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Sheet: JAMA

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[NAME], MD John H [NAME], Chicago, IL, USA |  |  | I think the major problem in Mr Y's case is really not what to do but what to tell him in response to his thoughtful reasons for refusal. HIV screening should be voluntary and without coercion. The only appropriate intervention should be to have an informed discourse with him and then let him have a third chance following the "expert" opinion, after his intuition and initial thoughts. Therefore the general approach will be to try to confidently provide informed answers and let him make the final decision. If he refuses, then as his physician, I would note it in his record and plan to discourse it with him later down the road when the relationship has been more established.   The embryonal doctor-patient relations is the first issue at stake here. He would likely think "my first visit and the doctor wants to screen for HIV. What does he think of me?" He runs the risk of perceiving the Physician as judgmental and his relationship with this physician at least will be strained or terminated at worse.   Other issues at stake here include the risk of progression of an unidentified infection and spread to his sexual partner(s). Nevertheless, these issues at stake in his case do not seem to make his screening HIV an emergency. We assume the HIV prevalence in the facility is above 0.1% to warrant routine screening in the first place.   His first concern was that he believes the absence of symptoms mean no disease. Though this seems to challenge the very rationale for screening, it should easily be addressed by explanation of the different phases of HIV infection, especially the asymptomatic phase which made take up to 10 years before symptoms appear. The very fact that he has no symptoms makes him even more suited for an HIV screening test, as this is the ultimate aim of screening in the first place.(2)   He worries about screening a patient at low risk for the infection. The CDC guidelines however do not take into consideration the risk of the patient. Most importantly, recent evidence shows that many persons at risk of infection might not be aware of their risk or even perceive it(1). However, given that Mr Y is not a "research paper", the results should be presented as justification of the CDC's recommendations and not reflective of his specific case.   He also presents with some traces of worries with regards to stigma and receiving an HIV test result, even by mail where they would be no one looking at him, maybe. That is definitely the reason why screening at the healthcare setting, where everyone is screened, without need for a separate consent for testing and the proximity of resources to immediately handle a positive results, is a better option.   1. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. [NAME]. 2006;55(RR14):1-17.   2. [NAME], [NAME] and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.   Conflict of Interest: None declared |  | P |  |  | 306 | 6 | 637
[NAME],  Third Year Medical Student  Lady Hardinge Medical College, New Delhi, India,  [NAME], MBBS |  |  | For whom is HIV screening indicated?   Recommended for all patients aged 13-64 years, in all health-care settings. After notifying the patient, the test is performed unless the patient opts-out screening, in a setting with background rate of HIV>1%. Also recommended for all high-risk groups, patients with Tuberculosis, and at STD clinics; as part of routine antenatal care for all pregnant women (1).In 2007, WHO and UNAIDS issued guidelines on provider-initiated HIV testing and counseling (PITC) in health facilities (2)   What is the rationale for routine HIV screening?   Anti-retroviral therapy can be initiated in HIV patients and this will delay progression of disease. People who are infected with HIV but unaware of status will unknowingly spread the disease(3).   What are its benefits and risks?   1) HIV /AIDS can be diagnosed before symptoms develop; 2) infected patients gain years of life with early treatment; 3) costs of screening are reasonable in relation to the anticipated benefits. 4) Better control of spread of HIV. 5) More patients accept recommended HIV testing when it is offered routinely to everyone, without pejorative risk assessment.6) Screening assists health care providers to plan healthcare, screening and surgery for patients. Risks of routine screening can include stress related to potentially false positive results and social stigmatization of positive cases.   What are the testing options for HIV infection?   Besides conventional HIV enzyme immunoassay tests ([NAME] has now approved 4 Rapid HIV Antibody tests for on-spot screening -OraQuick, Reveal, Multispot and aUni-Gold Recombigen. (4). These MUST be supplemented with confirmatory tests like Western Blot, Indirect Flourescent Antibody tests or PCR (Polymerase Chain Reaction).   What are the barriers to incorporating HIV screening into routine care?   Cost of screening is a major barrier in addition to the implication of a positive screening result. Because HIV and AIDS are still stigmatized, a positive result changes the life of person.   Is informed consent necessary? How should test results be communicated?   According to current CDC guidelines, a separate written consent for HIV testing is not required; general consent for medical care should be considered sufficient to encompass consent.HIV-positive test results should be communicated confidentially through personal contact by a clinician, nurse or counselor. Family or friends should not be used as interpreters to disclose HIV-positive test results. Active efforts are essential to ensure HIV-infected patients receive their positive test results and linkage to clinical care, counseling, support services. Persons known to be at high risk for HIV infection should also be advised of the need for periodic retesting and should be offered prevention counselling.   What would you recommend for Mr. [NAME]?   Since Mr. [NAME] is visiting the physician for the first time it is the duty of the physician to offer HIV screening as part of his initial panel of investigations. The physician is not offering the test because he suspects that Mr. [NAME] is infected or at high risk, but solely because the guidelines recommend screening in his age group; and even though his behavior does not put him at risk, his past sexual history may. My Y is free to opt-out of this screening as per the CDC 2006 guidelines. The doctor can counsel the patient and allay his fear of giving an additional blood sample, but cannot force the test on the patient. In this case Mr. [NAME] does not seem too eager to undergo testing. The doctor should explain the potential benefits and public health responsibility of testing to Mr. [NAME], and repeat the request on subsequent healthcare visits. However, the final call is with Mr Y.   REFERENCES:   1) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm   2) http://www.who.int/hiv/topics/vct/about/en/index.html   3) http://www.cdc.gov/hiv/topics/testing/   4) http://www.cdc.gov/hiv/topics/testing/resources/journal_article/pdf/rapid_review.pdf   Conflict of Interest: None declared |  | P |  |  | 306 | 6 | 637
Alisdair A MacConnachie,  MBChB MRCP PhD  Consultant Physician Infection Unit, [NAME], Gartnavel General Hospital, Glasgow, Scotland.,  Niall Conroy (MBChB, MPH, BSc(Hons)Public Health Registrar,Brisbane Sexual Health and HIV Service,Brisbane,Queensland 4000,Australia); [NAME] (Specialist Registrar, Infection Unit, [NAME], Gartnavel General Hospital, Glasgow, Scotland) |  |  | 1. For whom is HIV testing indicated?   This is simple to answer from a cost-effectiveness perspective: test anyone from a population with HIV prevalence greater than 0.5/1000 ([NAME] et al NEJM 2005; 352: 570-85). But, as Mr. [NAME] would likely agree, this is not a compelling answer from an individual patient perspective. In the consulting room we know that population level analyses are hard to apply to individuals and assumptions about individual risk and behaviour are capricious. But results of cost effectiveness models of HIV testing diverge rapidly as their assumptions are modified (ibid).   Another seemingly simple answer is to test anyone who is "high-risk". But doctors and patients are poor assessors of individual risk. In HIV testing a common error is to think anachronistically about risk factors. We would argue that, in 2011, HIV might say little about an individual's sexual practices. Heterosexually acquired HIV accounted for 32% of new HIV diagnoses in the USA, and 54% in the UK, in 2008 (CDC, 2010; HPA, 2010). Further, blinded HIV seroprevalence studies have suggested that a majority of people who don't know they are HIV positive may also report no HIV risk factors ([NAME]. Am J Public Health 1991; 81: 619-22). Consequently, an increasing evidence base shows that universal, "opt-out" testing strategies can be highly successful (Rayment et al. 2011. 18th Conference on Retroviruses and Opportunistic Infections. Abstract W-156; Poster #1054).   From an individual patient point of view, there is no simple answer to the question "who should be tested for HIV?". But the decision should not rest on out-dated assessments of perceived risk, and routine screening has many advantages.   2. What is the rationale for routine screening?   HIV testing meets all of the Wilson-Jungner criteria for appraising validity of a screening program (WHO, 1968). Specifically, despite availability of highly effective treatment, HIV remains an important health problem with a significant [NAME] burden in high resource countries. The natural history is well understood with an early stage detectable by a highly sensitive and specific test.   RCT data suggests starting treatment earlier in the natural history of HIV confers a better prognosis (Severe et al. NEJM 2010; 363: 257-65). Unsurprisingly, late diagnosis is associated with increased morbidity and mortality (Sabin et al. AIDS 2004; 18: 2145-51), poorer response to treatment (Walters L et al HIV Medicine 2011; 12: 289-98), and increased health care costs (Krentz HB et al HIV Medicine, 2004; 5: 93-8).   Patients that present late are often found to have had missed opportunities for diagnosis at previous clinical presentations ([NAME] al BMJ 2005; 330: 1301-2). When routine (universal, "opt-out") screening is introduced, testing rates and rate of positive diagnoses rise, and the CD4 count at time of diagnosis increases (Haukoos et al. JAMA 2010; 304: 284-92).   3. What are the risks?   The benefits of testing this gentleman are therefore significant. But what are the risks? Clinicians often worry about inducing anxiety by testing for HIV. It should be remembered that, if treated early, HIV has near-normal life expectancy ([NAME] et [NAME]; 372: 293-9) -- a much better prognosis that most illnesses we screen for. Patients respond to an offer of a test with minimal anxiety when it is well explained and not exceptionalised (Simpson BMJ 1998; 316: 262-7).   Other implications of testing vary by geographical setting. In the UK, HIV care is free at the point of delivery, and an insurance industry moratorium precludes asking about previous testing in applications for life insurance (ABI, 1994).   4. What are the barriers to testing?   Mr. [NAME] presciently highlights the biggest barrier to HIV testing: stigma. Routine testing, which doesn't discriminate on the basis of ethnicity or lifestyle factors, is one way to potentially reduce this problem. No stigma is attached to routine antenatal HIV testing. High prevalence countries like South Africa, Uganda and Botswana have demonstrated how universal testing strategies can diminish stigma (Weiser et al PLoS 2006; 3:e261).   5. Is informed consent necessary?   Absolutely, if Mr. [NAME] does not want the test then that decision should be respected.   6. How should results be communicated?   Our experience is that a face to face appointment is preferable when giving the results of a HIV test. The patient is likely to have follow-up questions. Some would suggest that those who are low risk can be given their results by phone. However, as discussed earlier, our opinion is that this maintains the artificial distinction between subsets of the patients.   7. What would you recommend?   We would recommend HIV testing for all of the reasons above.   Conflict of Interest: None declared |  | P |  |  | 306 | 6 | 637
[NAME],  MD  [NAME], Jr. Hospital of Cook County & Ruth M. Rothstein CORE Center |  |  | Mr Y, would benefit from education on the role of disease screening in general, and screening for HIV in particular. Explaining the rationale for HIV screening may represent an effective response to a reluctant Mr. [NAME]   You could start by telling Mr. [NAME] about the 1968 World Health Organization white paper entitled 'Principles and Practices of Screening for Disease' that outlined justifications for disease screening, [NAME]):   1) The disease represents a serious health disorder that can be detected before symptoms develop. 2) Treatment is more beneficial when begun before symptoms develop. 3) Reliable, inexpensive, acceptable screening tests are available. 4) The costs of screening are reasonable in relation to anticipated benefits. 5) Treatment for the disease must be accessible.   HIV satisfies each of these criteria.   Highlighting reasons for HIV screening presented in the CDC's 2006 HIV testing guidelines could help inform Mr. [NAME]'s decision (2). Recent data estimate that approximately 50,000 people become infected annually in the US (3). Further, one in five remain unaware of their HIV infection (3). While identifying HIV early decreases mortality, employing risk- based HIV testing often diagnoses patients late. South Carolina HIV surveillance data showed that of the state's 4000 plus cases diagnosed between 2001 - 2005, 41% proceeded to AIDS within one year of diagnosis. Most late testers had multiple prior healthcare visits during which HIV testing had not been offered (4).   Importantly, we have real world data showing that HIV screening can work. In the US, screening pregnant women for HIV has drastically reduced the incidence of pediatric HIV (5). In addition, multiple modeling studies have documented the cost-effectiveness of HIV screening (6).   Emphasizing the great strides made in HIV treatment could also erode Mr Y's ambivalence. The HIV Outpatient Study demonstrated a dramatic decline in HIV mortality coincident with the inception of combination anti -retroviral therapy (7). [NAME] et [NAME]. estimated that anti-retroviral therapy has saved two million person-years in the US alone (8). Treatment is so good now that life-expectancy for someone started early on HIV treatment approximates that of a HIV uninfected person (9).   Despite these justifications, I suspect Mr. [NAME] just does not perceive his own risk. Mr. [NAME] reports 10 lifetime sexual partners. How many partners has each of those 10 people had? Have any of his partners' partners had HIV, used intravenous drugs or traded sex for drugs? The instinctual nature of our sexuality often clouds our self-assessment of risk.   While self-assessment has intrinsic shortcomings, the sexual histories volunteered to physicians are likely more deficient. One study comparing sexual histories obtained by audio computer assisted self- interview (ACASI) vs. clinicians found significant discrepancies. People more often reported oral sex, transactional sex, same sex behavior and sex with amphetamine use to ACASI vs. clinicians (10).   The inherent limitations of both physicians' and patients' risk assessments underscore the need to de-stigmatize HIV disease and its screening. By telling Mr. [NAME] that HIV screening is equally justified as screening for high cholesterol, we start to take down the roadblock of stigma, allowing our patients access to a clear path toward better health.   References:   1. [NAME] and treat: HIV update 2011. Cleve. [NAME]. [NAME]. 2011; 78(2): 95-100.   2. Branson B, Handsfield H, [NAME], et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. [NAME]. Mortal. Wkly. Rep. 2006; 55(RR-14): 1-17.   3. Prejean J, Song R, Hernandez A, et al. Estimated HIV Incidence in the United States, 2006-2009. [NAME] ONE. 2011; 6(8): e17502.   4. [NAME], [NAME], [NAME] T, et al. Missed opportunities for earlier diagnosis of HIV infection -- South Carolina, 1997-2005. [NAME]. Mortal. Wkly. Rep. 2006; 55(47): 1269-1272.   5. [NAME], [NAME], Bardeguez AD, et [NAME]. HIV policy: The path forward - a joint position paper of the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians. Clin. Infect. Dis. 2009; 48(10): 1335-1344.   6. [NAME] R, [NAME], [NAME], [NAME] effectiveness of HIV testing and treatment in the United States. Clin. Infect. Dis. 2007; 45(S4): 248-254.   7. Palella FJ, [NAME] RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. [NAME]. 2006; 43(1): 27-34.   8. Walensky R, [NAME], Losina E, et [NAME]. The survival benefits of AIDS treatment in the United States. J Inf Dis. 2006; 194(1): 11-19.   9. van Sighem A, [NAME], Reiss P, Brinkman K, de Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010; 24(10): 1527-1535.   10. Kurth AE, [NAME], Golden MR, et [NAME]. A comparison between audio computer-assisted self-interviews and clinician interviews for obtaining the sexual history. Sex Trans Dis. 2004; 31(12): 719-726.   Conflict of Interest: None declared |  | P |  |  | 306 | 6 | 637
[NAME],  MD  General Practice |  |  | Screening of people in low-risk populations always carries risk. Even with a test as good as the HIV test with a high sensitivity of 99.9% and a specificity of 99.99% due to a very low base rate (e.g. 1:10.000)among heterosexual men with low-risk behavior, the chance of HIV infection can be as low as 50% when a man tests positive in a screening(1). If this problem is not recognized and adressed before testing, the result of a positive result of HIV testing Mr. [NAME] might be disastrous.   1. Psychological Science in the Public Interest 2008;8:53-96   Conflict of Interest: None declared |  | NR |  |  | 306 | 6 | 637
[NAME],  MD  Department of Veterans Affairs |  |  | For decades, risk-based HIV testing has failed at reducing the number of new HIV diagnosis annually in the US (50,000-60,000 every year) (1,2). Restricting HIV testing to only those individuals who admit to risk factors ignores two important facts: most patients are not completely honest with healthcare providers and/or may not be aware of their risk. Studies have shown that it is likely that those who are unaware of their infection are likely transmitting it to others (3). Currently, there is no cure for HIV. There is no vaccine. But there are highly effective medications that can significantly improve health outcomes and reduce transmission rates. (4,5) Even so, it is only those individuals who are aware of their HIV status can benefit from these life- saving treatments. There is no medical benefit, or societal benefit, to not knowing one's HIV status. Furthermore, the risk of not knowing your HIV status can be devastating. Since 2006, the CDC has recommended routine HIV screening for all adults and adolescents in all healthcare setting for communities where the HIV prevalence is above 0.1%. (6) Studies have shown that it is as cost- effective to conduct routine HIV screening as breast cancer or colon cancer screening (7). The HIV test is cheap and easy. Rapid testing technology even allows for results to be available in 20 minutes, eliminating the need to follow-up on results days later. The CDC also recognized that written informed consent was a significant barrier to routine HIV testing; It is a time-consuming, cumbersome process for providers and has exceptionalized the test(6). Recently, the Department of Veterans Affairs (VA) recognized the benefit for eliminating written informed consent. In 2009, after Federal law change (8), VA revised HIV testing policy to ensure that the test was be offered as a part of routine medical care for all Veterans (regardless of risk) and aligned more closely with CDC recommendations by eliminating the requirement for written informed consent and prescribed pre and post test counseling. Verbal consent is still required and must be documented in the medical record and written educational material must be provided to the patient (9,10).   Living in New York City, with HIV prevalence much above the 0.1% CDC threshold, Mr. [NAME] should absolutely be offered an HIV test by any provider who believes in offering high, quality comprehensive healthcare. Mr. [NAME] has no reason to decline the test, even if he believes he is not at risk. It is a simple, cost-effective procedure with enormous benefit for himself and his sexual partners. If it is positive, Mr. [NAME] should be notified in- person and linked to care in a timely manner. HIV is no longer a death sentence. Anyone can live a long, healthy life HIV positive as long as they receive appropriate medical care. If he is HIV negative, he will have reassurance.   References:   1. CDC. HIV Prevalence Estimates 2006. [NAME], [NAME]. 57, No. 39; 2008.   2. CDC. HIV/AIDS Surveillance Report. Vol. 19; 2009.   3 Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006;20:1447--50.   4 Dieffenbach, C. and [NAME] Universal Voluntary Testing and Treatment for Prevention of HIV Transmission. [NAME]. 2009;301(22):2380-2382   5 Cohen MS. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. NEJM. July 18 2011.   6 CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55   7 Walensky RP. Cost-effectiveness of HIV testing and treatment in the United States. Clinical Infectious Diseases. 2007 Dec 15:45.   8 Public Law 100-387. Veteran Mental Health and Other Care Improvements Act. 110th Congress. Oct. 10, 2008.   9 VHA Directive 2009-036. Testing for Human Immunodeficiency Virus in Veterans Health Administration Facilities. August 14, 2009.   10 VHA Handbook 1004.01. Informed Consent for Clinical Treatments and Procedures. August 17, 2009.   Conflict of Interest: None declared |  | P |  |  | 306 | 6 | 637
[NAME],  M.D.  University of California, Davis School of Medicine,  Eleanor Loomis, BA, [NAME], [NAME], M.D., M.B.A, Professor and Chair, Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine |  |  | This case describes a 15-year-old adolescent (Ms. [NAME]) who experienced a concussion. Our goal in this Ã¢â‚¬Å“Clinical CrossroadsÃ¢â‚¬ï¿½ letter is to address the risks of major depressive disorder (MDD) post-concussion.   Based on the case presentation, and an unknown duration of loss of consciousness (LOC), Ms. [NAME] likely suffered mild to moderate traumatic brain injury (TBI), using the The American Congress of Rehabilitation Medicine guidelines. In the U.S. over 1.4 million people each year experience TBI, with over 300,000 requiring hospitalization [1]. The highest injury incidence is in young adults or adolescents age 15-35 years [1] [2].   Further research is needed regarding the diagnosis and management of mood disorders post-TBI. No guidelines currently exist regarding how frequently these patients should be monitored or screened. Ms. [NAME] should be monitored carefully by her primary care physician (PCP) or mental health professional for the development of a mood disorder, as MDD can significantly impair high school grades, interpersonal skills, self esteem, and preparation for college or work.   Approximately 25-60% of TBI patients develop a major depressive episode within eight years following TBI [3], and major depressive disorder following TBI is associated with poorer functional outcome [4]. The diagnosis of depression may be facilitated in the same manner as in non-TBI patients with the use of screening and tracking tools such as the Patient Health Questionnaire (PHQ). The PHQ-9 is a nine question self or clinician administered screening instrument which takes five minutes to complete and has high reliability and validity in the primary care setting [5].   The PCP should complete a full psychiatric history. Patients without a prior history of psychiatric illness are at highest risk for depression within the first 6-12 months after TBI, while those with a psychiatric history are at higher risk 2-3 years after injury [7]. A positive family history of psychiatric illness may help predict the onset of a future depressive episode. If no depressive episode is identified, it is important to educate Ms. [NAME] and her parents about her risks of developing depression post TBI, so that she can follow up with her PCP if she develops the mood, vegetative or cognitive symptoms of major depressive disorder. If the patient has a prior psychiatric illness, or if a depressive episode is diagnosed, the PCP should consider antidepressant medication for Ms. [NAME], or possibly refer her to a psychiatrist for a combined treatment with medication and psychotherapy.   With regard to medication management, Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to be safe and effective in treating depression secondary to TBI. Studies show that there may be decreased serotonin activity following TBI, suggesting that SSRIs or other serotonergic agents may be effective in treating post-TBI depression. Sertraline given at 25-200 mg per day has been found to reduce depressive symptoms and self-reported symptomatic stress in mild-TBI patients 3-24 months post injury [7]. Other studies also show improvement in depression severity scores with the use of sertraline [7] [8]. Citalopram has been suggested as second line to sertraline, given its safety, tolerability, and minimal drug-drug interactions [9] [10].   In closing, careful assessment and early intervention of patients who experience major depression following TBI can improve recovery and reduce morbidity.   Conflict of Interest: None declared |  | P |  |  | 306 | 1 | 79
[NAME],  MD  The Children's Hospital of Philadelphia and The Hospital of the University of Pennsylvania,  [NAME], The Children's Hospital of Philadelphia |  |  | It is appropriate to conduct a primary assessment of the ABCDEs in the field. Any cervical tenderness or neurologic deficit warrants further evaluation in the emergency department.   The subsequent evaluation of an athlete sustaining a direct blow to the head or indirect blow to the body resulting in transmitted impulsive forces to the head should include a complete neurological examination with particular attention to cognition, balance and visual tracking. The athlete should not return to play that day and should be monitored for any neurological changes as concussion symptoms frequently evolve after injury. A specific assessment tool such as the SCAT2 1 for balance and cognition and the King-Devick test2 for visual tracking may be useful.   Return-to-play is often the primary concern of student-athletes and their families. Physicians must emphasize that the return-to-play issue is on the long-horizon, while the return-to-school issue is the more pressing short-horizon concern. Cognitive rest sounds simple, but in reality, concrete examples are essential: any interactive cognitive activity such as reading, texting, video games, computer use or school work constitutes a metabolic strain that can slow the symptomatic resolution of concussion. Specific instructions in the form of a concussion care plan must include cognitive brain-rest until symptom-free, followed by the step-wise re- introduction of cognitive activities at home and then school as long as symptoms are not induced. This must include academic accommodations for an incremental return to a full academic workload. Only after a full return to academic activity can the athlete initiate a return to athletic activities as outlined in the Zurich Consensus Guidelines.1   Student-athletes who have concussive symptoms lasting 6-8 weeks benefit from cardiac exertion as part of their rehabilitation regimen. While physical rest is important during the acute recovery from concussive injury, physical activity plays an important role in the rehabilitation of post-concussive syndrome. 3,4 Patients who have chronic headache symptomatology benefit from referral to neurology for headache syndrome management.   Previous concussion is a known risk factor for subsequent concussion; three concussions have been well-documented to be associated with a threefold increased risk of future re-injury in the student-athlete.5 There also appear to be detectable balance and neuropsychological deficits after even one or two concussions.6,7,8 Physicians caring for student- athletes suffering from concussion must take into consideration the length of recovery and return to baseline when counseling about return to sport. Each decision is an individual one, taking into account the opportunity- cost for each student-athlete in terms of time lost from sports and academics balanced with the benefit of sports participation.   For Ms. [NAME], we recommend that she wear a helmet while downhill skiing which is a high-velocity sport. In addition, many are utilizing baseline computerized neuropsychological testing as a part of the assessment of the athlete recovering from concussion. More data are needed to make universal recommendations, but as with other emerging medical advances, there are many early adopters. We would recommend testing Ms. X during recovery in an attempt to determine her baseline for future use.9   1. McCrory PR, Meeuwisse W, [NAME], Dvorak J, Aubry M, Molloy M et al. Consensus statement on concussion in sport. 3rd International Conference on Concussion in Sport. [NAME]; 19-185-200.  2. [NAME]; [NAME] J; [NAME]; [NAME]; Delicata D; Tennant AT; Branas CC; [NAME]; et [NAME]. The King-Devick Test as a Determinant of Head Trauma and Concussion in Boxers and MMA Fighters. Neurology February 2011;76(17):1456-62.  3. [NAME], [NAME], Donnelly JP, Pendergast DR, [NAME], [NAME] A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. [NAME]; 20(1):21-7.  4. [NAME] I, [NAME], [NAME] D, [NAME], Iverson GL. Active rehabilitation for children who are slow to recover frollowing sport- related concussion. Brain Inj 2009; 23(12):956-64.  5. Reddy CC, Collins MW. Sports concussion: management and predictors of outcome. Curr Sports Med rep 2009; 8(1):10-5.  6. Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes. Neurosurgery 2002; 51:1175-81.  7. [NAME], McCrea M, Marshall SW, Cantu RC, [NAME], [NAME], et al. Cumulative effects associated with recurrent concussion in collegiate football players. The NCAA Concussion Study. JAMA 2003; 290:2549-55.  8. Guskiewicz K, Weaver N, [NAME], [NAME] of concussion in collegiate and high school football players. Am J Sports Med 2000:28:643-50.  9. Halsted ME, [NAME]. Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report: Sport-related concussion in children and adolescents. Pediatrics 2010; Sept; 126(3):597-615.  Conflict of Interest: None declared |  | P |  |  | 306 | 1 | 79
[NAME],  MD MPH  Clinic on The Common |  |  | There is a recent NIH paper which approves the use of Buprenorphine ( Subutex TM ) as a "maintenance" opioid during pregnancy, and we do exactly that at the Friday Buprenorphine Clinics that I run. It is pretty a simple strategy; switch the addicted patient from an opioid that makes them "high" to one that does not, an opioid substitute that stops cravings at the same time. Buprenorphine meets both criteria. Stability can be achieved, and maintained, and we use urine testing, each visit, to assure compliance. (We are running this program as an outpatient clinic and thus have risk of noncompliance.) Buprenorphine is now available as a generic drug, so is low cost, a much better choice than Methadone. In a prison setting, it should be easy to duplicate this diversionary treatment plan and to enforce compliance. The only remaining question is when/if to detox the patient, ie. slowly detox during pregnancy and deliver drug free, , or continue the Subutex through until and beyond the delivery date. I have not been able to find any peer reviewed literature, that is compelling, on any increased risk of pregnancy complication that is undertaken when a gradual detox plan is adopted. I have two pregnant women in late second trimester who are on a "glide pattern" to be drug free well before delivery. Unless someone convinces me otherwise,I will continue this path and see no reason why a similar plan should not be adopted with an incarcerated patient [NAME] MPH   Conflict of Interest: None declared |  | P |  |  | 305 | 9 | 923
[NAME],  MD  Virginia Hsopital Center,  [NAME], MD |  |  | Preface: this letter is in response to a Clinical Crossroads/Readers Respond piece in JAMA online February 9, 2011.doi: 10.1001/jama.2011.125. Authors and contact info at bottom. No conflict of interest for either author. Pregnant In Prison Sign-out was all a buzz this morning as there was a term laboring patient from the local prison. She was charged with a violent crime and was said to be vicious. Her room was the very last one at the end of the L&D hall. She had 2 armed guards at her door and wasn't allowed any visitors. I remember thinking I sure feel bad for the person that has to labor that patient...wait that's the intern...wait that was me! I started thinking to myself about what the plan would be for delivery (as I did for any other patient) but admittedly I thought about how the fact that she came from prison would affect/change those plans. The fact of the matter was that no matter this patient's creed or crime, she was still a pregnant patient who needed my help...our help to safely bring her child into the world. I remember being very nervous when first entering the patient's room. I had the nurse accompany me. I introduced myself and went over the then current plan for delivery. She introduced herself and admitted to me that as this was to be her first delivery, she was nervous and wasn't sure what to expect. When finished I asked reflexively if the patient had any questions, and to my surprise they were normal questions! How does my baby's heartbeat look on the monitor doctor? When do you think the baby will be born? How soon after the baby is born can I breastfeed? Medical management in the strictest sense should not differ for these women as they are still patients. The still have past medical and surgical histories, they still have allergies, and they still report events like vaginal bleeding, loss of fluid, or contractions. Without sounding too idealistic and philosophical, it should be stressed that aside from their criminal record, these women are pregnant women just the same as women who are not imprisoned. Antepartum management and delivery of these patients should again be no different. Pregnant prisoner may not have the advantage of a one-on-one relationship with a board-certified health care provider, as they often receive prenatal care through an Ob/Gyn or Family Medicine resident-supervised clinic. Traditionally, when labor ensues, pregnant women, who routinely have 24/7 access to a private physician via an answering service, receive reassurance and instructions when to go to the hospital. In the case presented, the patient came close to delivering on-site at the prison while awaiting ambulance transport to the hospital. This scenario would be unlikely to occur with a non-incarcerated patient as most patients have a friend/family member who will drop everything to take that patient to the hospital immediately upon the physician's request. Patients should be monitored and cared for on labor and delivery units with staff trained in...labor and delivery and its complications. With that said, it should be kept in mind, that these women are charged with or have been convicted of breaking the law, and that the hospital staff has every right to his/her safety and security which is why the presence of guards accompanying these patients is appreciated. These women should also be allowed to make choices surrounding their antepartum, intrapartum, and postpartum courses that are within the confines of the law assuming that these choices will be safe for the patient, her child, and the staff needed to guide her through the labor and delivery stages. In terms of pregnant women in prison addicted to narcotics, again their medical management should not differ from those women who are pregnant, addicted to narcotics, and not imprisoned. Suggestions include transitioning a patient to an effective dose of Methadone to avoid the unpleasant and potentially lethal symptoms of narcotic withdrawal, and avoiding the temptation to wean or attempt to discontinue narcotic substitution to minimize newborn withdrawal. In addition to the use of methadone, Buprenorphine, a newer narcotic, may be considered in the armamentarium of agents used to minimize maternal narcotic withdrawal. Ideally, once these women have delivered, given that it is indeed safe for them to have their child in the room, rooming-in should be allowed during the duration of the hospital stay. Upon discharge, some prisons have mother-baby units where women are allowed to nest with their newborns for several weeks after delivery until further plans for the care of the child have been arranged. This would be best disposition for both the new mother and her child; however, in cases in which facilities like these are not available, hospital social workers should aide in helping these patients transition the care of their newborn to either family willing to accept the child, or government protective services, as the patient sees fit. The ultimate goal would be that, once the patient has completed her sentence, she has the choice and/or opportunity to rejoin her child in a residential parenting program much like the one Ms. [NAME] had the opportunity participate in. For the most part, Ms. [NAME]'s chronicle of her labor, delivery, and eventual outcomes was as close to ideal as possible. She had a safe delivery and was eventually reunited with her child in a safe environment for the both of them. The matter that was perhaps not the most ideal was how Ms. A felt during her delivery and afterwards because she was made to deliver and bond with her child in the presence of a prison guard. Improvement in the care for pregnant women, especially during the labor and delivery course has everything to do with reminding healthcare professionals that again, aside from the crimes these patients committed, these women are patients. These women require some level of privacy and have the need to bond with their child just the same. They have the same concerns and questions as many of our other patients do and they hope for an uncomplicated delivery and the birth of a healthy child just the same. [NAME], MD, PGY-1, Washington Hospital Center Ob/Gyn Residency Jon M. Katz, MD, Director, Maternal-Fetal Medicine, Virginia Hospital Center 1635 North George Mason Drive Suite #190 Arlington, VA 22205 [PHONE] [PHONE] (fax) [EMAIL]  Conflict of Interest: None declared |  | NR |  |  | 305 | 9 | 923
[NAME],  MD  Virginia Hospital Center,  [NAME], [NAME], |  |  | Preface: this letter is in response to a Clinical Crossroads/Readers Respond piece in JAMA online February 9, 2011.doi: 10.1001/jama.2011.125. Authors and contact info at bottom. No conflict of interest for either author. Please note our previous response was > 500 words, thus this is an edited version (now 561 words).   [NAME], MD, PGY-1, Washington Hospital Center Ob/Gyn Residency Jon M. Katz, MD, Director, Maternal-Fetal Medicine, Virginia Hospital Center 1635 North George Mason Drive Suite #190 Arlington, VA 22205 [PHONE] [PHONE] (fax) [EMAIL]   Medical management should not differ for these women. They still have past medical and surgical histories, they still have allergies, and they still report events like vaginal bleeding, loss of fluid, or contractions. Without sounding too idealistic, it should be stressed that aside from their criminal record, these women are pregnant women just the same as women who are not imprisoned. Antepartum management and delivery of these patients should again be no different. Pregnant prisoner may not have the advantage of a one-on-one relationship with a board-certified health care provider, as they often receive prenatal care through an Ob/Gyn or Family Medicine resident-supervised clinic. Traditionally, when labor ensues, pregnant women, who routinely have 24/7 access to a private physician via an answering service, receive reassurance and instructions when to go to the hospital. In the case presented, the patient came close to delivering on-site at the prison while awaiting ambulance transport to the hospital. This scenario would be unlikely to occur with a non- incarcerated patient as most patients have a friend/family member who will drop everything to take that patient to the hospital immediately upon the physician's request. Patients should be monitored and cared for on labor and delivery units with staff trained in labor and delivery. Hospital staff has every right to his/her safety which is why the presence of guards accompanying these patients is appreciated. These women should also be allowed to make choices in their antepartum, intrapartum, and postpartum courses that are within the confines of the law, assuming that these choices will be safe for the patient, her child, and the staff needed to guide her through the labor and delivery stages.   In terms of pregnant women in prison addicted to narcotics, their medical management should not differ from those women who are pregnant, addicted to narcotics, and not imprisoned. Suggestions include transitioning a patient to an effective dose of Methadone to avoid the unpleasant and potentially lethal symptoms of narcotic withdrawal, and avoiding the temptation to wean or attempt to discontinue narcotic substitution to minimize newborn withdrawal. In addition, Buprenorphine, a newer narcotic, may be considered in the armamentarium of agents used to minimize maternal narcotic withdrawal.   Ideally, once these women have delivered, rooming-in should be allowed. Upon discharge, some prisons have mother-baby units where women nest with their newborns for weeks after delivery until further plans for the care of the child have been arranged. This would be the best disposition for both the new mother and her child; however, in cases in which facilities like these are not available, hospital social workers should aide in helping these patients transition the care of their newborn to either family willing to accept the child, or government protective services. Once the patient has completed her sentence, she would have the choice and/or opportunity to rejoin her child in a residential parenting program much like the one Ms. [NAME] had the opportunity participate in.   For the most part, Ms. [NAME]'s chronicle of her labor, delivery, and eventual outcomes was as close to ideal as possible. She had a safe delivery and was eventually reunited with her child in a safe environment. The matter that was perhaps not the most ideal was how Ms. A felt during her delivery and afterwards because she was made to deliver and bond with her child in the presence of a prison guard.   Conflict of Interest: None declared |  | NR |  |  | 305 | 9 | 923
[NAME],  MD, PhD  Rheumatology and rehabilitation department; Faculty of Medicine Cairo University, Cairo Egypt,  Dr [NAME] ;Rheumatology and rehabilitation department;Suez Canal University, Cairo Egypt |  |  | Dear Editor We read carefully the case of [NAME], first we totally disagree that the case is Unprovoked Venous Thromboembolism, after careful review of the case I can see that the diagnosis was missing in this case although it is obvious in the CT angiographic findings. To our knowledge this is a straight forward case of Huges Stovin syndrome which is a rare autoimmune disorder of unknown cause that is characterized by the combination of multiple pulmonary artery aneurysms and deep vein thrombosis . The syndrome is considered a form of incomplete BehÃ§et's disease. Although the patient has no definite pulmonary aneurysms in the pulmonary artery yet fusiform dilation was evident on CT angiographic findings presented, the dilated main pulmonary artery and also the cuts of the terminal branches of pulmonary arteries are also evident of CT angiography. And if we have other CT cuts we may see what is so called mycotic pulmonary artery aneurysms that typical of pulmonary vasculitis in either BehÃ§et's disease or Huges Stovin syndrome. So for how long to be maintained on anticoagulant therapy is quite important issue to address as the mainstay now treatment for pulmonary vasculitis in BehÃ§et's disease and Huges Stovin syndrome is to give Immune Modulator drugs and anticoagulation should be revised in such case in view of the CT angiographic findings as we presented. I recommended for Ms W to receive Azathioprine 100 mg/day/PO or Cellcept 1000 mg/day. The main issues to discuss here is that for any patient present with DVT and then chest pain pulmonary embolism seems likely, but in view of our previous comments I can see that this is a case of pulmonary thrombi due to underlying pulmonary vasculitis and not due to pulmonary embolism secondary to DVT. Moreover we can consider to stop anticoagulant for her so long no extensive thrombi is present in the pulmonary arterial branches and many patients do well on that lines of treatment. Sp please consider our comments and CT cuts should be reviewed in view of our previous comments.  Conflict of Interest: None declared |  | NR |  |  | 305 | 9 | 923
[NAME],  MD, MA  University of California, San Francisco Obstetrics & Gynecology, Dept. of Public Health, Jail Health,  [NAME], MD, MPH Fellow, [NAME] Clinical Scholars Program, Departments of Obstetrics and Gynecology and General Internal Medicine, [NAME] of Medicine at University of California, Los Angeles |  |  | Pregnancy for incarcerated women represents a complex crossroads of care: medical standards, correctional regulation, gender discrimination, criminal and medical management of substance abuse, and the impact of these on birth outcomes. The 8th amendment guarantees the right to health care for incarcerated persons; nonetheless, the variable and often inadequate services have been well documented 1, 2.  For many women, jail intake may be the first time they learn they are pregnant. This moment in pregnancy care highlights the challenges of "choice" in a setting where even mundane choices -- like when to wake up -- are limited. Incarcerated women have a constitutional right to obtain an abortion 2. However, one study found that while 68% of correctional health professionals said women can obtain an abortion, many fewer facilitate access 3.  When a woman chooses to continue a pregnancy, she should receive standard prenatal care, either on-site or via transport to a local hospital. Despite clear protocols from APHA 4 and NCCHC 5, an evaluation found that 38 states had inadequate prenatal services 1. The lack of standard prenatal care further challenges the management of common co-morbidities, like substance abuse. Acute opiate withdrawal during pregnancy increases the risk of miscarriage and stillbirth, and opiate-addicted women are transitioned to methadone or buprenorphine 6. This medical management requires immediate attention and prolonged waits in holding cells may put the pregnancy at risk.  Nowhere is the "crossroads" more apparent than in the practice of shackling in labor. Both ACOG and the NCCHC condemn this medically unsafe practice citing its danger when obstetric emergencies occur; the United Nations also declares it a human rights violation 7. From a security perspective, shackling is unnecessary; 65% of women are incarcerated for non-violent crimes 8. Additionally, labor pains and use of epidural anesthesia make fleeing unlikely. Nonetheless, only 10 states have anti-shackling laws.  Birth outcomes have been shown to be worse than in the general population, indicating that these are high risk pregnancies. However, when compared to disadvantaged controls, incarcerated women had lower rates of stillbirth and low birthweight 9. While the relative stability incarceration may improve immediate outcomes, few studies have reported the long term consequences on families. Most mothers become separated from their babies after delivery, as only 13 states have prison nursery programs. Postpartum separation is disruptive not only for the nuclear family, but also for extended families and communities which assume the responsibility of childcare 10.  Much needs to be done in this country to improve the care of incarcerated pregnant women. The report Mothers Behind Bars provides a comprehensive evaluation of pregnancy care in prisons, with concrete recommendations for change 1. As physicians, we should encourage our state legislatures to put an end to the unsafe and inhumane practice of shackling in labor. Currently, 12 states are hearing bills which pertain to this issue (Table 1). If the US is to improve care for incarcerated, pregnant women, it must see the complex social, economic, and political circumstances which underpin the need to improve pregnancy care.  Table 1 States with Active Anti-Shackling Bills in State Legislature  Arizona HB 2294  California AB 568  Connecticut GA 124  Florida SB 1086, HB 779  Hawai'i HB 131, SB 219  Idaho HB 163  Illinois HB 1958  Iowa SF 101, SF173  New York SB 375  New Jersey Assembly No 3492  Oregon SB 632  Rhode Island SB 165, HB5257   *Courtesy of ACLU Reproductive Freedom Project, February 18, 2011     Abbreviations  ACOG: American College of Obstetricians and Gynecologists APHA: American Public Health Association NCCHC: National Commission on Correctional Health Care  References  The Rebecca Project for Human Rights. Mothers Behind Bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. 2010 National Women's Law Center. [NAME],L. 2007 Women Don't Check Their Reproductive Rights at the Jailhouse Door Women, Girls and Criminal Justice. Feb/Mar 2007: 21-28. Sufrin CB, [NAME], and [NAME]. Incarcerated Women and Abortion Provision: A Survey of Correctional Health Professionals. Perspectives on Sexual and Reproductive Health 2009 Mar; 41(1): 6-11. Standards for Health Services in Correctional Institutions. American Public Health Association. Washington, DC; 2003:108. National Commission on Correctional Health Care. Women's Health Care in Correctional Settings (2005 Update). Journal of Correctional Health Care. 2005; 11:381-389. [NAME], [NAME], Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. 2010. N Engl J Med. 363: 2320-31. United Nations Human Rights Committee, Eighty-seventh session, July 2006, page 11. US Department of Justice: Bureau of Justice Statistics. [NAME]: Prisoners in 2009.http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=2232 (Accessed February 22, 2011) Knight M & Plugge E. The outcomes of pregnancy among imprisoned women: A systematic review. 2005; 112: 1467-1474. Golden, R. (2005). War on the Family: Mothers in Prison and the Families They Leave Behind. New York: Routledge. Conflict of Interest: None declared |  | P |  |  | 305 | 9 | 923
[NAME],  MD  A. Gemelli University Hospital, Rome |  |  | To the Editor: With regard to Dr Delbanco's discussion,(1) in particular what are the outcomes for the new mother, the child and nuclear family, as a paediatrician I think that the same sanitary assistance given to the population outside prison must be equally guaranteed to prisoners. Children are clearly a separate category, with needs more different from other prison populations. In our experience, the law allows female prisoners to keep their babies with them until the age of 3 years in specific "nest areas" inside female detention centres.(2) Parental contact is fundamental for the child and must be guaranteed inside the prison as a constitutional principle. There should be a balance between the possible damage of separating children from their mothers and the potential harm to children kept in prison. The choice to separate mothers and children is rarely justified; it often took place because of the inadequacy of the detention centre. Although there is poor direct evidence about the long-term effects of separating or keeping mothers with their babies while in prison, the role of the family as an essential element for mental and emotional development of the child is well known. From 0 to 3 years of age the interactive context of children coincides with the maternal figure and the mother's psyche becomes an integral part of the child's mind.(3,4) The mother and baby relationship can promote prisoners' rehabilitation to the community.(5) Children living in prison with their mother represent a vulnerable group with particular healthcare needs and the access to the prison health service may be the first opportunity for an inmate to receive medical care. Moreover, the period in prison could offer opportunities to improve the prisoner's health. We have verified that during their stay in prison the children's health was not damaged (relative to their growth, immunisation status and medical assistance) but on the contrary there was an improvement in their health.(2,6) To improve the condition of these mothers and their relationships with the babies, more attention should be paid to healthcare promotion by providing healthcare educational programmes, with periodic meetings on important themes such as breast-feeding, infant sleeping position, accident prevention, first steps, alcohol and drugs use. Prison may act as a gateway to facilitate the health and general well-being of these babies. A civil society is one that cares for its babies. Finally, I recommend for Ms A simply to be mum. Like all mothers of the world.   [NAME], MD  A. Gemelli University Hospital  Rome  [EMAIL]  1. [NAME] A 25-Year-Old Woman Pregnant in Jail. JAMA 2011  February 9;305,6.[Epub ahead of print]. 2. Ferrara P, Gatto A, Nicoletti A, Emmanuele V, Fasano A, [NAME] care of children living with their mother in prison compared with the general population. Scand J Public Health 2009 May;37(3):265-272.  3. [NAME] mothers’ contact with children, perceived family relationships, and depressive symptoms. J Fam Psychol 2005;19:350-357.  4. [NAME], [NAME], [NAME], Brooks-Gunn J. Early mother-child separation, parenting, and child well-being in Early Head Start families. Attach Hum Dev 2011 Jan;13(1):5-26.  5. Hotelling BA. Perinatal needs of pregnant, incarcerated women. J Perinat Educ 2008;17(2):37-44.  6. [NAME], [NAME], Joestl SS. Intergenerational transmission of attachment for infants raised in a prison nursery. Attach Hum Dev 2010 Jul;12(4):375-393.).  Conflict of Interest: None declared |  | P |  |  | 305 | 9 | 923