In this large trial of patients with end stage kidney disease, patients were randomized to initiation of dialysis at a GFR of 10-14 or GFR of 5-7. Mean time to dialysis initiation was 1.8 months versus 7.4 months, but there was no difference between the groups (after a median of 3.6 years) in death or adverse events (including complications of dialysis). Dialysis initiation can be delayed until the development of symptoms (abstract)

In this retrospective cohort of almost 500 patients who died in the hospital, researchers found over half of them were admitted with an end-stage disease, and 15% died during CPR. In assessing 16 quality indicators to assess the quality of the dying experience, they found almost 1/3 of patients did not receive recommended care for applicable indicators. This quality assessment can identify areas of needed improvement for palliative symptom management in patient dying in the hospital setting (abstract)

Facts matter. Here is an example.

Based on comments by some, you would have thought that individual and small business insurance rates have gone up because of payments to hospitals and doctors or because insurers were somehow trying to take advantage of this group. It turns out that a well-intended provision in the Massachusetts universal access law created a moral hazard, a “situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly.”

Kay Lazar reports in today’s Boston Globe:

The number of people who appear to be gaming the state’s health insurance system by purchasing coverage only when they are sick quadrupled from 2006 to 2008, according to a long-awaited report released yesterday from the Massachusetts Division of Insurance.

The result is that insured residents of Massachusetts wind up paying more for health care, according to the report.

… [T]he gaming in the system . . . is adding as much as $300 million dollars to the health care system in Massachusetts’’ each year, said Tara Murray, spokeswoman for Blue Cross Blue Shield of Massachusetts, the state’s largest insurer.

I received this email on Sunday night. Perhaps it is just me, but it feels weird to get a solicitation like this, as though this were just a house or condominium building for sale. Note the postscript, too. Are hospitals now commodities?

Sr. Vice President
[company name]

PS: Are you curious about what hospitals are worth in today’s market?

Call me at [number]

Study shows young couples less likely to abuse drugs and alcohol than single peers.

When reminiscing about our first relationships, many of us tend to romanticize the past: stolen glances, first dates, first kisses and so on. Now, new research shows that young love may account for more than sweet memories; it may make young adults less likely to abuse drugs or alcohol.

According to a study recently published in the Journal of Health and Social Behavior, which followed close to 1,000 people from grade school through young adulthood, people in their late teens and early 20s in committed relationships are almost 40 percent less likely to abuse drugs and alcohol than their single or multi-dating peers.

Joanne Cox, MD, medical director of Children’s Hospital Boston’s Young Parents Program, says the data aren’t surprising based on the typical behavior of kids fresh out of high school. “At that age, single people are more likely to be in groups and out partying, where as if they were in a relationship, they may spend more time with a partner,” she says. “Even when couples are in group scenarios where they might be using drugs or alcohol, they usually have another person looking out for them, which can decrease their risk-taking behaviors.”

The researchers took into account many other factors that have traditionally affected drug and alcohol abuse, like gender and employment status, but age seemed to play the biggest role when linking a young person’s drug and alcohol use with their dating history. Yet Cox is quick to point out that every teenager is different.

Joanne Cox, MD

“Kids not yet dating may be more likely to be studying or focusing on sports and other goals for the future,” she says, noting that teens who date seriously in high school are more likely to go to parties or social events where underage drinking occurs than their single peers. “It’s something for parents to be aware of, but the underpinnings of these findings have a lot to do with the individual and where he or she is developmentally and socially.”

Just because Cox wasn’t surprised by the study’s results doesn’t mean she thinks the data is unimportant. She says parents should use any opportunity they can to talk with their kids about how their current behavior could affect their future; if this information resonates within a household, parents should use it strike up a conversation.

Study shows young couples less likely to abuse drugs and alcohol than single peers.

When reminiscing about our first relationships, many of us tend to romanticize the past: stolen glances, first dates, first kisses and so on. Now, new research shows that young love may account for more than sweet memories; it may make young adults less likely to abuse drugs or alcohol.

According to a study recently published in the Journal of Health and Social Behavior, which followed close to 1,000 people from grade school through young adulthood, people in their late teens and early 20s in committed relationships are almost 40 percent less likely to abuse drugs and alcohol than their single or multi-dating peers.

Joanne Cox, MD, medical director of Children’s Hospital Boston’s Young Parents Program, says the data aren’t surprising based on the typical behavior of kids fresh out of high school. “At that age, single people are more likely to be in groups and out partying, where as if they were in a relationship, they may spend more time with a partner,” she says. “Even when couples are in group scenarios where they might be using drugs or alcohol, they usually have another person looking out for them, which can decrease their risk-taking behaviors.”

The researchers took into account many other factors that have traditionally affected drug and alcohol abuse, like gender and employment status, but age seemed to play the biggest role when linking a young person’s drug and alcohol use with their dating history. Yet Cox is quick to point out that every teenager is different.

Joanne Cox, MD

“Kids not yet dating may be more likely to be studying or focusing on sports and other goals for the future,” she says, noting that teens who date seriously in high school are more likely to go to parties or social events where underage drinking occurs than their single peers. “It’s something for parents to be aware of, but the underpinnings of these findings have a lot to do with the individual and where he or she is developmentally and socially.”

Just because Cox wasn’t surprised by the study’s results doesn’t mean she thinks the data is unimportant. She says parents should use any opportunity they can to talk with their kids about how their current behavior could affect their future; if this information resonates within a household, parents should use it strike up a conversation.

In 1989, I took a job with Children’s Hospital of Wisconsin as a nursing instructor for the recently opened Intermediate Intensive Care Unit. In the intervening years, I have been a staff nurse and educator. I’ve served on shared governance committees, participated in research and quality improvement initiatives and served on professional boards. Currently, I am a clinical educator at Children’s Hospital. My work has given me the privilege to travel to developing countries to provide much needed medical care.

I have traveled on 10 medical mission trips in the past 25 years. I have been to the state of Chiapas, Mexico, the Dominican Republic and Costa Rica.  Seven of these trips were to Haiti. I spent time in small villages and in the famous slum, Cite Soleil, in the capital city, Port-au-Prince. It took a catastrophic earthquake earlier this year to reveal to the rest of the world what I learned years ago – the needs of Haiti are enormous, and the people of Haiti are beautiful, kind, gracious and deserving.

Mission work can be complicated at times, but through the leadership of organizations like Vision Health International and the Episcopal Diocese of Quincy, Ill., I have worked in a dental clinic, a medical clinic and as a post-anesthesia recovery unit nurse. The logistics can be daunting – scheduling physicians, nurses and anesthesiologists to work in concert with health care providers present in such impoverished countries. Supplies we take for granted – IV pumps, monitors, etc. – can be ancient or simply nonexistent. Still, one of the most enjoyable parts is the opportunity to be both independent and creative in making do with what is available. Last year in Mexico, I had to administer intravenous medicine to a young girl. No online dosage handbook, no pump and high stakes (as her vision was threatened), but I was so happy that we had the medication at all.

In the Dominican Republic, I cared for a boy who had bilateral cataracts; we operated on both eyes a couple of days apart. After the second surgery he sat up very straight and he smiled. Actually, we all sat up straighter and smiled, too.

There are barriers of language compounded by wide spread illiteracy, lack of medical supplies and medications, and minimal education. For instance, I learned that handing out a one-page sheet on how to recognize and treat diarrhea would be pointless since so many could not read. Instead, I watched in awe as an American public health nurse taught a large group of Haitian villagers the recipe for homemade rehydration solution. Another time, I was trying to comfort a young Haitian boy in his native language of Kreyol (Kreyol is a language with close ties to the Creole spoken in Louisiana). I struggled to find the right words in his language. There will always be barriers, but I do not let that stop me. As I said, these are beautiful people whose lives are just as important as yours or mine.

I am only one of so many who help and volunteer their time. Over the years, I have met and have worked side by side with Haitian seminarians, villagers, missionaries, nuns and a host of Americans who make up the global giving community I have come to know and love. All of us know the real truth: that we are the ones who benefit most. Our lives of privilege are changed forever. And while the needs are always great, I don’t intend to give up. I look at it this way – if everybody else does a little bit, then I can go and feel like I have helped.

I was not in Haiti at the time of the earthquake but hope to return early next year.  I cannot give up despite the newest set of obstacles. My heart tells me that this is where I need to be. I will be forever grateful to Haiti for teaching me about myself as a person and as a nurse.

-Jan Holzauer, RN

The Congressional health care reform boondoggle, otherwise known as the “Patient Protection and Affordable Care Act” expanded government funded health care to about 32 million Americans but other than some tepid insurance restrictions, basically screwed the rest of us. How is the new reform law doing at 90 days? Why, mired in bureaucratic red tape, of course.

The process for making rules is long and rigorous, and new rules often have to go through multiple agencies and departments. It will also take many more people with specific expertise to carry out the various parts of the law, and hiring in itself can be a slow process in the federal government.

“The average rule takes 18 months, which means that there are many of those that take two or three years to do, because they have controversy or they require integration with some other rulemaking process. So this is a tsunami of rulemaking that has tipped the Department of Health and Human Services,” said Michael Leavitt, HHS secretary under former President George W. Bush.

I like to think of the new health reform law – which, if anything, is more of an insurance reform law – as being similar to the creation of the Department of Homeland Security. Both laws are attempts to address and correct significant institutional problems with massive amounts of money and additional layers of government bureaucracy. Both are more accurately thought of as massive spending bills that take advantage of a “crisis” to funnel billions towards specific private sector industries while the benefit to the greater population is dubious and difficult to verify.

Let me put this another way.

If the Federal government were a small town council then their response to a crime spree would be to spend tens of millions of tax payer funds to purchase an M1 Abrams tank and parade it in front of city hall. This after salesmen from General Dynamics spent millions of dollars taking various city council members on exotic vacations and to fancy dinners and conferences where they were given presentations on the crime fighting and deterrent effects of the M1.  Town citizens who haven’t been a victim of crime since the tank arrived are more than happy to give credit to the high spending council.

Americans generally support massive spending bills – like a big, expensive tank that sits in front of city hall – because the perception is that anything that is expensive must work. The economic reality is that everything else being unchanged, the prices for goods and services in a system will invariably increase in response to any massive infusion of cash. This is already beginning to happen to health insurance premiums and the funding hasn’t even started.

The political reality is that most Americans wanted secure affordable health insurance – hence, the name of the new law.

The reality is that most Americans are not going to get it.

By ROB LAMBERTS, MD The post that forever doomed the world to have my writing forced onto them was one called Shame, in which I describe my frustration with how society stigmatizes people who are obese. It was picked up…

A procalcitonin assay has recently been approved for use in the United States. Unfortunately many hospitals do not run the assay in house. The principles behind procalcitonin and the current state of use are covered in a recent review in LabMedicine (reproduced in full text at Medscape).

PCT seems to be useful as an adjunct to guide antimicrobial treatment. Questions remain as to its value in diagnosing or excluding infection.

Contrary to popular belief LBBB does not mask the changes. Brief report and illustrative tracings here.

Dixie Coskie is the mother of a child who lived through both a traumatic brain injury and cancer. In this blog post, Dixie writes about the stress that comes from being the primary caregiver of a sick child and the importance of taking care of yourself. Click here to read more of Dixie’s writing, including excerpts from her book, Unthinkable! A Caregiver’s Companion.

Dixie and her son, Paul

No one is immune to getting that phone call—the one that tells you something bad has happened to your family. Be it a diagnosis of a life-threatening disease or an involvement in a horrific accident, you never expect it to happen to someone you love. When it does, most of us are totally unprepared for the constant caregiving that follows and how it can impact your life emotionally, spiritually and physically.

I received such a call in 2001 when my 13-year-old son was involved in a bike accident without a helmet. Among many other severe injuries, he incurred traumatic brain injury. Not expected to live, Paul was given last rites. Doctors warned me that if he did survive, his quality of life would be questionable. Finally, Paul woke from a two-month coma. He couldn’t walk, talk or perform the simplest of tasks.

Suddenly, in addition to taking care of the needs of my other seven children, with ages ranging from 6 to 16, I needed to learn medical techniques used in caring for a severely handicapped child. My husband and I worked as a nonstop team, one of us caring for the rest of the household while the other took care of Paul at a rehab hospital an hour from our home. In the shuffle, there was no time for us to take care of our own needs. The caregiving was isolating, demanding and never-ending.

A year after the crash, my son healed enough to be able to return to school in a wheelchair. They were my first moments of reprieve. My mind and body now had time to register what we’d been living through—all the fear, exhaustion and stress—and I collapsed under the strain. The pain shooting through my body was excruciating. My husband and children once again faced the dread of medical uncertainty. I saw a neurologist and endured numerous invasive tests to identify the mystery pain, but results were inconclusive. Possibly I had multiple sclerosis, or bone spurs in my neck or fibromyalgia. I saw a rheumatologist to check for Lyme disease, arthritis and lupus. I was put on a high dose of pain medications, which left me groggy and dizzy. I was desperate to get better and get back to caring for Paul and the rest of my family.

Paul took guitar lessons while receiving treatment at Children's

A specialist in Boston finally diagnosed my condition: post-traumatic stress syndrome and something called thoracic outlet syndrome. My doctor recommended counseling because she thought I may have been experiencing caregiver burnout. She also recommended physical therapy to help decompress the muscle tension around my shoulders and upper arms, which had become incredibly tight because of all the stress.

After four years of speech, occupational and physical therapy, Paul was walking, talking and taking steps once thought impossible. But then during his junior year of high school, a new and unrelated medical problem surfaced; Paul was diagnosed with leukemia. I knew another enormous fight was in front of us, with lots of procedures and hospital stays.

Paul was scared but bravely prepared himself for another round of long hospital stays and doctor visits. Fortunately for us his primary oncologist at Children’s Hospital Boston, Jennifer Whangbo, MD, PhD, was great and remains a driving force in his recovery. She is not only compassionate, but a very real, knowledgeable and dedicated professional who cares deeply about her patients. She helped Paul and our family in more ways than she knows.

Because of our first catastrophic medical experience I knew this time I needed to take care of myself in order to be able to take care of Paul and my family. I sought out positive people for support. I took breaks from the hospital to exercise, meditate or just have a moment to myself. I realized that asking for help was not a weakness, and when friends asked what they could do, I gave them a list of chores like shopping, carpooling and meal preparation. I rid myself of guilt and acknowledged my strengths. I educated myself on the diagnoses and worked to improve the line of communication with family and friends.

Dr. Whangbo, shown center, has been a driving force in Paul's recovery.

Those of us who have had a brush with death, catastrophic injury or illness realize more deeply how fleeting life is. Tell others how much you love them, and tell them often. Try to never take anyone for granted. Choose to react to your situation with a sense of faith, hope, patience, humor, passion and a lot of love. Be realistic about what you can and cannot do and take care of yourself along the way.

Epilepsy is a disease that remains stubbornly bewildering—to the nearly three million Americans who have it and the doctors who treat it. In some cases, it can be traced to an underlying disease, injury or brain malformation. But in most cases, its origins are a mystery. Last night, 60 Minutes re-aired an episode featuring the epilepsy research of Children’s Frances Jensen, MD. Make sure to check out this blog post by Jensen, where she explains the importance of funding epilepsy research. Jensen was also just appointed president of the American Epilepsy Society.

Watch CBS News Videos Online

I have written before about the strange things going on in the Massachusetts health care insurance market. For those from out of state, here are some quotes that will give you a sense of the contradictions in the public policy arena.

They are, respectively, from two stories that appeared on the same day in the Boston Globe: “Rate cap for insurer overturned” and “Officials give up cutting health perks.”

(1) An insurance appeals board yesterday overturned the state’s cap on health premium increases for small business and individual customers covered by Harvard Pilgrim Health Care . . . [finding] that rate increases Harvard Pilgrim initially sought in April are reasonable given what it must pay to hospitals and doctors. That ruling trumped the Insurance Division’s earlier finding that the requested increases were excessive.

(2) The state’s public employee unions won a major victory this week when the Legislature abandoned efforts to allow cities and towns to trim generous health care benefits enjoyed by thousands of municipal employees, retirees, and elected officials.

You can read the rest and related stories, but what is most disturbing is that the spirit of cooperation and compromise that existed when Massachusetts approved its health care reform law in 2006 has broken down. Part of the reason is that commitments made at that time have not be delivered upon. For example, the state had promised to lift Medicaid payment rates to something closer to the cost of delivering that service. Once the economy sank and state budgets were stressed, that was not possible. This left providers needing to collect more of their income from private insurers.

Meanwhile, the underlying determinants of health care cost increases continued apace — wages and salaries of health care workers, supplies and equipment, drug prices, increased utilization, the medical arms race, and unhealthy life styles. Certain providers received disproportionate payment increases based on their market power and used those excess revenues to gain market share. Collectively, the industry did little to reduce harm and improve quality and garner the cost savings that would be possible from that. Access to primary care did not improve, forcing patients to go to emergency rooms. Those primary care practices that do exist often functioned as triage way stations for patients to go see higher priced specialists. For those who thought payment reform (i.e., capitation) was the answer, little progress was made, in part because insurers have yet to see a market for the restricted networks (i.e., reduced consumer choice) that would facilitate that kind of pricing regime.

So, now we are in a situation in which everyone is blaming everyone for the problem. Truthfully, everyone is the problem, and so this is an accurate representation, but it is not a helpful approach. Deadlock is the result.

At times like this, people often look for a global solution to sort things out. That is a mistake. There is not a politically possible global solution. There are too many legitimate vested interests to pass a bill or adopt a regulation that shifts hundreds of millions of dollars of costs from one group to another. As seen in the two stories above, it will either be legally unacceptable or politically infeasible.

Instead, it is a time for incremental changes that are directionally appropriate. There are things that can garner majority support that will move the system towards a more sustainable level.

But to agree on those, the rhetoric needs to be toned down, both within the field and from the government. The demonization of any particular sector destroys the kind of trust that enables people of good will to invent solutions that create value for all.

I have written before about the strange things going on in the Massachusetts health care insurance market. For those from out of state, here are some quotes that will give you a sense of the contradictions in the public policy arena.

They are, respectively, from two stories that appeared on the same day in the Boston Globe: “Rate cap for insurer overturned” and “Officials give up cutting health perks.”

(1) An insurance appeals board yesterday overturned the state’s cap on health premium increases for small business and individual customers covered by Harvard Pilgrim Health Care . . . [finding] that rate increases Harvard Pilgrim initially sought in April are reasonable given what it must pay to hospitals and doctors. That ruling trumped the Insurance Division’s earlier finding that the requested increases were excessive.

(2) The state’s public employee unions won a major victory this week when the Legislature abandoned efforts to allow cities and towns to trim generous health care benefits enjoyed by thousands of municipal employees, retirees, and elected officials.

You can read the rest and related stories, but what is most disturbing is that the spirit of cooperation and compromise that existed when Massachusetts approved its health care reform law in 2006 has broken down. Part of the reason is that commitments made at that time have not be delivered upon. For example, the state had promised to lift Medicaid payment rates to something closer to the cost of delivering that service. Once the economy sank and state budgets were stressed, that was not possible. This left providers needing to collect more of their income from private insurers.

Meanwhile, the underlying determinants of health care cost increases continued apace — wages and salaries of health care workers, supplies and equipment, drug prices, increased utilization, the medical arms race, and unhealthy life styles. Certain providers received disproportionate payment increases based on their market power and used those excess revenues to gain market share. Collectively, the industry did little to reduce harm and improve quality and garner the cost savings that would be possible from that. Access to primary care did not improve, forcing patients to go to emergency rooms. Those primary care practices that do exist often functioned as triage way stations for patients to go see higher priced specialists. For those who thought payment reform (i.e., capitation) was the answer, little progress was made, in part because insurers have yet to see a market for the restricted networks (i.e., reduced consumer choice) that would facilitate that kind of pricing regime.

So, now we are in a situation in which everyone is blaming everyone for the problem. Truthfully, everyone is the problem, and so this is an accurate representation, but it is not a helpful approach. Deadlock is the result.

At times like this, people often look for a global solution to sort things out. That is a mistake. There is not a politically possible global solution. There are too many legitimate vested interests to pass a bill or adopt a regulation that shifts hundreds of millions of dollars of costs from one group to another. As seen in the two stories above, it will either be legally unacceptable or politically infeasible.

Instead, it is a time for incremental changes that are directionally appropriate. There are things that can garner majority support that will move the system towards a more sustainable level.

But to agree on those, the rhetoric needs to be toned down, both within the field and from the government. The demonization of any particular sector destroys the kind of trust that enables people of good will to invent solutions that create value for all.

I just finished riding in the Tour de Shuls, a cleverly named bike ride that benefits a special program to meet the social and religious needs of developmentally challenged Jewish adolescents who attend Camp Ramah. As noted on the web site:

The Tikvah (“hope”) Program provides these youth with the full Ramah experience – swimming, boating, sports, the arts, dance, dramatics, and more – under the supervision of specially trained staff.

The ride comprises several legs connecting synagogues in the Boston suburbs. It goes through some beautiful areas, and you receive friendly welcomes and refreshments at each host site. The only reported problem — and I don’t mean this in any stereotypical way! — is that some people complain there is too much food and that they therefore gain weight from their 10-, 25-, 50-, or 75-mile ride . . .

Donations are still welcome, here.

I just finished riding in the Tour de Shuls, a cleverly named bike ride that benefits a special program to meet the social and religious needs of developmentally challenged Jewish adolescents who attend Camp Ramah. As noted on the web site:

The Tikvah (“hope”) Program provides these youth with the full Ramah experience – swimming, boating, sports, the arts, dance, dramatics, and more – under the supervision of specially trained staff.

The ride comprises several legs connecting synagogues in the Boston suburbs. It goes through some beautiful areas, and you receive friendly welcomes and refreshments at each host site. The only reported problem — and I don’t mean this in any stereotypical way! — is that some people complain there is too much food and that they therefore gain weight from their 10-, 25-, 50-, or 75-mile ride . . .

Donations are still welcome, here.

By Matthew Holt I don’t often write about Footy any more on THCB, but England is out of the World Cup today, stuffed 4–1 by Germany. So I thought I’d give my opinion, and for the moment I’m dropping my…

By JOHN GOODMAN The International Monetary Fund is warning that the U.S. national debt will exceed 100% of GDP within the next five years, and economists both here and abroad are expressing alarm. The debt problem is mainly an entitlements…

This week on Thrive:

Is Lady Gaga too much for kids? Michael Rich, MD, MPH, is Children’s media expert. This week he talks about music videos’ influence on kids, specifically Lady Gaga. With catchy choruses and an infectious sound, her music is widely popular, even with younger children, but the thinly-veiled sexuality in her lyrics and videos has some parents concerned.

Working parents, please join the discussion! Claire McCarthy, MD, wrote a Thrive post defending working mothers, in response to a study from the UK linking busy schedules to increased rates of childhood obesity. The post generated a lot of discussion and several readers chimed in with some great advice for raising healthy kids while working full-time. What do you think? Here’s one reader’s reaction:

“Thanks Claire for your well-thought out, well-articulated comments. As a FT working Mom, I agree that there are so many factors that can contribute to our children’s health (or lack of). It’s easier to take one correlation and create a scapegoat rather than take a look at all of the contributors. The societal contributions, especially, often seem too daunting or even impossible to change, so we focus on the scapegoats. We all need to take the appropriate amount of responsibility (no more for those already swimming in Mommy guilt and no less for government officials who don’t provide enough funding for all schools to have healthy options and plenty of exercise) and each do our part.” -Michele

Boston Med, the ABC News documentary series about life in three Boston hospitals, aired this week. In a Thrive video exclusive, James Mandell, MD, chief executive officer at Children’s Hospital Boston, introduces some of the Children’s families that will be featured in the series and shares his hope that by allowing cameras inside the hospital, the public will gain a clearer understanding of the inner workings of life at Children’s.

Harvard research shows soda tax might work. Read the Thrive interview with one of the researchers involved in the study. Not everyone is buying into the idea of a soda tax though; check out what some readers said:

“Too much tv time is harmful too. Why don’t you tax TVs and computers 35% too??? Where do you draw the line? Maybe if we taxed cars another 35% – people would walk more. Since the issue seems to be price discrepancy how about discounting the price of the “good for you” stuff rather than adding a tax to the “bad”. After all – not adding sugar should make the product cheaper to make! Nice bicycles shouldn’t cost more than a used car.” Anonymous

“Typical progressive idea…control everyone’s behavior and choices by taxing them to death. Give people information, and let them choose for themselves.”-Taxman

Kids with elevated blood pressure are okay to play sports, but need to monitor their condition closely and adjust workout levels accordingly. At least that’s the stance taken by the AAP, here’s what our expert says on the topic.

Children’s doctor Ofer Levy, MD, PhD, in the Division of Infectious Diseases, is working on new ways to vaccinated babies, which will protect them from disease very early in life. He’s received a $2.4 million grant from the Bill & Melinda Gates Foundation to help in his work. It’s a controversial topic. Here’s what a few of our readers are saying:

“Enhance or overstimulate the immune system? Isn’t this what’s already done with adjunctives? Will this not inspire autoimmunity?” -Autoimmunity in Oregon

“Most people expressing their negative opinions on vaccines at birth wouldn’t be there if vaccines were not invented. We should stop criticizing without acknowledging that “chemicals” as someone called it, made out lifestyle possible. If you were the parents of a newborn dying from pertussis, then I guess your viewpoint would be different. Vaccines are the single most advance in medicine after clean water.” -Highfly

Whooping cough cases approach epidemic levels in California. Health officials say five infants have died from whooping cough in California recently, which is at epidemic levels as the number of cases of the disease has quadrupled since last year.

Is your child getting enough vitamin D? If not it could make his asthma worse. New study shows kids with lower vitamin D levels in their blood are more likely to suffer severe asthma attacks.

Are schools really trying to ban best friends? Some schools are discouraging “cliques” and “exclusive friendships” over fear of bullying.

Milk banks for non-lactating moms are becoming popular as more studies point to the benefits of breast milk. But these are expensive and not available in all areas so some moms are forming and joining donor clubs, where breast milk is donated by lactating women with breast milk to spare moms. While this may be a nice gesture, some doctors are concerned about how trading unregulated breast milk could have negative effects on some kids.

In this prospective cohort 1005 patients scheduled for elective vascular surgery, all had an echo performed. Of all the patients, 21% had asymptomatic diastolic dysfunction, and 19% had asymptomatic systolic dysfunction. After multivariate adjustment, LV dysfunction independently predicted risk of 30 day cardiovascular events (OR 2.3 and 1.8 for systolic and diastolic dysfunction, respectively) and long term cardiovascular mortality (HR 4.6 and 3.0 for systolic and diastolic dysfunction, respectively) in patients undergoing open vascular surgery. Although the authors recommend routine pre-operative echo for patients undergoing vascular surgery, as of now it is unclear what interventions would be performed to reduce the risk of events (abstract)

Beta blockers have long thought to be contraindicated in patients with cocaine-associated chest pain. In this retrospective single center analysis of 331 patients with chest pain and cocaine-positive drug screens, almost half received a beta blocker. There was no significant differences in EKG changes or troponin levels between those that did and did not receive a beta blocker, but those discharged on a beta blocker had significantly lower long term cardiovascular mortality. Use of beta blockers appears to be safe in patients with cocaine-associated chest pain, and may actually improve long term mortality (abstract)

The Washington Post recently published this article by Anne Applebaum about vuvuzelas, the loud horns that you hear in the World Cup matches.

For those who haven’t been following, the vuvuzela is a longish plastic trumpet that produces a buzzing noise, something like an overgrown penny whistle. When thousands of people blow these whistles at once, they make a very loud buzzing noise, something like a massive swarm of bees. When played in a World Cup soccer stadium, they create an irritating background hum — one that is capable of ruining the sound on a billion television sets around the world.

She then talks about the different reactions to these horns by folks from around the world. I did my own survey of fellow soccer players and parents of the girls I coach. Typical responses:

I hate that noise. It must go. It’s enough to embrace curling as a favorite sport.

I am enjoying watching the games at home with the sound turned off.

Meanwhile, there is this article by Devin Powell at Inside Science that suggests that the ball (the Jabulani) being used in the World Cup doesn’t behave right, especially at low speeds when it is not spinning. It appears that there is an unexpected knuckle ball effect.

[Tests showed] that as the ball slows, its behavior becomes more like that of a smooth sphere than previous World Cup balls. At just under 45 mph, turbulent flow becomes laminar and the ball suddenly feels heavy drag forces that put on the brakes.

[Also, the] sideways force on the Jabulani fluctuates more than the forces on the 2006 World Cup ball, which could cause it to bend in unpredictable ways and help to explain the reactions from goalkeepers.

But, before you think that those guys from France have an excuse, look at this final point:

Considering all of the other variables involved in the World Cup — from pitches at high altitudes to inconsistent player performances — it’s unclear whether these differences in the ball in this are extreme enough to affect the final scores.