^1,2 In 2016, the Foodborne Diseases Active Surveillance Network (FoodNet) detected 24,029 infections, 5,212 hospitalizations, and 98 fatalities.¹ FoodNet has 10 sites serving 49 million people (15% of the U.S. population). These 2016 numbers changed only modestly from the 3 prior years.

The big two

The most frequent 2016 foodborne pathogens were Campylobacter and Salmonella, at approximately 8,000 illnesses each, detected by traditional cultures or culture-independent diagnostic tests (CIDTs). (See table.) CIDTs are relatively new molecular-based, mostly multiplex assays that test for more than a dozen pathogens in one assay.

Campylobacter-contaminated domestic food in 2016 was mostly raw/undercooked poultry or unpasteurized milk/fruit drinks. Campylobacter can be detected in up to 88% of chicken carcasses at processing plants and approximately 50% of raw chicken at grocery stores. However, Campylobacter from imported food most often came from fresh produce.²

Overall, Salmonella originated from diverse sources (eggs, poultry, meat, unpasteurized milk/juice/cheese, or raw fruits/vegetables/spices/nuts). But, in 2016, U.S. Salmonella outbreaks were from eggs, alfalfa sprouts, poultry, pistachios, and organic shake/meal products.

The runners-up

Most of the remainder of the 2016 foodborne illnesses were caused by Shigella, with nearly 3,000 cases; shigatoxin-producing Escherichia coli (STEC), with nearly 2,000 cases; and Cryptosporidium, also with nearly 2,000 cases. (See table.)

Hemolytic uremic syndrome (HUS)

HUS rates, mostly resulting from E. coli 0157 H7 in meat, did not vary from 2013 to 2016, with a total 62 pediatric HUS cases in FoodNet (0.56 /100,000 population). Slightly over half (56%) occurred in children under 5 years old at 1.18 per 100,000 population.

Does CIDT increase detection rates?

Detection of the “big two” did not change from 2013 to 2016 or over the past 2 decades. That said, Campylobacter detection was actually down 11% if considering only culture-confirmed cases. That is, if we do not count detections made exclusively by CIDT.

This is important because CIDT – now supplanting culture in many laboratories – identifies pathogens not likely detected by standard culture because culture is generally selective and CIDT is more sensitive. CIDT can increase detection rates (solo and multiple pathogens), even if illnesses do not really increase. The CDC suggested that this contributed to increased STEC and Yersinia detection in 2016. Some would not have been detected if only culture had been utilized.

Viable bacterial/viral isolates are not available from CIDT. A replicating pathogen is needed to characterize shifting/emerging pathogen strains (for example, analysis for mutations or new pathogens via sequencing or antimicrobial susceptibility testing).

To compensate, some CIDT-using laboratories perform “reflex cultures.” CIDT positive specimens also are cultured to provide viable isolates. However, this adds cost to an already costly CIDT test.

The role of imported food

Surveillance systems, such as the Foodborne Disease Outbreak Surveillance System, also track imported foodborne illness. Despite an approximately 50% decrease in overall U.S. foodborne outbreaks since 2000, imported food-related outbreaks increased to 195 during 2006-2014 from 54 during 1996-2004, with 10,685 illnesses, 1,017 hospitalizations, and 19 deaths since 2009. Also, imported food-related outbreaks rose from a mean 3 per year pre-2000 to a mean 18 per year during 2009-2014. Most imported food outbreaks (86% of total) had three causes: scombroid toxin (42% of total), Salmonella (33%), and hepatitis A virus (11%).

A foreign origin for approximately 19% of U.S.-consumed food makes it unsurprising that imported foods increasingly cause foodborne outbreaks. Much imported food is “outbreak prone.” Perhaps surprising is that a staggering 97% of fish/shellfish, 50% of fresh fruits, and 20% of fresh vegetables are imported, according to 2016 estimates by the U.S. Department of Agriculture.

Most imported food illnesses were from Salmonella (4,421 from 52 outbreaks), Cyclospora (2,533 from 33 outbreaks), hepatitis A virus (1,150 from 11 outbreaks), and Shigella (625 from 6 outbreaks). While eggs, ice cream, and poultry are notorious origins for Salmonella in domestic food, most imported Salmonella were from produce: fruits (26%), seeded vegetables (20%), sprouts (11%), nuts/seeds (10%), spices (7%), and herbs (2%).

Seafood/fish caused 55% of outbreaks but few illnesses per outbreak (median 3 illnesses/outbreak), so only 11% of total illnesses were caused by seafood/fish. In contrast, fresh produce caused only 33% of outbreaks but 84% of illnesses (median 40 illnesses/outbreak).

Geographic source, outbreak locations

The origin was known in 91% of outbreaks. Latin America and the Caribbean were most common, followed by Asia.³ Main contributing countries were Mexico (42 outbreaks), Indonesia (17) and Canada (11).

 

Contaminated fish/shellfish originated from all regions except Europe, most commonly from Asia (the majority of fish/shellfish outbreaks were from Indonesia, Vietnam, China, Philippines, Taiwan, and Thailand) with smaller contributions from the Bahamas and Ecuador.

Contaminated produce originated from all regions, mostly (64%) from Mexico and the Americas (Chile, Guatemala, and Honduras). All but one dairy outbreak originated in Latin America/the Caribbean.³ Outbreaks occurred in 31 states, most commonly California (30), Florida (25), and New York (16). Additionally, 43 (22%) were multistate outbreaks.

Conclusions

Outbreaks from domestic foods decreased, but those from imported foods increased. This makes sense given recent increases in outbreak-prone food imports, such as seafood/fish and produce.

To reduce overall foodborne illness outbreaks, governmental agencies need to:

• Develop/enforce regulations that promote proper growing, handling, and processing of foods.
• Strengthen surveillance networks and share standard culture and molecular detection/characterization protocols to identify outbreaks as close to real time as possible.
• Ensure rapid traceability not only to country of origin but to an exact farm or seafood/fish harvesting entity.
• Provide rapid public knowledge of outbreaks and origins, plus outbreak-specific recommendations to control/minimize resultant illnesses.

Individuals can help protect themselves by avoiding inadequately washed or incompletely cooked foods or foods of uncertain origin.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

References

1. MMWR. 2017 Apr 21;66(15):397-403.

2. Emerg Infect Dis. 2017 Mar;23(3):525-8.

3. Technical appendix in Emerg Infect Dis. 2017 Mar;23(3):525-8.

 

Are foodborne illness outbreaks more common now, or are we simply better at detection? Have the foods and sources associated with foodborne illness changed? Two recent Centers for Disease Control & Prevention reports provide insight.^1,2 In 2016, the Foodborne Diseases Active Surveillance Network (FoodNet) detected 24,029 infections, 5,212 hospitalizations, and 98 fatalities.¹ FoodNet has 10 sites serving 49 million people (15% of the U.S. population). These 2016 numbers changed only modestly from the 3 prior years.

The big two

The most frequent 2016 foodborne pathogens were Campylobacter and Salmonella, at approximately 8,000 illnesses each, detected by traditional cultures or culture-independent diagnostic tests (CIDTs). (See table.) CIDTs are relatively new molecular-based, mostly multiplex assays that test for more than a dozen pathogens in one assay.

Campylobacter-contaminated domestic food in 2016 was mostly raw/undercooked poultry or unpasteurized milk/fruit drinks. Campylobacter can be detected in up to 88% of chicken carcasses at processing plants and approximately 50% of raw chicken at grocery stores. However, Campylobacter from imported food most often came from fresh produce.²

Overall, Salmonella originated from diverse sources (eggs, poultry, meat, unpasteurized milk/juice/cheese, or raw fruits/vegetables/spices/nuts). But, in 2016, U.S. Salmonella outbreaks were from eggs, alfalfa sprouts, poultry, pistachios, and organic shake/meal products.

The runners-up

Most of the remainder of the 2016 foodborne illnesses were caused by Shigella, with nearly 3,000 cases; shigatoxin-producing Escherichia coli (STEC), with nearly 2,000 cases; and Cryptosporidium, also with nearly 2,000 cases. (See table.)

Hemolytic uremic syndrome (HUS)

HUS rates, mostly resulting from E. coli 0157 H7 in meat, did not vary from 2013 to 2016, with a total 62 pediatric HUS cases in FoodNet (0.56 /100,000 population). Slightly over half (56%) occurred in children under 5 years old at 1.18 per 100,000 population.

Does CIDT increase detection rates?

Detection of the “big two” did not change from 2013 to 2016 or over the past 2 decades. That said, Campylobacter detection was actually down 11% if considering only culture-confirmed cases. That is, if we do not count detections made exclusively by CIDT.

This is important because CIDT – now supplanting culture in many laboratories – identifies pathogens not likely detected by standard culture because culture is generally selective and CIDT is more sensitive. CIDT can increase detection rates (solo and multiple pathogens), even if illnesses do not really increase. The CDC suggested that this contributed to increased STEC and Yersinia detection in 2016. Some would not have been detected if only culture had been utilized.

Viable bacterial/viral isolates are not available from CIDT. A replicating pathogen is needed to characterize shifting/emerging pathogen strains (for example, analysis for mutations or new pathogens via sequencing or antimicrobial susceptibility testing).

To compensate, some CIDT-using laboratories perform “reflex cultures.” CIDT positive specimens also are cultured to provide viable isolates. However, this adds cost to an already costly CIDT test.

The role of imported food

Surveillance systems, such as the Foodborne Disease Outbreak Surveillance System, also track imported foodborne illness. Despite an approximately 50% decrease in overall U.S. foodborne outbreaks since 2000, imported food-related outbreaks increased to 195 during 2006-2014 from 54 during 1996-2004, with 10,685 illnesses, 1,017 hospitalizations, and 19 deaths since 2009. Also, imported food-related outbreaks rose from a mean 3 per year pre-2000 to a mean 18 per year during 2009-2014. Most imported food outbreaks (86% of total) had three causes: scombroid toxin (42% of total), Salmonella (33%), and hepatitis A virus (11%).

A foreign origin for approximately 19% of U.S.-consumed food makes it unsurprising that imported foods increasingly cause foodborne outbreaks. Much imported food is “outbreak prone.” Perhaps surprising is that a staggering 97% of fish/shellfish, 50% of fresh fruits, and 20% of fresh vegetables are imported, according to 2016 estimates by the U.S. Department of Agriculture.

Most imported food illnesses were from Salmonella (4,421 from 52 outbreaks), Cyclospora (2,533 from 33 outbreaks), hepatitis A virus (1,150 from 11 outbreaks), and Shigella (625 from 6 outbreaks). While eggs, ice cream, and poultry are notorious origins for Salmonella in domestic food, most imported Salmonella were from produce: fruits (26%), seeded vegetables (20%), sprouts (11%), nuts/seeds (10%), spices (7%), and herbs (2%).

Seafood/fish caused 55% of outbreaks but few illnesses per outbreak (median 3 illnesses/outbreak), so only 11% of total illnesses were caused by seafood/fish. In contrast, fresh produce caused only 33% of outbreaks but 84% of illnesses (median 40 illnesses/outbreak).

Geographic source, outbreak locations

The origin was known in 91% of outbreaks. Latin America and the Caribbean were most common, followed by Asia.³ Main contributing countries were Mexico (42 outbreaks), Indonesia (17) and Canada (11).

 

Contaminated fish/shellfish originated from all regions except Europe, most commonly from Asia (the majority of fish/shellfish outbreaks were from Indonesia, Vietnam, China, Philippines, Taiwan, and Thailand) with smaller contributions from the Bahamas and Ecuador.

Contaminated produce originated from all regions, mostly (64%) from Mexico and the Americas (Chile, Guatemala, and Honduras). All but one dairy outbreak originated in Latin America/the Caribbean.³ Outbreaks occurred in 31 states, most commonly California (30), Florida (25), and New York (16). Additionally, 43 (22%) were multistate outbreaks.

Conclusions

Outbreaks from domestic foods decreased, but those from imported foods increased. This makes sense given recent increases in outbreak-prone food imports, such as seafood/fish and produce.

To reduce overall foodborne illness outbreaks, governmental agencies need to:

• Develop/enforce regulations that promote proper growing, handling, and processing of foods.
• Strengthen surveillance networks and share standard culture and molecular detection/characterization protocols to identify outbreaks as close to real time as possible.
• Ensure rapid traceability not only to country of origin but to an exact farm or seafood/fish harvesting entity.
• Provide rapid public knowledge of outbreaks and origins, plus outbreak-specific recommendations to control/minimize resultant illnesses.

Individuals can help protect themselves by avoiding inadequately washed or incompletely cooked foods or foods of uncertain origin.

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at pdnews@frontlinemedcom.com.

References

1. MMWR. 2017 Apr 21;66(15):397-403.

2. Emerg Infect Dis. 2017 Mar;23(3):525-8.

3. Technical appendix in Emerg Infect Dis. 2017 Mar;23(3):525-8.

 

Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)

1. Texas SB 1148 The MOC Bill
2. Low back pain (Women Surgeons)
3. Domestic volunteerism
4. Hour limits for staff/attending surgeons?
5. Health Care Reform
6. A day on Capitol Hill
7. Reactions to the “Replacement” of our Surgeon General?
8. Any input on this article?
9. Another tough case
10. Rectal prolapse (Colon and Rectal Surgery)

To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to acscommunities@facs.org.

 

Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)

1. Texas SB 1148 The MOC Bill
2. Low back pain (Women Surgeons)
3. Domestic volunteerism
4. Hour limits for staff/attending surgeons?
5. Health Care Reform
6. A day on Capitol Hill
7. Reactions to the “Replacement” of our Surgeon General?
8. Any input on this article?
9. Another tough case
10. Rectal prolapse (Colon and Rectal Surgery)

To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to acscommunities@facs.org.

 

Here are the top discussion threads in ACS Communities this week. (All of these threads are from the General Surgery community except where indicated.)

1. Texas SB 1148 The MOC Bill
2. Low back pain (Women Surgeons)
3. Domestic volunteerism
4. Hour limits for staff/attending surgeons?
5. Health Care Reform
6. A day on Capitol Hill
7. Reactions to the “Replacement” of our Surgeon General?
8. Any input on this article?
9. Another tough case
10. Rectal prolapse (Colon and Rectal Surgery)

To join communities, log in to ACS Communities at http://acscommunities.facs.org/home, go to “Browse All Communities” near the top of any page, and click the blue “Join” button next to the community you’d like to join. If you have any questions, please send them to acscommunities@facs.org.

 

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

The evidence that moving through life in a state of mindfulness, or awareness, is beneficial has developed at multiple levels in the adult literature. Mindfulness is consistently associated with greater self-esteem, competence, life satisfaction, and positive emotions. In addition, greater mindful awareness correlates with reductions in anxiety, depression, doctors’ visits, physical complaints, hostility, and self-consciousness.² These findings hold across many populations, including medical students and community samples, as well as those with physical and stress-related disorders.^3-5 Neuroscience findings supporting the benefits of mindfulness also are multiplying. For experienced meditators, mindfulness appears to prevent cortical thinning in important areas of the brain related to executive functions (prefrontal cortex) and mind-body connection (insula).⁶ Even for novices, Dr. Kabat-Zinn’s 8-week MBSR program shows declines in life stress that move alongside decreases in amygdala gray matter, essentially shrinking the brain’s fight-or-flight worry center.⁷ This training also increases neuronal growth in the hippocampus, an area implicated in learning, memory, and emotion regulation.^8,9 The hippocampus typically is diminished by depression and PTSD, but, as with MBSR, neurogenesis occurs here with exercise or SSRI antidepressant medications.

The evidence base for mindfulness in children and adolescents is more nascent, but is also broadening. A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.¹⁰ Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.¹¹ This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.¹²

In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.¹³ Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.

While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.¹⁴

Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
 

 

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

 

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

The evidence that moving through life in a state of mindfulness, or awareness, is beneficial has developed at multiple levels in the adult literature. Mindfulness is consistently associated with greater self-esteem, competence, life satisfaction, and positive emotions. In addition, greater mindful awareness correlates with reductions in anxiety, depression, doctors’ visits, physical complaints, hostility, and self-consciousness.² These findings hold across many populations, including medical students and community samples, as well as those with physical and stress-related disorders.^3-5 Neuroscience findings supporting the benefits of mindfulness also are multiplying. For experienced meditators, mindfulness appears to prevent cortical thinning in important areas of the brain related to executive functions (prefrontal cortex) and mind-body connection (insula).⁶ Even for novices, Dr. Kabat-Zinn’s 8-week MBSR program shows declines in life stress that move alongside decreases in amygdala gray matter, essentially shrinking the brain’s fight-or-flight worry center.⁷ This training also increases neuronal growth in the hippocampus, an area implicated in learning, memory, and emotion regulation.^8,9 The hippocampus typically is diminished by depression and PTSD, but, as with MBSR, neurogenesis occurs here with exercise or SSRI antidepressant medications.

The evidence base for mindfulness in children and adolescents is more nascent, but is also broadening. A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.¹⁰ Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.¹¹ This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.¹²

In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.¹³ Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.

While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.¹⁴

Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
 

 

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

 

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

The evidence that moving through life in a state of mindfulness, or awareness, is beneficial has developed at multiple levels in the adult literature. Mindfulness is consistently associated with greater self-esteem, competence, life satisfaction, and positive emotions. In addition, greater mindful awareness correlates with reductions in anxiety, depression, doctors’ visits, physical complaints, hostility, and self-consciousness.² These findings hold across many populations, including medical students and community samples, as well as those with physical and stress-related disorders.^3-5 Neuroscience findings supporting the benefits of mindfulness also are multiplying. For experienced meditators, mindfulness appears to prevent cortical thinning in important areas of the brain related to executive functions (prefrontal cortex) and mind-body connection (insula).⁶ Even for novices, Dr. Kabat-Zinn’s 8-week MBSR program shows declines in life stress that move alongside decreases in amygdala gray matter, essentially shrinking the brain’s fight-or-flight worry center.⁷ This training also increases neuronal growth in the hippocampus, an area implicated in learning, memory, and emotion regulation.^8,9 The hippocampus typically is diminished by depression and PTSD, but, as with MBSR, neurogenesis occurs here with exercise or SSRI antidepressant medications.

The evidence base for mindfulness in children and adolescents is more nascent, but is also broadening. A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.¹⁰ Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.¹¹ This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.¹²

In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.¹³ Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.

While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.¹⁴

Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
 

 

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

 

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

More frequent perhaps is the concern from parents and youth that mindfulness is “too New Age” or “too soft.” My hope is that the behavioral and neuroscience evidence discussed in last month’s article can help combat this misbelief. In broad strokes, mindfulness builds the brain’s executive control functions (impulse control, focus, judgment, self-regulation) subserved by the prefrontal cortex while quieting the fight-or-flight, fear-learning circuits seated in the amygdala. This fosters a greater capacity to be in a calm and emotionally regulated state, with less time spent reacting to danger signals when in a generally safe environment.

Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.

A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.

Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

 

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@frontlinemedcom.com.

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

 

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

More frequent perhaps is the concern from parents and youth that mindfulness is “too New Age” or “too soft.” My hope is that the behavioral and neuroscience evidence discussed in last month’s article can help combat this misbelief. In broad strokes, mindfulness builds the brain’s executive control functions (impulse control, focus, judgment, self-regulation) subserved by the prefrontal cortex while quieting the fight-or-flight, fear-learning circuits seated in the amygdala. This fosters a greater capacity to be in a calm and emotionally regulated state, with less time spent reacting to danger signals when in a generally safe environment.

Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.

A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.

Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

 

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@frontlinemedcom.com.

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

 

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

More frequent perhaps is the concern from parents and youth that mindfulness is “too New Age” or “too soft.” My hope is that the behavioral and neuroscience evidence discussed in last month’s article can help combat this misbelief. In broad strokes, mindfulness builds the brain’s executive control functions (impulse control, focus, judgment, self-regulation) subserved by the prefrontal cortex while quieting the fight-or-flight, fear-learning circuits seated in the amygdala. This fosters a greater capacity to be in a calm and emotionally regulated state, with less time spent reacting to danger signals when in a generally safe environment.

Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.

A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.

Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

 

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@frontlinemedcom.com.

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

 

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Some of the reasons are biological. Adolescent sleep is marked by a phase change in circadian rhythm, so that teens become sleepy about 2 hours later than younger children and need to sleep later to get adequate sleep. There also is a change in sleep homeostasis, so that it takes a teenager longer to feel sleepy after waking. These biological forces are compounded by external forces: school work, athletics, jobs, and the gravitational pull of friendships provide multiple reasons to stay up rather than sleep. Most high schools in the United States start by 7:30 a.m., meaning teens must get up after only 6-7 hours of sleep. Ambitious teenagers are often involved in sports and extracurricular activities which take several hours after every school day. Homework can consume several hours every night. Even with exquisite organization and discipline, it is challenging to fulfill these commitments and still get 9 hours of sleep nightly.

Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.²

It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.

Even a few days of inadequate sleep can lead to anxiety and depressive symptoms, and chronic sleep deprivation is associated with a higher incidence of clinical depression. The relationship between inadequate sleep and depression is also two-way – disrupted sleep is a hallmark of depression. Beyond the links with depression, there appears to be an association between suicide attempts and inadequate sleep. One recent study found a threefold increase in the rate of suicide attempts in those adolescents who were getting less than 8 hours of sleep nightly, compared with their peers who were getting 8 or more hours of nightly sleep. The degree of risk is inversely related to the amount of sleep.³

Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.

Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.

Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.

While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.

Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.

 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

 

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Some of the reasons are biological. Adolescent sleep is marked by a phase change in circadian rhythm, so that teens become sleepy about 2 hours later than younger children and need to sleep later to get adequate sleep. There also is a change in sleep homeostasis, so that it takes a teenager longer to feel sleepy after waking. These biological forces are compounded by external forces: school work, athletics, jobs, and the gravitational pull of friendships provide multiple reasons to stay up rather than sleep. Most high schools in the United States start by 7:30 a.m., meaning teens must get up after only 6-7 hours of sleep. Ambitious teenagers are often involved in sports and extracurricular activities which take several hours after every school day. Homework can consume several hours every night. Even with exquisite organization and discipline, it is challenging to fulfill these commitments and still get 9 hours of sleep nightly.

Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.²

It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.

Even a few days of inadequate sleep can lead to anxiety and depressive symptoms, and chronic sleep deprivation is associated with a higher incidence of clinical depression. The relationship between inadequate sleep and depression is also two-way – disrupted sleep is a hallmark of depression. Beyond the links with depression, there appears to be an association between suicide attempts and inadequate sleep. One recent study found a threefold increase in the rate of suicide attempts in those adolescents who were getting less than 8 hours of sleep nightly, compared with their peers who were getting 8 or more hours of nightly sleep. The degree of risk is inversely related to the amount of sleep.³

Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.

Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.

Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.

While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.

Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.

 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

 

Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.

Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.¹ Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?

Some of the reasons are biological. Adolescent sleep is marked by a phase change in circadian rhythm, so that teens become sleepy about 2 hours later than younger children and need to sleep later to get adequate sleep. There also is a change in sleep homeostasis, so that it takes a teenager longer to feel sleepy after waking. These biological forces are compounded by external forces: school work, athletics, jobs, and the gravitational pull of friendships provide multiple reasons to stay up rather than sleep. Most high schools in the United States start by 7:30 a.m., meaning teens must get up after only 6-7 hours of sleep. Ambitious teenagers are often involved in sports and extracurricular activities which take several hours after every school day. Homework can consume several hours every night. Even with exquisite organization and discipline, it is challenging to fulfill these commitments and still get 9 hours of sleep nightly.

Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.²

It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.

Even a few days of inadequate sleep can lead to anxiety and depressive symptoms, and chronic sleep deprivation is associated with a higher incidence of clinical depression. The relationship between inadequate sleep and depression is also two-way – disrupted sleep is a hallmark of depression. Beyond the links with depression, there appears to be an association between suicide attempts and inadequate sleep. One recent study found a threefold increase in the rate of suicide attempts in those adolescents who were getting less than 8 hours of sleep nightly, compared with their peers who were getting 8 or more hours of nightly sleep. The degree of risk is inversely related to the amount of sleep.³

Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.

Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.

Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.

While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.

Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.

 

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.

Resources

1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)

2. Pediatrics. 2014 Sep;134(3):e921-32.

3. Sleep. 2004 Nov 1;27(7):1351-8.

The typical primary care physician has a patient base that consumes $10 million of health care a year. Yet the PCP receives only 6%-7% of those payments, with the rest of the costs resulting largely from the PCP’s referrals or lack of PCP care management of that patient.

The average PCP makes 1,000 referrals a year. Often, the referee specialist or facility not only does not coordinate with the PCP’s patient-centered medical home, they make their own downstream referrals.

One study showed that the typical PCP orthopedic referrals for a year resulted in 74 downstream office visits, 21 office procedures, 3.3 inpatient procedures and surgeries, 59 in-office diagnostics, 9.9 outpatient procedures and surgeries, 12 referrals for diagnostics, and 7 referrals to other specialists. The end result: 186.2 chargeable events.

A revolution in your compensation is underway. Under MACRA and other accountable care models, providers across the continuum of care are now being held responsible for the overall costs of those patients, not just their charges.

This is still hard to grasp, isn’t it? I was recently talking to a preeminent primary care physician who was an active member of an accountable care organization board of directors. I was fairly excited about the new impact this highly professional community leader could have on patients, now that he was in the PCP-driven ACO, not to mention his shared savings payment opportunities.

I was on a roll until he said, “But Bo, I’m already as efficient in treating patients as I can get.” He was still fighting the barriers you all face to do the best he could under the circumstances for the patients in his office each day.

Later, however, on a better day for me, we were working together on a cardiac care white paper. The physician leader told me, “I get it now – the biggest value-adding impact I might have is for the patient I don’t ever see.”

The above statistics show just what an opportunity you have in the new value care.

You can legally control referrals and patient care coordination with specialists. They don’t have to be in your ACO. You don’t even need to be in an ACO to take advantage of high-value referrals under the Medicare Merit-based Incentive Payment System (MIPS) program under MACRA. But how?

Let’s start by assuming the specialist you need to refer to is not in your ACO. You might be able to do this without an ACO, but it’s hard to get the critical mass of primary care physicians. If you’re under the Medicare Shared Savings Program or Next Gen initiative, there are important Stark Law and antikickback liability waivers that would benefit you by being in an ACO.

Otherwise, you should consider a high-value referral affiliation agreement.

If a critical mass of primary care physicians can access data that create a short list of high-value specialists, they can put them on the high-value specialist list. Specialists do not need to get part of the shared savings pool or other financial incentives – just referrals because of their high-quality and high-efficiency care. A superstar specialist or acute care or post–acute care facility may ultimately be invited into the ACO as a full participant.

The specialist/facility basically agrees to coordinate all care with the medical home and comanage that care with you. The agreement specifies that they will observe the care protocols of the ACO for that disease state. The provider will share data and agree to be monitored.

What is a high-value specialist/facility? The current common approach is to look at the insurance companies’ top tiers, but they are often too weighted to allowed charges. It’s really about being care coordinators and about readmission and complication rates.

For example, some bundled-payment specialists are selected solely based on the surgeons’ and anesthesiologists’ complication rates. If fees are mentioned at all, they are well down the list.

Of course, if the specialist is in the ACO with the primary care physician, this can be done internally.

How do you find value-added protocols involving specialists? I was lucky to be on a multiyear grant program whereby I worked with many primary care physicians and specialists to create white papers setting out high-value, practical initiatives. There are also guides for internists and family physicians. A condition of the grant was that they all can be accessed free of charge; they’re available at www.tac-consortium.org/resources.

This is a new day. Primary care is being asked to lead health care delivery today and be paid to do it. You are being rewarded or punished financially now based on the overall costs of your patients. You must have specialists and facilities coordinate with you in this new health care model. We have attempted to provide a road map to assist you on your journey.
 

 

Mr. Bobbitt is head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

The typical primary care physician has a patient base that consumes $10 million of health care a year. Yet the PCP receives only 6%-7% of those payments, with the rest of the costs resulting largely from the PCP’s referrals or lack of PCP care management of that patient.

The average PCP makes 1,000 referrals a year. Often, the referee specialist or facility not only does not coordinate with the PCP’s patient-centered medical home, they make their own downstream referrals.

One study showed that the typical PCP orthopedic referrals for a year resulted in 74 downstream office visits, 21 office procedures, 3.3 inpatient procedures and surgeries, 59 in-office diagnostics, 9.9 outpatient procedures and surgeries, 12 referrals for diagnostics, and 7 referrals to other specialists. The end result: 186.2 chargeable events.

A revolution in your compensation is underway. Under MACRA and other accountable care models, providers across the continuum of care are now being held responsible for the overall costs of those patients, not just their charges.

This is still hard to grasp, isn’t it? I was recently talking to a preeminent primary care physician who was an active member of an accountable care organization board of directors. I was fairly excited about the new impact this highly professional community leader could have on patients, now that he was in the PCP-driven ACO, not to mention his shared savings payment opportunities.

I was on a roll until he said, “But Bo, I’m already as efficient in treating patients as I can get.” He was still fighting the barriers you all face to do the best he could under the circumstances for the patients in his office each day.

Later, however, on a better day for me, we were working together on a cardiac care white paper. The physician leader told me, “I get it now – the biggest value-adding impact I might have is for the patient I don’t ever see.”

The above statistics show just what an opportunity you have in the new value care.

You can legally control referrals and patient care coordination with specialists. They don’t have to be in your ACO. You don’t even need to be in an ACO to take advantage of high-value referrals under the Medicare Merit-based Incentive Payment System (MIPS) program under MACRA. But how?

Let’s start by assuming the specialist you need to refer to is not in your ACO. You might be able to do this without an ACO, but it’s hard to get the critical mass of primary care physicians. If you’re under the Medicare Shared Savings Program or Next Gen initiative, there are important Stark Law and antikickback liability waivers that would benefit you by being in an ACO.

Otherwise, you should consider a high-value referral affiliation agreement.

If a critical mass of primary care physicians can access data that create a short list of high-value specialists, they can put them on the high-value specialist list. Specialists do not need to get part of the shared savings pool or other financial incentives – just referrals because of their high-quality and high-efficiency care. A superstar specialist or acute care or post–acute care facility may ultimately be invited into the ACO as a full participant.

The specialist/facility basically agrees to coordinate all care with the medical home and comanage that care with you. The agreement specifies that they will observe the care protocols of the ACO for that disease state. The provider will share data and agree to be monitored.

What is a high-value specialist/facility? The current common approach is to look at the insurance companies’ top tiers, but they are often too weighted to allowed charges. It’s really about being care coordinators and about readmission and complication rates.

For example, some bundled-payment specialists are selected solely based on the surgeons’ and anesthesiologists’ complication rates. If fees are mentioned at all, they are well down the list.

Of course, if the specialist is in the ACO with the primary care physician, this can be done internally.

How do you find value-added protocols involving specialists? I was lucky to be on a multiyear grant program whereby I worked with many primary care physicians and specialists to create white papers setting out high-value, practical initiatives. There are also guides for internists and family physicians. A condition of the grant was that they all can be accessed free of charge; they’re available at www.tac-consortium.org/resources.

This is a new day. Primary care is being asked to lead health care delivery today and be paid to do it. You are being rewarded or punished financially now based on the overall costs of your patients. You must have specialists and facilities coordinate with you in this new health care model. We have attempted to provide a road map to assist you on your journey.
 

 

Mr. Bobbitt is head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.

The typical primary care physician has a patient base that consumes $10 million of health care a year. Yet the PCP receives only 6%-7% of those payments, with the rest of the costs resulting largely from the PCP’s referrals or lack of PCP care management of that patient.

The average PCP makes 1,000 referrals a year. Often, the referee specialist or facility not only does not coordinate with the PCP’s patient-centered medical home, they make their own downstream referrals.

One study showed that the typical PCP orthopedic referrals for a year resulted in 74 downstream office visits, 21 office procedures, 3.3 inpatient procedures and surgeries, 59 in-office diagnostics, 9.9 outpatient procedures and surgeries, 12 referrals for diagnostics, and 7 referrals to other specialists. The end result: 186.2 chargeable events.

A revolution in your compensation is underway. Under MACRA and other accountable care models, providers across the continuum of care are now being held responsible for the overall costs of those patients, not just their charges.

This is still hard to grasp, isn’t it? I was recently talking to a preeminent primary care physician who was an active member of an accountable care organization board of directors. I was fairly excited about the new impact this highly professional community leader could have on patients, now that he was in the PCP-driven ACO, not to mention his shared savings payment opportunities.

I was on a roll until he said, “But Bo, I’m already as efficient in treating patients as I can get.” He was still fighting the barriers you all face to do the best he could under the circumstances for the patients in his office each day.

Later, however, on a better day for me, we were working together on a cardiac care white paper. The physician leader told me, “I get it now – the biggest value-adding impact I might have is for the patient I don’t ever see.”

The above statistics show just what an opportunity you have in the new value care.

You can legally control referrals and patient care coordination with specialists. They don’t have to be in your ACO. You don’t even need to be in an ACO to take advantage of high-value referrals under the Medicare Merit-based Incentive Payment System (MIPS) program under MACRA. But how?

Let’s start by assuming the specialist you need to refer to is not in your ACO. You might be able to do this without an ACO, but it’s hard to get the critical mass of primary care physicians. If you’re under the Medicare Shared Savings Program or Next Gen initiative, there are important Stark Law and antikickback liability waivers that would benefit you by being in an ACO.

Otherwise, you should consider a high-value referral affiliation agreement.

If a critical mass of primary care physicians can access data that create a short list of high-value specialists, they can put them on the high-value specialist list. Specialists do not need to get part of the shared savings pool or other financial incentives – just referrals because of their high-quality and high-efficiency care. A superstar specialist or acute care or post–acute care facility may ultimately be invited into the ACO as a full participant.

The specialist/facility basically agrees to coordinate all care with the medical home and comanage that care with you. The agreement specifies that they will observe the care protocols of the ACO for that disease state. The provider will share data and agree to be monitored.

What is a high-value specialist/facility? The current common approach is to look at the insurance companies’ top tiers, but they are often too weighted to allowed charges. It’s really about being care coordinators and about readmission and complication rates.

For example, some bundled-payment specialists are selected solely based on the surgeons’ and anesthesiologists’ complication rates. If fees are mentioned at all, they are well down the list.

Of course, if the specialist is in the ACO with the primary care physician, this can be done internally.

How do you find value-added protocols involving specialists? I was lucky to be on a multiyear grant program whereby I worked with many primary care physicians and specialists to create white papers setting out high-value, practical initiatives. There are also guides for internists and family physicians. A condition of the grant was that they all can be accessed free of charge; they’re available at www.tac-consortium.org/resources.

This is a new day. Primary care is being asked to lead health care delivery today and be paid to do it. You are being rewarded or punished financially now based on the overall costs of your patients. You must have specialists and facilities coordinate with you in this new health care model. We have attempted to provide a road map to assist you on your journey.
 

 

Mr. Bobbitt is head of the health law group at the Smith Anderson law firm in Raleigh, N.C. He is president of Value Health Partners, LLC, a health care strategic consulting company. He has years of experience assisting physicians form integrated delivery systems. He has spoken and written nationally to primary care physicians on the strategies and practicalities of forming or joining ACOs. This article is meant to be educational and does not constitute legal advice. For additional information, readers may contact the author at bbobbitt@smithlaw.com or 919-821-6612.