What parents need to know about baby monitoring apps

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If you want to know how your baby is doing, checking your smartphone app may not be your best bet.

That’s the bottom line of an opinion piece in the Journal of the American Medical Association about the new apps that monitor the heart rate, oxygen level, and other vital signs of babies, using sensors that go in clothing or bedding, and sound alarms if something seems awry.

I’ve been a new mom a few times, and I totally understand the appeal of these apps. I have gone in repeatedly to check my baby’s breathing, getting my face down to hear them, putting a hand on their back to feel its rise and fall. I’ve worried and fretted over little noises, and wondered if they were pale. Being able to do all that from my smartphone sounds like a dream come true.

But here’s the problem — there is no evidence that these actually work

These apps are not marketed as medical devices, and so aren’t subject to any testing or regulation. The developers can simply make any claim they want to make. Not that the developers are trying to fool people. I think that they genuinely do want to help parents monitor their babies, and keep babies safe. But we simply have no data to show that they keep babies safe at all — in fact, they may keep babies less safe.

One way they could make babies less safe is by subjecting them to medical visits and tests for no good reason. The thing is, it’s not uncommon for a heart rate or breathing rate of a baby to go up or down briefly, or for their oxygen level to drop and then come back up. There are all sorts of reasons it happens — and the vast majority of the time it’s nothing to worry about. The vast majority of the time, actually, we don’t even realize it happened because the baby looks and acts completely fine (because the baby is completely fine).

But with these devices, parents will see these blips (alarms could go off) and could easily panic and end up at the doctor’s office or emergency room. Many doctors will end up feeling obligated to do tests that truly aren’t needed based on information from the app.

These devices could very easily make parents crazy, because after all, imagine if you missed something? Anxious new parents could end up glued to their devices, worrying about every little number and bit of information, which could make it hard for them to drive, work, do chores, exercise, read, talk to their friends and family — oh, yeah, and parent.

The apps could also, on the flip side, give a false sense of security. Why go check on the baby if the sensor and app have it covered? If the device hasn’t alarmed, all must be fine, right? Except that sensors fall off, apps malfunction, phones get silenced, and batteries die. Not to mention the fact that we have no data (remember?) as to whether the information gathered by the app has any predictive value whatsoever. We don’t know if the apps can truly prevent SIDS or let you know when your baby is getting sick. We have no idea.

What parents can and should do — no app needed

What worries me the most, though, is that these apps may undermine something that parents need to do: paying attention to and getting to know their babies. When parents go and check on babies IRL (In Real Life), they learn their sounds and movements. They learn the difference between normal breathing and fast or forced breathing. They learn the difference between a cranky baby and a sick one, the difference between a hungry cry and a cry of pain. They learn their baby’s normal color, and how to tell when they are more limp or stiff than usual. They become attuned to the small hints and cues that let them know if their baby is fine — or if there is a problem. This is crucial knowledge. When a parent calls and says that something is wrong with the way their child is acting, I get worried — because they are usually right.

Technology can make our lives safer and better, there is no question. But we have to be really thoughtful and careful in how we choose and use technology when it comes to the health and safety of our children.

If you really want to know how your baby is doing, don’t look at your phone. Look at your baby.

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Taking medications correctly requires clear communication

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Early in December, Ms. Silva (not her real name) came to the hospital for a bladder infection that just kept getting worse. She’d been having symptoms — pain when she urinated, feeling constantly like she had to go to the bathroom — for about a week. She did all the right things. She called her doctor, picked up her prescriptions at the pharmacy, saw her doctor for a follow up appointment soon after, and swore that she was taking her antibiotic. But the pain got worse and she started having fevers. She needed to be admitted to the hospital.

Ms. Silva was an elderly lady in her 60s from Brazil. Without much grey hair, she looked much younger than her 60 years, yet the infection had wiped her out. She looked exhausted. As she returned from the bathroom, she tried to contort her hospital gown in a futile attempt to get it to cover more of her body. “Why wasn’t the antibiotic working?” she asked, stating the question on everyone’s mind that night.

At first I was worried about drug-resistant bacteria.  The bacteria causing her infection should have been killed by the antibiotic that she was given. If she had taken them as prescribed, then drug-resistant bacteria would be the only explanation for why she was getting worse.

So, we chatted about the antibiotic. She said she took every pill and was also taking something for the pain, that unrelenting, squeezing feeling of urgency. She took the pill bottles out of her purse, saying, “see, this was the bottle of the antibiotics,” showing me an empty bottle of pyridium (phenazopyridine). “And this bottle is the medication for the urinary pain,” she said, showing me a bottle still full of antibiotic pills.

This solved the mystery. She didn’t have resistant bacteria. Ms. Silva’s infection worsened because she had confused the antibiotic pills for the pills for pain, taking the latter with regularity while the infection continued to rage.

Doctors and patients are not always on the same page when it comes to which medications are important

Ms. Silva’s story reminded me of an article published this past fall in the Annals of Family Medicine that showed a large difference between patient and physician perceptions about which medications are important. The study found that up to 20% of medications considered important by doctors were not correctly taken by patients. Taking medications as prescribed is called medication adherence, as this is adhering to the doctor’s recommendations that are trying to maximize the drugs’ benefit while minimizing its side effects. About half the time, patients forgot, ran out of medication, or were careless about when they took the medication, a situation the study authors called unintentional non-adherence. The other half of the time, the patients deliberately chose not to take the medication correctly.

The study authors point out that this discrepancy between patients and doctors is a symptom of a larger problem in healthcare. It stems from challenging clinic environments that make it difficult for patients and doctors to partner together in shared decision making. They point out that good doctor-patient communication requires a good doctor-patient relationship, but some studies show that as a physician’s responsibilities increase through medical school, residency and on to practice, that their communication skills decline. So does their empathy.

Differences in gender, race, or socioeconomic class can also influence doctor-patient communication. Sometimes patients are bashful about telling their doctor they don’t understand or that they can’t read. Plus, it’s hard for anyone to think about and ask all the important questions when a rushed doctor has his or her hand on the doorknob.

Still, it’s hard to say exactly why the misunderstanding occurred in Ms. Silva’s case. While she speaks Portuguese, the nurse Ms. Silva spoke to on the phone documented that an interpreter was used. The doctor she saw in the office speaks Portuguese.

At the same time, Ms. Silva had never finished elementary school. It wasn’t clear that she could read, and even if she could, her pill bottle was labeled with neither the name of the medication, nor its purpose. Without knowing a lot about medications, she wouldn’t know which drug was the antibiotic. It also isn’t clear what she was told and what she understood at that critical moment when she picked up the medications at the pharmacy.

How to fix communication gaps

It would be ideal if we could solve all of the myriad factors leading to communication problems in one doctor visit. But that’s wishful thinking. So, the study authors suggest engaging with other health professionals, like pharmacists, nurses, and physician assistants, to help bridge these communication gaps by checking a patient’s understanding of their medications and filling in knowledge gaps when they arise.

Engaging other health professionals may have helped Ms. Silva. Her experience shows that between the doctor’s office and the pharmacy, there were a number of missed opportunities to make sure she understood which medication was the antibiotic. Working with family members may have helped as well. Ms. Silva’s daughter brought her to the hospital and may have been a useful partner to avoid misunderstandings.

Thankfully, after a short stay in the hospital (being sure she was taking the right medicine), Ms. Silva improved and went home. But her delay in getting well is an unfortunate example of just how much can go wrong between a doctor’s prescription and a patient getting better, especially when there are misunderstandings about medications.

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Roger Federer’s Win Is New Hope for Tiger Woods

The greatest player of his age, perhaps of all time.

An injury that destroyed his game and a rehab that took much longer than expected.

The prime of his career appearing over.

Then suddenly, victory. Victory at the highest level. Victory when victory seemed no longer possible.

It’s the story Tiger Woods desperately desires. It’s the story Roger Federer delivered on Sunday.

During the 2000s, Woods and Federer formed a cross-sport friendship largely out of the shared trait of being that much better than literally everyone else in their sport.

Consider: Woods has had two different stretches of time when he spent 281 and 264 weeks as No. 1 in the world, and won 14 Major titles in the span of 11 years

Federer knows what those type numbers mean. He’s been No. 1 in men’s tennis for 302 weeks, including 237 in a row, and won 16 Grand Slams in seven years.

While Woods went through controversy and returned to No. 1 in 2013, Federer had to contend with a host of new talent in his sports – Rafael Nadal, Andy Murray, Novak Djokovic. He won once more at Wimbledon in 2012, then began to slip slowly in the Top 10.

In 2016, a knee injury kept Federer out for several months, and after he returned, he hurt his back, missing the French Open, his first time not participating in a Grand Slam even since 2000. After losing in the Wimbledon semifinals, he announced he would miss the rest of the season to fully heal from the knee injury.

He returned to action two weeks ago at the Australian Open, and at the age of 35 became the second-oldest man to win an ATP Grand Slam, knocking off countryman Stanislas Wawrinka in the semifinals and longtime rival Nadal in the final in five sets.

In the process, he jumped from 17th to 10th in the ATP world rankings.

 

 

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Americans Rodgers, Snedeker Tied for Torrey Pines Lead

Patrick Rodgers shot a 5-under 67 to race up the leaderboard and tie Brandt Snedeker for first place at the end of 54 holes at the Farmers Insurance Open in California on Saturday.

Snedeker is 18 holes away from becoming just the fourth back-to-back champion at Torrey Pines. He also won the event in 2012.

Rodgers must be getting some good mojo from former roommate Justin Thomas, who recently won back-to-back events and set a new PGA record for lowest score under par at the Sony Open in Hawaii.

“I can’t sit here and say it hasn’t been hard at times,” Rodgers said. “Obviously, these are my best friends so I’m happy every time they have success. But on a personal level, I mean, those are the guys that I’ve always competed with and so it definitely tests my patience to see them have success and it’s incredibly motivating.”

Like Thomas and Jordan Spieth, Rodgers is from the graduating high school class of 2011 in the US. Amazingly, so are C.T. Pan of Tawai and Ollie Schniederjans.

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Justin Rose Takes 1-Stroke Lead to Weekend at Torrey Pines

Justin Rose came back down to earth on Friday at the Farmers Insurance Open, but so did everyone else.

Thus Rose’s 1-under was good enough to keep the Brit in the lead at 8-under. “Everyone has played both courses now, and now we get to play the bruiser for the next two days,” Rose said. “So you just want to basically put yourself within shot.”

He has the same lead over the same two men – Canadian Adam Hadwin and American Brandt Snedeker, the defending champion. If he were to rally to the victory, Snedeker would join J.C. Snead, Tiger Woods, and Phil Mickelson as the only men to ever win the tournament back to back.

Rose was 2-under through 13 holes before bogeying 14 and 15 in succession. He birdied 18 to give himself a high note leaving the course. An amazing 34 players are within 5 strokes of the lead with 36 holes to play.

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Personalized activity intelligence: A better way to track exercise?

Perhaps the best-known problem with fitness trackers is that people often retire them to a junk drawer after a few months, once their novelty wears off. But that’s not the only issue with these devices, which are typically worn around the wrist or clipped to clothing. Sure, they’ll count your steps, display your heart rate, and even estimate how many calories you’ve burned, although you’ll probably need to sync it with an app on your smartphone, tablet, or computer to see such data.

However, very few of the popular, free apps related to physical activity are based on published evidence. And they don’t necessarily follow well-established exercise guidelines. Even if you do meet recommended daily exercise goals — like 30 minutes of brisk walking or 10,000 steps — how do you know if you’re really working your heart enough to keep it healthy?

Easy as PAI?

Now, a new scientifically validated tool, dubbed Personalized Activity Intelligence, or PAI, may have the answer. Developed by a international team of researchers, PAI is a formula that converts your heart rate to a number of points, based on your age, gender, resting heart rate, and maximum heart rate. The idea is to get an average of 100 points over an entire week, which you could earn through short stints of intense exercise, longer bouts of more moderate activity, or a combination of the two. Think of PAI as an index of how hard and how often you challenge your heart.

“It’s a different way of quantifying cardiovascular fitness that captures something that step trackers don’t, which is physical activity other than walking,” says Dr. Lauren Elson, a physiatrist at Harvard-affiliated Massachusetts General Hospital. For example, if you’re biking or raking leaves, you won’t accrue very many steps, but your heart rate may rise more than it would during a leisurely stroll.

On the flip side, some people are on their feet and active during the day and may rack up 8,000 or more steps, but their heart rates don’t necessarily go up very high. “We know that that’s better than being sedentary, but it actually doesn’t count as cardiovascular exercise,” says Dr. Elson.

Tracking the evidence

PAI was created and validated in large Norwegian fitness study that included more than 39,000 people who were followed for an average of about 26 years. Researchers developed the formula based on a subset of about 4,600 of the participants and then tested it on data from the entire group.

People who reached the weekly goal of 100 points were about 20% less likely to die of heart disease compared to those who didn’t reach that goal. Having a PAI score under 100 was linked to a shorter life — nearly 4 years less for women and 6 years less for men when compared to people with a score of 100 or higher.

It doesn’t matter if you prefer to walk at a relatively low intensity for hours or exercise at a high intensity for shorter periods of time, as long as you earn 100 PAI points per week, says study lead author Ulrik Wisløff, head of the Cardiac Exercise Research Group at the Norwegian University of Science and Technology in Trondheim. The Mio Slice will be the first wearable device to feature PAI, but Mio plans to license the use of the PAI algorithm to other companies, Wisløff notes.

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Justin Rose Jumps Ahead at Torrey Pines

Justin Rose stroked a 7-under 65 to take the Day One lead at the Farmers Insurance Open being held in Torrey Pines, California.

All eyes were on Tiger Woods as he returned to his first regular action since August of 2015.  Woods staggered to a 4-over 76 and is tied for 133rd place.

It was a wild round for Rose. He shot two eagles in a five-hole stretch on the front nine, then gave up two strokes with consecutive bogeys on 14 and 15 down the stretch.

Rose takes a 1-stroke lead into Friday over Canada’s Adam Hadwin, who put up a 1-bogey round. The 29-year-old rebounded from the bogey on No. 12 with consecutive birdies on 13, 14, and 15.

Seventy-six players are at least one stroke under par, including American Phil Mickelson (-1) playing for the first time since his second sports hernia surgery. Mickelson was 1-over after 15 holes, then birdied 16 and 17 to get under par

Woods bogeyed his first hole on the day, then complete the front nine with eight straight pars. He looked on form when he birdied 10 and 11 back to back to get to 1-under, but was a mess from there, bogeying 12, 13, and 14, then double-bogeying 15 to balloon up to 4-over. He was up to 5-over with another bogey on 17 before birdying No. 18 to pull back one stroke.

“Well, it was tough out there, period,” said Woods, who failed to hit a single fairway on the back nine and hit only four for the round. “I was in the rough most of the day and it was tough. It was wet.

“The very first hole, OK, here we go. We’ve got a ball that’s sitting into the grain. Not only was it into the grain, but it was buried underneath there and it was going from left to right, which that’s the path I needed to take. So I’m like OK, this is the very first hole. Let’s not do this anymore. Unfortunately, I did it most of the day.”

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Does your doctor’s gender matter?

Follow me on Twitter @RobShmerling

I’ve read medical research studies that surprised me. I’ve read medical news that inspired me to learn more. And, sure, there have been plenty of studies that went way over my head. But it’s rare that I’ve read a study that made me feel defensive. Until now.

Researchers publishing JAMA Internal Medicine reported that older adults admitted to the hospital fare better if under the care of a female physician rather than a male physician. More specifically, the patients in this study were less likely to end up back in the hospital, or die, in the 30 days after discharge if cared for by female physicians than similar patients cared for by male physicians.

How “good” was the study?

The study was large. Nearly 1.6 million hospital admissions among people covered by Medicare were analyzed for deaths within 30 days. Another 1.6 million admissions were analyzed for readmission within 30 days. When comparing care provided by male to female internists, the results clearly demonstrated small differences that consistently favored the female physicians:

• Deaths within 30 days of admission occurred in 11.07% of patients cared for by female physicians while 11.49% of patients cared for by male physicians died in that timeframe.
• Readmission to the hospital within 30 days of discharge occurred in 15.02% of patients with female physicians but in 15.57% of those cared for by male physicians.
• Even after accounting for several relevant factors, such as severity or type of patients’ illness, or type of medical training, age or experience of the physicians, the findings remained largely the same.

Although these differences may seem small, they could have a large impact on unnecessary suffering, premature death, and costs of care when considered over the millions of hospital admissions that occur each year.

Your reaction, please

When I surveyed the members of my household about these results, the reactions ranged from “Of course, everyone knows women are better at everything,” (my wife’s perspective) to, “There must be some other reason for these findings; the researchers must have missed something.”   OK, that last one was from me. Did I mention I was feeling defensive?

But after reading the research report’s results carefully, it’s hard to come up with an alternative explanation for the study’s findings. And there is other research that suggests that female physicians outperform their male counterparts in certain aspects of medical care, such as communication skills.

So, what’s their secret?

And that brings us to this question. If female physicians are getting better results, how do they do it? Just what are the differences in the ways male and female physicians practice that lead to better outcomes for patients of women doctors?

The answer is important. Identifying the differences in how male and female physicians provide care could lead to improved care across the board, regardless of physician gender.

The study’s authors are appropriately cautious in their conclusions because a study of this type cannot determine why the results turned out as they did. But they did offer a few possibilities:

• Female physicians may follow clinical guidelines more often.
• Female physicians may communicate better, with less medical jargon.
• Male physicians may be less “deliberate” in addressing complicated patients’ problems (as suggested by past research).

I would add a couple of other possibilities:

• Perhaps female physicians listen more carefully.
• Female physicians may spend more time with their patients, and this could allow the doctor to get a better sense of the patient’s symptoms and help ensure that her recommendations are understood well by the patient.

There are more questions to answer

Beyond making us think about what female physicians are doing right, this study raises a number of other questions:

• Would the results be the same if other areas of medicine were similarly studied? This study excluded patients of care for by other types of doctors such as surgeons, obstetricians, and psychiatrists.
• Would physician gender matter if the patients were younger? The average age of patients in this Medicare-covered study population was nearly 81.
• How would the results be affected if outpatients were included?

How can we use this information to improve care of patients?

Undoubtedly, future research will try to tease out how female and male doctors practice differently. Then it will be important to figure out why these differences exist and which ones matter most. It’s probable that each gender has something to teach the other. One thing is certain: accepting the possibility that female physicians may outperform male physicians in certain aspects of medical care, and then trying to understand why, is much more constructive than being defensive about it.

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What is prediabetes and why does it matter?

When I’m seeing a new patient, I am especially alert to certain pieces of their history. Do they have a strong family history of diabetes? Are they of Latino, Asian, Native-American, or African-American ethnicity? Did they have diabetes in pregnancy? Are they overweight or obese? Do they have polycystic ovarian syndrome (PCOS)?

Why do I care about these things? Because they may be clues that the patient is at risk for developing adult-onset (type 2) diabetes, and that can lead to multiple major medical problems.

Many people have heard of type 2 diabetes, a disease where the body loses its ability to manage sugar levels. Adult-onset diabetes most often affects people with known risk factors and can take years to fully develop, unlike juvenile (type 1) diabetes, which can develop randomly and quickly.

Here is why high blood sugar is a problem

Untreated or undertreated diabetes means persistently high blood sugars, which can cause horrible arterial blockages, resulting in strokes and heart attacks. High blood sugars also cause nerve damage, with burning leg pain that eventually gives way to numbness. This, combined with the arterial blockages, can result in deformities and dead tissue, which is why many people with diabetes end up with amputations. The tiny blood vessels to the retina are also affected, which can cause blindness. And don’t forget the kidneys, which are especially susceptible to the damage caused by high blood sugar. Diabetes is a leading cause of kidney failure requiring dialysis and/or kidney transplant. But wait! There’s more. High blood sugar impairs the white blood cell function critical to a healthy immune system, and sugar is a great source of energy for invading bacteria and fungi. These factors put folks at risk of nasty infections of all kinds.

These facts scare me. Not just because I’m the doctor who gets to help manage these not-fun issues, but because I’m of Latina descent and diabetes runs in my own family. I’m at risk too.

So, what can we do? If we know who is at risk for diabetes, and it takes years to develop, we should be able to prevent it, right? Right!

Keeping prediabetes from becoming diabetes

A recent in-depth article by endocrine experts declares prediabetes a worldwide epidemic (which it is).¹ Prediabetes is defined by fasting blood sugars between 95 and 137, or an abnormal result on an oral glucose tolerance test. What can we do to treat prediabetes? The authors reviewed multiple large, well-conducted studies, and all showed that prediabetes can be targeted and diabetes delayed or prevented.

One of the largest studies was conducted here in the U.S.² Over 3,000 people from 27 centers who were overweight or obese and had prediabetes were randomly assigned to one of three groups: standard lifestyle recommendations plus the medication metformin (Glucophage); standard lifestyle recommendations plus a placebo pill; or an intensive program of lifestyle modification. The intensive program included individualized dietary counseling, as well as instruction to walk briskly or do other exercise for 120 minutes per week, with the goal of some modest weight loss.

Investigators followed the subjects over three years, and the results were consistent with those from many other studies: the people in the intensive lifestyle modification group (nutrition counseling and exercise guidance) were far less likely to develop diabetes in that time span than those in either of the other groups.^3,4,5 Want numbers? The estimated cumulative incidence of diabetes at three years was 30% for placebo, 22% for metformin, and 14% for lifestyle modification. The incidence of diabetes was 39% lower in the lifestyle modification group than in the metformin group. As a matter of fact, they shut down the study early because it was deemed unethical to keep the subjects in the placebo and metformin-only groups from proper treatment.

The authors of the prediabetes review also looked at the multitude of other studies that more closely examined what kinds of diets are useful and concluded that “The consensus is that a diet rich in whole grains, vegetables, fruit, monounsaturated fat, and low in animal fat, trans fats, and simple sugars is beneficial, along with maintenance of ideal body weight and an active lifestyle.”

It’s really just common sense. And that’s why my husband and I greatly limit our intake of sugar and carbs, get four-plus servings of plant-based foods daily, and exercise.

A word about medication

For my patients who for whatever reason cannot change their diet and lifestyle, I do recommend a medication. For patients who are on the cusp of diabetes and who have multiple risk factors or other diseases, medication really is indicated. There are also people who want to add a medication to diet and exercise in order to boost weight loss and further decrease their risk, and that’s fair as well.

I know that using medications for prediabetes is controversial. Other doctors have warned that the label “pre-diabetes” is over-inclusive and that it’s all a vast big-pharma marketing scam.⁶ It’s true that we have to be informed about what we’re prescribing and why. But based on what I’ve seen in my career, I definitely do NOT want to develop diabetes myself, and if you’re at risk, believe me, you don’t either. So, consider the pros and cons of everything, talk to your doctor, and decide for yourself what action you want to take. And then, take action.

Sources

1. Edwards CM, Cusi K. Prediabetes: A Worldwide Epidemic. Endocrinology and Metabolism Clinics of North America, December 2016.
2. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, February 7, 2002.
3. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care, April 1997.
4. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine, May 3, 2001.
5. Lindstrom J, Peltonen M, Eriksson JG, et al. Improved lifestyle and decreased diabetes risk over 13 years: long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia, February 2013.
6. Prediabetes: can prevention come too soon? Blog post by Richard Lehman, Cochrane UK Senior Fellow in General Practice, November 11, 2016.

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Why medical experts say that teens should be allowed to make the abortion decision without telling their parents

I am the mother of three daughters, and if one of them were to get pregnant and be thinking about an abortion, I’d want to know. It’s heartbreaking to me to think about not knowing — and about them going through that alone.

But for their own safety and well-being, they should have the right not to tell me.

That’s the consensus of several medical organizations, including the American Academy of Pediatrics, the American Medical Association, the Society for Adolescent Health Medicine, the American Public Health Association and the American College of Obstetrics and Gynecology. And I agree.

Here in the United States, minors have a right to an abortion without parental consent unless otherwise specified by state law, and many states do specify otherwise. The Supreme Court has said it’s okay for the states to do that, as long as there is a way for teens who think that telling their parents is a bad idea to get “judicial bypass,” that is, they can go to court and get permission. But many teens don’t know about judicial bypass, and it’s not always easy to do.

The thing is, making it mandatory to tell parents doesn’t improve family communication. What it does is delay appropriate medical care — and increase the number of teen births.

Teen births are generally on the decline, which is a good thing. Teen pregnancy makes it less likely that the teen will finish high school. It makes it more likely that the baby will be born early and small, and that the mother will end up a single mother. Boys born to teen mothers are more likely to end up incarcerated, and girls born to teen mothers are more likely to end up teen mothers themselves. One teen pregnancy can start a cycle that can go on for generations.

And when teens go through with pregnancies they don’t want (very few place babies for adoption), they are not only more likely to suffer psychological consequences for it, but it can have consequences for the child as well to have been “unwanted.”

The medical consequences of making teens tell their parents can be significant. Teens tend to realize later than adults that they are pregnant, so they are already off to a later start with decision-making — and if they don’t want to tell their parents, or if they have to go in front of a judge, they often delay (or the system delays them) and end up with a second-trimester abortion, which is much more dangerous medically and psychologically than a first trimester abortion (generally very safe). Teens may do things to try to induce an abortion, which can be very dangerous.

Parents may understandably worry that their teen isn’t capable of making such an important decision without their input — but studies show that teens are actually quite capable. And it turns out that the majority of teens do talk to their parents or a trusted adult, especially younger teens. The ones that don’t tend to have a good reason; one in three teens who don’t want to tell their parents has a history of family violence. Forcing teens to tell their parents doesn’t improve family communication, and some families can be punitive or coercive.

It’s not that these medical organizations don’t want teens to talk to their parents. They do; their consensus statement strongly encourages it, for all the same reasons I would want my daughters to talk to me.

Obviously, talking should start before a pregnancy, and can help prevent teen pregnancy in the first place. Make sure you talk to your daughters — and sons — about sex and pregnancy, about birth control, about healthy relationships and healthy choices. Make sure, too, that they have access to their doctor and the ability to ask confidential questions and get confidential care. Sometimes teens feel awkward discussing these topics with their parents.

But ultimately, as medical professionals what is most important to us is the health and safety of our patients — based on what the medical evidence tells us. And in this case, what it tells us is that teens should be allowed to make this choice without their parents. It’s the right thing to do.

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Let the sun shine: Mind your mental health this winter

Although the winter season begins with a bit of holiday cheer, many people feel a little “off” as the cold weather drags on. I’ve already seen a few patients who are puzzled by how easily they become irritated. “Is there something wrong with me?” “Why am I so unhappy?”  Often, their bodies are just responding to the darker and colder days.

We are governed by circadian rhythms, our body’s natural clock that helps regulate important functions including sleep/wake cycles and mood. These rhythms can be thrown off by the winter season.¹ The sky gets bright later in the morning, and dark earlier in the evening; yet, our hectic schedules require us to keep going as if nothing has changed. This shift, along with other factors – including genetics and body chemistry – may affect your mental health.

Maintaining wellness

Exercising, eating nutritious foods, practicing mindfulness, and maintaining social support systems are core components of maintaining a healthy lifestyle. Not only is physical activity a fantastic outlet for stress, exercising 30 minutes daily may help your body release endorphins, your natural “happy hormones.” It may be challenging during the holidays to eat healthy, but try to fill up first on healthy fruits and vegetables to maintain a balanced diet then have the occasional indulgence.

Meditation has been shown to improve symptoms in people suffering from depression and anxiety, and may also help you to stay well. Meditation can be as short as a 10-minute session every other day when you take the time to be mindful and check in with your body. Some people, especially those who find it difficult to quiet their minds, may find guided meditation helpful. There are plenty of apps such as Headspace and podcasts available to help you. Other meditative practices such as yoga, taking a quiet stroll in a park, or even closing your eyes to focus on listening to your favorite song can also be helpful.

Keeping in touch with your family, friends, and other caring people in your life strengthens your sense of community, and provides you with a strong support system to call on when you feel down.

Light therapy

Some studies² have shown that light therapy may benefit those with depression, especially if it is related to the season. A review article³ showed that light boxes that produce light intensities of more than 2,500 lux are beneficial (to compare, a cloudy winter day provides around 4,000 lux whereas a sunny day provides 50,000– 100,000 lux!). We usually recommend that light therapy be used early morning when you wake up, using a fluorescent white light box of 10,000 lux without ultraviolet wavelengths⁴ (these are sold specifically for seasonal mood problems). You should position the light 12-18 inches from yourself for approximately 30 minutes, keep your eyes open but do not look directly into the light. Many people will place it nearby as they eat breakfast or begin their daytime chores. Although light therapy is generally well tolerated, you should consult your doctor before starting the therapy, especially if you have preexisting conditions such as eye disease. Possible side effects include headache, eye strain, nausea, and even agitation or sleep disturbance, although this is usually related to using the light later in the day.

When to seek medical attention

Depression can come on during any season, and although some people might think they feel just a little “off,” it is important to call your doctor when you have these concerning signs of depression:

• depressed mood most of the day
• decreased interest or pleasure in activities that you used to enjoy
• difficulty sleeping or sleeping more than usual
• moving slower or feeling more hyperactive during the day
• feeling tired and less energetic
• feeling worthless or excessively guilty
• difficulty concentrating more than usual
• thoughts of death, suicide, or harming others

If you notice these symptoms almost every day during the week, or have thoughts of harming yourself or others, seek medical attention right away. It is also important to reach out to the supportive people in your life. If you notice these symptoms tend to occur in the winter months, you may suffer from seasonal affective disorder (SAD), which could benefit from medical treatment.

References

1. Duffy JF, Czeisler CA. Effect of Light on Human Circadian Physiology. Sleep Med Clin., 2009.
2. Golden RN, Gaynes BN, Ekstrom RD, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry, 2005.
3. Westrin A, Lam RW. Seasonal Affective Disorder: A Clinical Update. Annals of Clin Psychiatry, 2007.
4. Kurlansik SL, Ibay AD. Seasonal Affective Disorder. Am Fam Physician, Dec. 2012.

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Hudson Swafford Climbs Ahead at CareerBuilder

Hudson Swafford shot his second straight 7-under par on Friday to take a 1-stroke lead at the halfway point of the CareerBuilder Challenge in La Quinta, California.

Swafford’s 7-under 66 got him to 14-under for the tournament, one stroke ahead of Day One leader Dominic Bozzelli, and Australian Danny Lee, who fired an 8-under 64.

The move on the scoreboard that drew the most attention was that of Phil Mickelson, who rose to a tie for ninth after notching a 6-under 66 to reach 10-under. Mickelson is in his first action since having a second sports hernia surgery performed.

Swafford has been on the PGA Tour since 2014 and is still in search of his first tournament win. He played in the Web.com Tour finals in 2013 and finished 21st in 2014 to earn his card for the PGA Tour.

 

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Martin Kaymer Forges Ahead at Abu Dhabi

Martin Kaymer recorded his second straight 66 on Friday to take the lead at the Abu Dhabi Championships through 36 holes.

He’s a step ahead of Spain’s Rafa Cabrera Bello and two ahead of Paul Dunne and Kiradech Aphibarnrat. The former No. 1 got off to a slow start and was 1-over through seven holes. He eagled No. 8 to hit the turn one stroke under, then fired off six birdies on the back nine.

Kaymer has not won an event since his triumph at the 2014 US Open. Prior to that victory it had been three years since he won. Abu Dhabi success has been something of a snap for Kaymer over the years.

He shot -15 in 2008 to win the event, won it again in 2010 and repeated as champion in 2011.

Day One leader Henrik Stenson shot a 1-under 71 and dropped back to a tie for ninth.

 

 

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Justin Thomas Sets PGA 72-Hole Mark

Justin Thomas is so hot, he’s burning up the PGA record books.

Thomas won the Sony Open in Hawaii last week by shooting a 253, breaking the 14-year-old record for a 72-hole score set by Tommy Armour III (254 at the 2003 Texas Open). He also tied Steve Stricker’s 54-hole record of 188.

Thomas is the second player ever to win the Hawaii tournaments back to back, joining Ernie Els, who did it in 2003. He’s only the third player to start the PGA season with three wins in five events, joining Tiger Woods – who did it three times – and Johnny Miller, who did it twice.

Thomas jumped into the top 10 with the string of wins, up to No. 8 from No. 12. He has climbed 14 spots from No. 22 at the end of 2016.

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5 ways to hold on to optimism — and reap health benefits

In these turbulent times, it may be a struggle to maintain a glass half full view of life. A poll just released by the Associated Press on New Year’s Day indicated that most Americans came out of 2016 feeling pretty discouraged. Only 18% feel things for the country got better, 33% said things got worse, and 47% believe things were unchanged from 2015.

However, 55% of those surveyed said they expect their own lives to improve in 2017. If you are among this majority, it may serve you well. A growing body of research indicates that optimism — a sense everything will be OK — is linked to a reduced risk of developing mental or physical health issues as well as to an increased chance of a longer life.

One of the largest such studies was led by researchers Dr. Kaitlin Hagan and Dr. Eric Kim at the Harvard T.H. Chan School of Public Health. Their team analyzed data from 70,000 women in the Nurses’ Health Study, and found that women who were optimistic had a significantly reduced risk of dying from several major causes of death over an eight-year period, compared with women who were less optimistic. The most optimistic women had a 16% lower risk of dying from cancer; 38% lower risk of dying from heart disease; 39% lower risk of dying from stroke; 38% lower risk of dying from respiratory disease; and 52% lower risk of dying from infection.

Yes, you can acquire optimism.

Even if you consider yourself a pessimist, there’s hope. Dr. Hagan notes that a few simple changes can help people improve your outlook on life. Previous studies have shown that optimism can be instilled by something as simple as having people think about the best possible outcomes in various areas of their lives,” she says. The following may help you see the world through rosier glasses:

1. Accentuate the positive. Keep a journal. In each entry, underline the good things that have happened, as well as things you’ve enjoyed and concentrate on them. Consider how they came about and what you can do to keep them coming.

2. Eliminate the negative. If you find yourself ruminating on negative situations, do something to short-circuit that train of thought. Turn on your favorite music, reread a novel you love, or get in touch with a good friend.

3. Act locally. Don’t fret about your inability to influence global affairs. Instead, do something that can make a small positive change — like donating clothes to a relief organization, helping clean or replant a neighborhood park, or volunteering at an after-school program.

4. Be easier on yourself. Self-compassion is a characteristic shared by most optimists. You can be kind to yourself by taking good care of your body, eating well, exercising, and getting enough sleep. Take stock of your assets and concentrate on them. Finally, try to forgive yourself for past transgressions (real or imagined) and move on.

5. Learn mindfulness. Adopting the practice of purposely focusing your attention on the present moment and accepting it without judgment can go a long way in helping you deal with unpleasant events. If you need help, many health centers now offer mindfulness training. There are also a multitude of books and videos to guide you.

 

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Phil Mickelson and Caddie Rebuilt for 2017

If you notice an extra spring in the step of American golfer Phil Mickelson and caddie Jim “Bones” Mackay this weekend at the CareerBuilder Challenge, it’s no illusion – both men are walking pain free.

Mickelson is back from the second of two sports hernia surgeries while Mackay had both of his knees replaced a month ago.

“My knees hurt for years, especially last year,” said Mackay, who has been on the bag for all but one of Mickelson’s 42 career PGA Tour victories. “The weird thing was that ultimately when the doctor who agreed to do both knowing what I do and how important it was for me not to miss any work … when I saw him the first time after the surgery, he said my knees were much worse than he expected. It was a disaster.”
Mackay has been Mickelson’s caddie since 1992.

While Mickelson turned heads with his play in last year’s Open Championship (he finished second) and the Ryder Cup, the 46-year-old has not won a Tour event since the 2013 Open Championship.

 

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Stenson Shreds Abu Dhabi Field with Opening 64

Henrik Stenson showed why he’s the No. 1 ranked player in Europe on Thursday, shooting a 64.

“I just want to keep on developing my game, keep on working hard on that and come into the majors well prepared and well rested and try to put myself into contention,” Stenson said.

“I feel like I can make that Claret Jug get some company if I can do that, so I’m going to try my hardest.

Ranked No. 4 in the world, Stenson is coming off a year in which he won his first Major – the Open Championship – and won the Race to Dubai championship for the second time in four years.

“I think I scored a bit better than I played, but I kept it under control somewhat, hit a couple of close iron shots and made the putts. There wasn’t too much stress out there after all.”

Stenson took a 2-stroke lead over Martin Kaymer and three others who shot 66.

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118-150 Robson by Amacon – Plans, Prices, Availability

At a Glance

• prime location at Robson & Cambie streets
• 30-storey mixed-use building
• 125 studio to 3-bedroom condos
• hotel with restaurant & lounge
• 1 block from BC Place Stadium
• 1 block from Vancouver Public Library
• goal of LEED Gold

Where Downtown Meets Yaletown
Canadian developer, Amacon, has proposed to redevelop the site of the Northern Electric Company Building at 118-150 Robson Street into a mixed-use building containing a 120-room hotel, 4,635 sq ft of commercial space, and a residential tower with 125 condominiums. The Art Moderne façade of the heritage building will be restored and re-purposed into retail shops and a hotel, above which a new luxury residential tower will be constructed.

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Located where Downtown Vancouver transitions into the residential neighbourhoods surrounding the north shore of False Creek, you’ll have within mere steps of your front door an exceptional range of eateries, shops, professional services, and leisure activities for unparalleled convenience. Revel in the nightlife of Granville Street or cheer on the home team at a BC Lions game in BC Place. Survey the brand name boutiques along Robson Street or enjoy a fine dining experience in one of Yaletown’s eclectic restaurants. Living more is driving less.

Pricing for 118-150 Robson
As this project is in the development application stage, pricing has not yet been finalized. To ensure you are kept up-to-date on this excellent purchase opportunity, we strongly recommend signing up to our VIP list above.

Floor Plans for 118-150 Robson
Current plans envision 125 residential suites, ranging from studios to 3-bedrooms, making this property suitable for families.

Amenities at 118-150 Robson
Residents will enjoy shared use of a fifth floor indoor amenity room and an outdoor area to enjoy fine summer days with family and friends. Have out-of-town guests visiting? What’s more convenient than staying at the attached 120-room hotel and have use of its amenities? So many more conveniences are located just outside your door.

Parking and Storage
Approximately 280 underground parking and 250 bicycle stalls have been proposed for residents, hotel guests, and retail customers. Of these, 56 will be electric vehicle charging stations.

Maintenance Fees at 118-150 Robson
Will be included with release of pricing information.

Developer Team for 118-150 Robson
Amacon, developer of prestigious properties such as Modern on Burrard Street, has partnered with GBL Architects to redevelop the former Downtown Vancouver Catholic Archdiocese property. For over four decades, Amacon has been one of the most influential real estate development and construction firms in Canada. With a spectacular portfolio of landmark developments in Vancouver and Toronto, Amacon has established a highly-regarded reputation for setting the standard in the development industry.

Amacon is driven by passion to design with architectural innovation; a commitment to constructing uncompromising standards of quality and superior craftsmanship; and offering responsive customer care and proven satisfaction. These are the building blocks that define Amacon’s signature developments and new communities.

GBL Architects is a comprehensive, energetic, and diverse firm of architects providing a full range of architectural services to the private and public sectors. The firm has built its reputation on high quality design, tight project management, technical proficiency, financial responsibility, and keen administrative skills.

Each project design is based upon our knowledge of traditional and innovative construction techniques, materials and methods, and our familiarity with the appropriate local codes and approval processes. The considerable number of projects successfully realized by GBL have helped to shape the form and development of communities and neighbourhoods throughout British Columbia.

Expected Completion for 118-150 Robson
TBA.

Are you interested in learning more about other homes in Yaletown, Southeast False Creek, or Chinatown?

Check out these great Yaletown Presales!

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What the 21st Century Cures Act means for behavioral health

The 21^st Century Cures Act represents a significant set of initiatives aimed at improving the care of people with mental and substance use disorders. It builds on important innovations introduced in the Mental Health Parity and Addictions Equity Act and the Affordable Care Act. It at once addresses vexing problems that demand immediate attention, efforts to fully implement existing policies and programs, makes new investments in longer-term outcomes, and takes on the challenging interactions of people with mental and substance use disorders with the public safety system.

The Act calls for new spending of $1 billion in grants to states to support efforts to prevent and treat the consequences of opioid misuse and abuse. The grants are tied to states and the mechanisms used to distribute substance abuse prevention and treatment block grant funds. The Act is not very prescriptive and relies on direction from the Department of Health and Human Services. President Obama’s 2017 budget requested slightly more than $1 billion to be directed primarily at efforts to close the treatment gap. Other immediate responses to behavioral health challenges in the Act include new spending for suicide prevention ($30 million), expanding crisis response capabilities ($12.5 million), and identification and treatment of maternal depression ($5 million).

The Act reauthorizes the Substance Abuse and Mental Health Services Administration (SAMHSA) and puts great emphasis on evidence-based programs and evaluation. It also gives special attention to the implementation of the Mental Health and Addictions Equity Act. It builds on recommendations from a recent Presidential task force and emphasizes requirements for insurers to disclose the processes and evidence they use to manage care, enforcement activities, and to make information and the remedy process more consumer-friendly.

Longer-term investments are reflected in a new $20 million program focused on mental health promotion, prevention of illness, and treatment for infants and the early childhood period. Other farsighted efforts include a new National Mental Health and Substance Use Policy Laboratory funded at the $14 million level. The laboratory is to focus on evaluating promising early-stage, evidence-based practices and services delivery models for scaling. Finally, the Act begins to address national and localized workforce shortages through support of training programs aimed at underserved areas and populations.

The Act reauthorizes and adjusts the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA) at $50 million per year. Through this mechanism, the Act pays to expand successful programs that divert people with mental and substance use disorders toward alternatives to incarceration. There are also new resources to support community re-entry for people with mental and substance use disorder leaving jails and prisons. Finally, new resources will be available for training police officers in effective responses to people with mental illness.

Together this package of initiatives caps a decade that has made some of the largest changes in mental health and substance use disorder policies in American history.

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Using Public-Private Partnerships to Bring Interoperability to Individuals

Dr. Vindell Washington, National Coordinator for Health Information Technology, Aisha Hasan, Senior Advisor to the National Coordinator for Health Information Technology, and Tricia Lee Wilkins, Pharmacy Advisor and Health IT Specialist Over the past 8 years, the Office of the National Coordinator for Health Information Technology (ONC) – in collaboration with our federal partners and […]

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Understanding head injuries

Ski season is here, and I am reminded of the story of Natasha Richardson (Liam Neeson’s wife), who tragically died of a head injury while skiing without a helmet in 2007. Here in the emergency department, we see many patients with concern for head injuries. We factor what may have caused the injury, your age, what we find when we examine you, the timing of the incident, the medicines you take, as well as some other factors, when deciding whether to do a CT scan or admit you to the hospital.

When a head injury causes bleeding in the brain

Ms. Richardson died of an epidural hematoma, one of several types of brain bleeding, but arguably one of the most severe.

Bleeding inside the skull can occur in several different areas. The brain is covered by three layers of tissue called the meninges. If bleeding occurs between the skull and the outermost brain tissue layer (the dura), it is called an epidural hematoma. These usually occur from high-pressure bleeding from an artery and can rapidly expand, putting pressure on the brain tissue and leading to death within hours. These types of bleeds are almost always treated surgically. Epidural hematomas usually result from high impact mechanisms, and trauma to the sides of the head, near where the larger arteries lie.

Bleeding underneath the dural layer of tissue, outside the brain tissue, is usually from a subdural bleed. This is generally a low-pressure bleed from a vein. When found, they may be monitored or treated surgically, depending on the size of the bleed as well as many other factors. This type of bleeding is more common after age 60, as the veins in the brain become slightly more taut due to natural shrinking of the brain tissue. These tight “bridging veins” are more easily sheared with a fairly low impact.

Bleeding inside the brain can be divided into subarachnoid or intraparenchymal, depending on the exact location. These bleeds, when caused by trauma, are generally treated without surgery unless they are very large.

Blood thinners such as Coumadin, Xarelto, Eliquis, Lovenox, or even Plavix put you at higher risk for dangerous bleeding after an injury. There are reversal agents for some of these medicines, but not all.

One thing to note is that while all of these types of bleeding can be seen on CT scanning, occasionally very small bleeds can be missed. Additionally, sometimes bleeding occurs several hours to days after the initial injury (delayed bleeding). Routine admission is not recommended, but if symptoms are suddenly worsening after being discharged from a hospital, please return to the emergency department for a repeat evaluation.

Concussions

Many people are worried about concussions, in part because there has been much press about them in football players and children. I see many people come into the ED, requesting a CT scan to see if they have a concussion. Unfortunately, we can’t see a concussion on a CT scan. A concussion is defined by a constellation of symptoms, generally: headache, dizziness, nausea, difficulty focusing, light sensitivity, and problems with balance and coordination. Symptoms usually last a few days, but can sometimes last weeks or even months. The most important factor that we know of right now to prevent long term problems, is to rest your brain after a concussion, to allow it to heal, and to avoid another injury on an already bruised brain. It’s okay to sleep, and frequent awakenings are no longer routinely recommended.

If you unfortunately need to be seen in an emergency department after an accident, know that we have guidelines (such as the Canadian CT head rule) that help us determine who needs CT scanning. We factor the risks of radiation against the likelihood of an injury, and so please do not take personally when we decide that you do or do not need to have an imaging test.

Please wear a helmet when you’re out on those slopes. Stay safe!

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Building The Value-Based Health Care System Of The Future Depends On Meeting Clinicians’ Data Needs

Data is the lifeblood of the value-based payment environment. Every time a doctor takes care of a patient, we have an opportunity to use information in ways that help patients get better care. The goal is to use the information from each patient encounter to make the next encounter better – across the entire healthcare […]

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