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IN THIS ISSUE

November/December 2005, Vol. 78, No. 9

Children’s Health Care Focus on Youth In our last edition of the year, we take a broad but thorough look at pediatric and adolescent health care. Once again we are fortunate to have an abundance of local experts writing on timely concerns ranging from teenage suicide, to the latest information on autism, to childhood obesity and substance abuse. We think you’ll enjoy the education and the information. Send your letters and comments to Managing Editor Edare Carroll at ecarroll@sfms.org, and watch for our January 2006 edition on environmental health.

11 A Suicide Survived John Kevin Hines 13 Autism Biology and the Environment Martha R. Herbert, MD, PhD 16 Fact Sheet for Autism Spectrum Disorders (ASD) 17 The Growing Epidemic: Child Overweight Rates on the Rise in California Assembly Districts Harold Goldstein, MD, and Stefan Harvey 19 Adolescent Obesity: A Local Solution Charles J. Wibbelsman, MD 21 George Mark Children’s House—A First in Pediatric Palliative Care Christy Torkildson, RN, PHN, MSN 23 In My Opinion—San Francisco Youth Center: In Dire Need of Guidance Ronel L. Lewis, MD

On Our Cover The November/December issue cover art features a photograph of Mei Mei Chun Moy, age 8, a patient at the George Mark Children’s House. See page 21 for more information about the first children’s respite and end of life care facility in the nation, right here in the Bay Area.

Reserve Your Spot for the Annual Dinner The SFMS Annual Dinner, celebrating the inauguration of President Gorden L. Fung, MD, will be held on Thursday, January 26, 2006 at Delancy Street Catering’s Town Hall in the Embarcadero. It’s not too early to reserve your space. Please call Posi Lyon at (415)5610850, ext. 260 for more information. Drug company reps are welcome, too.

26 Working with Community Providers to Respond to Today’s Child Health Challenges Philip Ziring, MD 27 Adolescent Substance Abuse: A Public Health Priority David C. Lewis, MD, and Kathryn Cates-Wessel 30 The Advent of a Childhood Immunization Registry in San Francisco Andrew J. Resignato and Che Waterman 32 Kiss It Better—A Systems Approach to Treatment of Delinquency Ray Curtis, LCSW, BCD 34 Perspective: Children as Ancestors Mike Denney, MD, PhD

Of Interest

MONTHLY COLUMNS

35 In Memoriam Nancy Thomson, MD, MPH

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President’s Message Alan G. Greenwald, MD

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Public Health Update Steve Heilig, MPH

MEMBER SERVICES 4

On Your Behalf

36 Hospital News

12 Calendar of Events

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November/December 2005, Volume 78, Number 9 Editor Corey S. Maas, MD

ON YOUR BEHALF

A sample of legislation and advocacy activities SFMS/CMA provide for you

Managing Editor Edare K. Carroll

Copy Editor Cynthia Rubin

Cover Artist Alex Rothwell

Editorial Board Corey S. Maas, Chairman Nancy Thomson, Obituarist Stephen Askin Wade Aubry Toni Brayer Mike Denney Jaqueline Dolev Jerome Fishgold Alan Greenwald Erica Goode Gretchen Gooding Samuel Kao Thomas Lee Arthur Lyons Alan Maloney Rita Melkonian Kenneth Maybury Judith Mates Ricki Pollycove Jordan Shlain Leonard Shlain David Smith Kathleen Unger Leo van der Reis Stephen Walsh Shieva Khayam-Bashi

SFMS Officers Alan G. Greenwald President Gordon L. Fung, President-Elect Stephen E. Follansbee, Secretary Randall Low, Treasurer Corey S. Maas, Editor E. Ann Myers, Immediate Past President

SFMS Executive Staff Mary Lou Licwinko, JD, MHSA, Executive Director Steve L. Heilig, MPH, Director of Public Health & Education Edare Carroll, Director of Communications/Managing Editor Posi Lyon, Director of Administration Thomas Young, Director of Membership

Board of Directors 2004-2006 Lucy S. Crain Stephen E. Follansbee Brian J. Lewis Jordan Shlain

Richard L. Caplin Jane M. Hightower Michael Rokeach

2001-2005 Mei-Ling E. Fong William J. Kapla John B. Sikorski John I. Umekubo

Steve H. Fugaro Charles A. Moser Peter W. Sullivan

2002-2004 Thomas E. Addison James A. Davis Jerome A. Franz Charles J. Wibbelsman

Gary L. Chan George A. Fouras Gordon L. Fung

CMA Trustee Robert J. Margolin

AMA Representatives H. Hugh Vincent—Delegate Judith L. Mates—Alternate Delegate Judith L. Mates—AMA’s Women Physicians Congress Governing Committee

Editorial and Advertising Offices 1409 Sutter Street, San Francisco, CA 94109 Phone 415/561-0850, ext. 261; Fax 415/561-0833 E-mail: ecarroll@sfms.org, web: http://www.sfms.org San Francisco Medicine reserves the right to edit all reader contributions for brevity, clarify and length as well as to reject any subject material submitted. All expressions of opinions and statements of supposed facts are published on the authority of the author over whose signature they appear and cannot be regarded as expressing the view of the SFMS, unless previously adopted by the society. Acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the SFMS. Subscriptions: $45 per year; $5 per issue. Advertising rates and information sent upon request.

Printing Sundance Press P.O. Box 26605, Tucson, AZ 85726-6605

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UCSF STUDENT SILENT AUCTION

The Associated Students of the School of Medicine along with the Dean’s Office is holding a silent auction/concert to benefit the medical community devastated by Hurricanes Katrina and Rita. On Friday, November 18 from 5:30 to 8:00 in Millberry Union, they will be auctioning items donated from UCSF faculty, students and the local community. Items include dinner at some of the city’s finest restaurants, tickets to local shows and time shares in Tahoe. Medical student bands will be providing entertainment, and there will be free hors d’oeuvres and a cash bar. All proceeds will go to the Louisiana Hospital Association. Don’t miss this opportunity to bid on exciting items and contribute to a good cause! For more information and to preregister online, go to http:// medschool.ucsf.edu/katrina. HAVE YOU CHECKED YOUR MEDICAL BOARD PROFILE RECENTLY?

Physician profiles have been available to the public on the Medical Board of California’s website since 1997, as required by Business and Professions Code sections 2027 and 803.1. CMA encourages physicians to periodically check their profiles for accuracy and advise the board of any corrections, especially changes to their addresses of record. The board cautions physicians against using their home addresses as their address of record, because the addresses become widely available to the public on the Internet. You may designate a post office box as your address of record but, by law, you also must provide the Medical Board with a street address. If you designate a P.O. box as your official address, the medical board will not make public your street address. Contact Sandra Bressler, (916) 444-5532 or

SAN FRANCISCO MEDICINE / NOVEMBER/DECEMBER 2005

sbressler@cmanet.org, information.

for

more

PHYSICIANS BEWARE OF ‘DISCOUNT HEALTH PLANS’

Department of Managed Health Care (DMHC) has stepped up enforcement against so-called “discount health plans” that are engaging in deceptive practices and selling insurance without a license. These bogus health plans promise consumers reduced rates on medical, dental and vision care, as well as on prescription drugs and other services, if they visit a provider on the companies’ lists. In most cases, the physicians on these companies’ lists have not agreed to the discounted prices, or they have unknowingly signed a health plan contract that permits the sale of the physicians’ discounted rates to other payers, such as these purported discount health plans. DMHC recently fined several discount health plans for making untrue and misleading statements. The department has also filed cease-and-desist orders against Equal Access Health/ Health Benefits of America, United Family Healthcare Group, the Cappella Group/Care Entrée, Affordable Health Care Solutions, Inc., and Platinum Health Plus. In addition, DMHC has ordered several purveyors of discount health plans, including International Association of Benefits, Inc., Prudent Choice, HealthCare Advantage, and Family Care, to seek a license if they want to do business in California. Physicians and patients are encouraged to report misleading discount health plan advertising or solicitations to DMHC at (888) HMO-2219. Physicians are asked to also fax a copy of any such solicitations to CMA’s Center for Economic Services at (916) 551-2027. Physicians are advised to review all

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contract offers carefully and to make sure they understand the terms of any new contract before signing it. Contact Aileen Wetzel for more information, (915) 4445532 or awetzel@cmanet.org. ETHNIC PHYSICIAN ORGANIZATIONS LAUNCH CANCER SCREENING PROJECT

The CMA Foundation’s Network of Ethnic Physician Organizations (NEPO) recently launched the Cancer Screening Project to increase awareness about cancer screening and highlight the need for early cancer detection in ethnic communities. NEPO has posted on its website references and resources for physicians and patients, including multicultural outreach materials (press releases, flyers, advertisements), clinical tools for physicians, and an online cancer screening CME course, “Physicians As Agents of Change.” Available in 11 different languages, the project’s patient education materials are designed to enhance communication between physicians and patients and reduce early cancer detection disparities in ethnic populations. Contact Doretha Williams-Flournoy for more information at (916) 551-2543 or dwilliamsflournoy@cmanet.org. CMA COMMENTS ON PROPOSED HMO DRUG COVERAGE RULES

CMA recently submitted comments on the Department of Managed Health Care’s revised HMO drug coverage regulations, urging the department to strengthen patient protections to ensure medications are accessible and affordable. The proposed regulations would implement a 2002 law (SB 842) that gave DMHC full authority to review and approve health plan outpatient prescription drug coverage exclusions and limitations, including copayments that affect patients’ access to prescription drugs. CMA expressed concern that the regulations continue to allow health plans to deny patients practical access to

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medically necessary prescription drugs. CMA believes that treating physicians should always determine medical necessity and that HMOs should not be able to deny patients medically necessary drugs, either by excluding the drugs from health plan formularies or by requiring patients to pay excessive out-of-pocket costs. For more information contact Astrid Meghrigian at (916) 444-5532 or ameghrigian@cmanet.org. MEDICAL BOARD IS LOOKING FOR EXPERT PHYSICIAN REVIEWERS

The Medical Board of California is currently seeking physicians to review complaints and investigate allegations of substandard care. CMA strongly encourages its members to get involved, as it is critically important for conscientious physicians to participate in this process. The medical board is seeking assistance in two areas of its investigative process. Physician “consultants” review incoming complaints and medical records and play a key role in determining whether a formal investigation is necessary. These physician consultants are paid $75 an hour and are not required to testify in court. Approximately 30 percent of all complaints are forwarded for formal investigation. In cases where a formal investigation is warranted, the board uses “expert reviewers” to examine case materials and provide written opinions on the standard of care provided. These expert physicians must be willing to testify in court and are paid $100 an hour for record review and $200 an hour for trial preparation and testimony. For information on becoming a physician consultant, contact Susan Cady at (818) 551-2129 or scady@medbd. ca.gov. Physicians interested in becoming expert reviewers can contact Susan Goetzinger at (916) 263-2424 or at sgoetzinger@medbd.ca.gov.

PHYSICIANS ASKED TO BE ON ALERT FOR WHOOPING COUGH

The Los Angeles Department of Health Services is asking physicians in Los Angeles County to heighten their clinical suspicion of pertussis (whooping cough) and order appropriate laboratory tests for patients of all ages with a persistent cough illness of two weeks or more. Physicians are also asked to suspect pertussis in infants experiencing a cough illness of any duration. Los Angeles County is experiencing a significant increase in reported cases of pertussis. Other California regions have also noted increases in reported whooping cough cases, but none as significant as that in Los Angeles. From January 1 to August 31, 178 pertussis cases were reported to the Los Angeles County Immunization Program, which is nearly a threefold increase in the number of cases reported during each of the previous five years. Physicians in other counties should also report suspected pertussis cases to their local health departments. MEMBER TESTIMONIALS WANTED FOR SFMS WEBSITE

The San Francisco Medical Society staff and website committee is getting ready to launch the new SFMS website, which the website committee, under the direction of Dr. Tom Lee, has worked on for over a year. Members are invited to send testimonials to Edare Carroll at ecarroll@sfms.org or by fax to (415) 5610833, stating why they value their membership in organized medicine and what specifically they enjoy about serving on committees. We will post the testimonials on the new website, which is scheduled to be launched in November. MEMBER DISCOUNT AVAILABLE ON DIRECTORY PRACTICE ADS

SFMS Membership Director Thomas Young is pleased to announce that all members are eligible to receive a discount on practice ads placed in the 2006 membership directory. This publication—used on a daily basis by many

Continued on page 10 NOVEMBER/DECEMBER 2005 / SAN FRANCISCO MEDICINE

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Alan G. Greenwald, MD President

President’s Message Look What’s Coming Next

I

t sounds pretty good that Medicare and insurance companies want to pay you more for the good job that you believe that you are already doing. Like the hair color commercial advises, you’re worth it. But what’s up with the newest carrot and stick that is called “pay-for-performance”? CMS, the federal Center for Medicare & Medicaid Services, wants to improve delivery of medical care and minimize mistakes and poor quality by incentivizing physicians with more money. The irony is that physicians have always been fighting reimbursement cuts in the face of medical service budget deficits or at best, budget neutrality. In fact lawmakers say that there won’t even be the funding for the sustainable growth rate (SGR), the spending catch-up monies that we depend on to bring Medicare reimbursement to usual levels, unless it is tied to a pay-for-performance program.

for incentives must be new money and not withheld from those that do not meet standards. Participation will be voluntary and the system will not penalize physicians for factors outside of their control such as serving minority or uninsured patients. Standards of performance will be based on accepted evidence-based medical information. The good news is that many of the policy makers and private insurance industry representatives agree with physicians that penalties and redistribution of money are a bad idea. If this type of plan is a certainty, then it will not work if there is no real value to the bonuses. In fact, there may be serious quality-ofcare concerns if bonuses are derived from reductions elsewhere. Maybe Congress will have the wisdom to listen to the experts who believe that physicians will do the right thing if treated fairly and with incentives rather than penalties.

Since pay-for-performance is inevitable, we need to ask some tough questions. One of the most important to be answered is whether the incentive money will be “new money” or a redistribution of the same tired funds. Currently, the leading Senate plan will withhold 1 to 2 percent of physician payments to redistribute to the top performers. How will improved quality be measured and by what rationale? What will it cost physicians to participate if expensive information technology is required to document and measure data? Will this by nature exclude physicians who are financially disadvantaged or who take care of sicker patients? Will physicians who don’t participate, or worse, not measure up to performance standards be penalized?

I am writing this last column as your president of SFMS. I would like to take the opportunity to thank all of you for your support this year. I am indebted to those of you who volunteered your time to do the work of this society. You could have spent your time in other ways but found a value in contributing to an organization with a mission to advocate for all the physicians and patients of San Francisco. The full-time staff have done a superb job on your behalf and I wish to acknowledge their excellent efforts. It has been an honor and pleasure to serve as president. Thank you. sfm

It isn’t hard to imagine physicians learning how to game such a system. Maybe many will not have the money to invest in participating or even the desire to risk losing reimbursement by failing to meet certain standards. Before becoming discouraged that organized medicine has failed us again, take note that CMA has set rational guidelines for a fair pay-for-performance program. It was so reasonable that it was adopted as an AMA proposal and taken to Congress. The main bullet points of the CMA/ AMA plan are to answer the questions already posed. The money

ATTENTION SAN FRANCISCO PHYSICIANS: Your journal currently seeks your CREATIVITY. We want poetry, short anecdotal stories, photography, photographs of paintings, drawings, sculptures, or other original works of art for publication in San Francisco Medicine. Don’t be shy. Submit your work and encourage other physicians to participate. We’d like to begin including original artwork in each issue. We are also looking for future cover art. Send to Edare Carroll, managing editor, at ecarroll@sfms.org or mail to San Francisco Medicine, c/o 1409 Sutter Street, San Francisco, CA 94109.

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Steve Heilig, MPH Director of Public Health and Education

Public Health Update Rebuilding San Francisco General Hospital San Francisco General Hospital (SFGH), or “the General,” is arguably the most important single institution in our city. For treatment, research and training, including taking care of our least fortunate fellow San Franciscans, it is unrivaled. At a minimum, any one of us could depend on its trauma services to save our life or that of our loved ones. But in this earthquakeprone city it also needs to be rebuilt to confirm to seismic standards, and therein lies a huge and daunting project. Mayor Gavin Newsom has said that rebuilding SFGH is among his highest priorities for the coming years. But where? The large-scale move of many of UCSF’s buildings and functions to Mission Bay seemed to present a opportunity for a new site. The existing Potrero site also has the advantage of being accessible to many of SFGH’s traditional patient communities. Thus, Newsom appointed a blue ribbon task force to advise him on this crucial question: Mission Bay or Potrero? The SFGH committee was skillfully chaired by our former director of public health Dr. Sandra Hernandez (now CEO of the San Francisco Foundation), with current DPH director Dr. Mitch Katz as vice-chair. It’s worth noting that both are clinicians at SFGH. The other 25 members were medical, business, academic, labor and other community leaders. I (Steve Heilig) was proud to be one of them, representing the SFMS. Among other links with SFGH, I’ve served on the ethics committee there for years and have always been profoundly impressed with the expertise, commitment and compassion of the diverse staff at the hospital. On any given day, the case load there can rival any so-called “reality TV” drama. The committee met five times, hearing many presentations of the vastly complex choices to be made. My file from those meetings is four inches thick. After detailed and at times heated deliberation, the committee’s consensus recommendations were that: 1. SFGH be rebuilt on the existing Potrero Avenue campus in the Mission District of the city. 2. The city and county form a planning and/or campaign http://www.sfms.org

committee, in the immediate future, to determine the feasibility of taking an SFGH rebuild General Obligation bond measure to city and county voters. 3. The city and county continue to work with elected officials to identify additional mechanisms to finance the hospital replacement. The committee’s first recommendation was based on the following key considerations: • Access to acute and emergency care services for residents in the southern and eastern portions of San Francisco. • Patient access to care and coordination of care issues inherent with a Mission Bay rebuild. • Higher construction, land acquisition and operating costs associated with building at Mission Bay. • Lack of adequate and available land at Mission Bay. It was not surprising that there really was no perfect choice. Some members, including myself, felt that our group decision was less than optimal but the best choice given these constraints, particularly the last one. It’s worth noting that the SFGH medical staff had already voted in favor of moving to Mission Bay. But at this point, the Mission Bay site was not available. In a more perfect world we might have been able to consolidate many of the historically shared functions between UCSF and SFGH, thus gaining some efficiencies and perhaps even better training, care and research as well. But it was simply too late to effect any real merger or even “co-location,” as the committee called it. I likened the discussion of this option to marriage counseling among two beloved parties who, while they share some important partner functions, do not want to live together or share funds. Note that the committee’s latter two recommendations concern cost. Building a hospital at this time can cost well over $2 million per bed. SFGH might thus cost well over $800 million. Mayor Newsom, at his annual visit to the SFMS Board of Directors meeting in September, focused on this issue as his next huge hurdle. I expect most of us in the health arena wish him the best, and will do our own best to help however we might. sfm NOVEMBER/DECEMBER 2005 / SAN FRANCISCO MEDICINE

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On Your Behalf Continued from page 4 people—will reach 1,500 physicians, hospitals and health care service providers in the greater San Francisco Bay Area. This is an excellent opportunity to announce your practice, promote your specialty, or just let your colleagues know that you are available for referral. Be sure to mention in your ad that you are an SFMS member. Please contact Thomas at (415) 5610850, ext. 268, for pricing.

BAN ON USE OF CIPRO-LIKE ANTIBIOTICS IN POULTRY (Editor’s Note: In 2001, the SFMS presented a conference on the use of antibiotics and agriculture and resultant increases in drug resistance. SFMS took a policy resolution on this topic to the CMA and then AMA; this resolution was cited in the FDA’s ban on one of the issues of greatest concern.) On July 28, 2005, FDA Commissioner Dr. Lester Crawford issued the FDA’s first-ever decision to curtail use of an agricultural antibiotic because of concerns about antibiotic resistance affecting humans. Bayer announced that it has decided not to seek judicial review of the ban and thus will not seek a stay pending such review. Accordingly, the ban took effect as scheduled on September 12. Both Baytril and Cipro are members of the fluoroquinolone class of antibiotics. Bayer was the only remaining manufacturer of fluoroquinolones for use in poultry. Abbott Labs previously manufactured fluoroquinolones for poultry use, but voluntarily withdrew its product from the market in 2000 when the FDA indicated that it intended to propose a ban on this use. The ban affects only use of Baytril in poultry; other approved veterinary uses of Baytril are not affected. The FDA has shown that use of Baytril in poultry reduces the effectiveness of Cipro in treating Campylobacter, one of the most common causes of severe bacterial food poisoning. The most recent data from the Centers for Disease Control and Prevention show that resistance to Cipro in Campylobacter in humans rose to 21 percent as of 2002; when Cipro-like drugs were first approved for use in poultry in 1995, such resistance was negligible. Many major medical groups, including the American Medical Association and the Infectious Disease Society of America, have publicly supported banning fluoroquinolone use in poultry. (Original source: www.keepantibioticsworking.com)

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CHILDREN’S HEALTH CARE

A Suicide Survived John Kevin Hines

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was 17 years of age, the year was 1998, and the month was May. It was late in this fateful month that I was diagnosed with bipolar disorder (or manic depression). I had finally decided, with much encouragement and anticipation from both my parents, to see a psychiatrist. A couple of months prior to my terribly frightening doctor visit, I had begun to feel oddly paranoid. I felt as though people around me were looking at me funny and possibly even making secretive comments about me. Within that paranoia, I was finding bits of depression and pieces of mania. At the time this was happening I knew not what these symptoms were, but only how they made me feel. During this time I could not communicate properly to my family and friends. I was even incapable of writing down my thoughts. Frankly it is safe to say that I could not clearly think my thoughts. My brain was on scrambled mode and it only seemed to be getting progressively worse. For six months after my diagnosis I struggled, suffered, and attempted to understand the metamorphosis I was going through. Maybe it was just a phase, maybe I was going to grow out of it? During these six months, I could not read, write, or speak effectively. When I would talk, the words came out in a fractured stutter. When I would try to read a book or a magazine, the words seemed literally to be bouncing off the page. And when I tried

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to write down my thoughts, my hands would shake so violently that the words were entirely illegible. I was also going through the motions of trying to find the right medications for my particular kind of manic depression. Some days the medication would feel like it was working,

❝ On September 24, a Wednesday night, I wrote a suicide letter; as a matter of fact I wrote seven letters before I picked the last version. Unslept, I packed my bag like I did every morning, and I prepared for another day at City College. Yet I knew this would be different, this day was to be my last.❞

other days it would not. This went on for two years and in the year 2000, I was on some very powerful medications. As the months passed, I began to seclude myself from my friends as the paranoia began to escalate, and the

mania and depressive episodes just kept getting worse. I became very introverted and quite scared for my future. Then in September of 2000, about every week starting on Monday, I would slide into extreme mania and overpowering paranoia. By Thursday or Friday, I would fall into a very deep depression—so deep that I could not sleep and did not sleep for several weeks. It was then that I became psychotic. It was then the thoughts of suicide unfolded. On September 24, a Wednesday night, I wrote a suicide letter; as a matter of fact I wrote seven letters before I picked the last version. Unslept, I packed my bag like I did every morning, and I prepared for another day at City College. Yet I knew this day would be different, this day was to be my last. At about 7 a.m., my father came into my room and asked me if I was okay. He offered to take me to work with him that day because he knew I was having trouble. He didn’t know how deep-seated my troubles actually were, as I didn’t let him know. I didn’t let anyone know but God. I convinced him that I was doing much better and that if he could drive me to school, I would take the bus home and see him after work. It was a blatant lie. I knew that morning that my plan was to go to the Golden Gate Bridge and jump off.

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A Suicide Survived Continued from page 11

My dad ended up dropping me off at college. I kissed him good-bye on the cheek like I did every day for as long as I can remember. I thought it would be the very last time of my life. He said, “I love you; I’ll see you at home.” I said, “I love you too, Dad,” and we parted. I entered the campus, skipped two of my classes, went to my English class, where I signed my suicide letter “John Kevin Hines, Please forgive me.” I got on the bus, stopped at Walgreen’s for my last meal—a starburst and a Skittles candy—jumped on one last bus and began to cry softly to myself. I got off the bus on the bridge, walked out onto the span and it was then that I truly broke down. I cried for at least 40 minutes, begging myself not to jump, not to carry out what my bipolar mind was thinking. The problem was not just my paranoid mind, the mania or the depression, but also the voices I was hearing inside my head. I was having auditory hallucinations, and they were repeating things like “you must die, you must die,” or “jump now, you deserve to die.” I thought briefly to myself, if one person comes up to me and asks if I am okay, if I need any help, I would tell them everything and I would ask for help. It was nearly at that moment that a woman wearing sunglasses, and speaking in a German accent, said, “Pardon me, will you take my picture.” So, like a gentleman, I took her picture a couple of times. I made my decision right there: “I am going to jump now, nobody cares!” She walked away; I turned around, looked at the traffic, darted to the rail, put my hands on the rail, and catapulted over it. Falling head first, I changed my mind—I didn’t want to die—and dropping at 32 feet per second and speed rising, I thought it was over. I was 19 years old and I was as good as dead. The water came up fast and hard, but I had thrown my head back, thinking that if I fell feet first, maybe I’d have a chance. Turns out 12

I did. I went down into the water about 50 feet, but I was alive, I WAS ALIVE!! I swam to the surface unaware of my injuries, thinking I must be dreaming, this can’t be real, so I pinched my right cheek. It was very real, too real. I waded in the water and something brushed by my leg, I thought it was a shark, but it turned out to be a seal and it was helping to keep me afloat. The Coast Guard arrived on the scene within minutes. They were like angels pulling me from the water’s raging currents. They brought me to their Marin port, where an ambulance took me to Marin General. The doctors told my father I had a 50-50 chance of living through the night. They operated on my back, fitting me with a metal plate and cage. I had shattered two vertebrae and the pieces had gone into my organs. The doctors saved my life. I had to learn how to walk again. It’s been a long hard struggle, but one that I have proven to be up for. I have been in three psychiatric wards in four years, but now I am doing just fine. I love God, I love my family, I love life, and most important, I love myself. My health is fine now but I had to learn how to walk again and I had to enter a psychiatric ward soon after I was able to walk. I can now walk without a cane and even run. My mental state has not been better since before my diagnosis. I spent time in two psychiatric hospitals, one in 2003 and one as recent as 2004, but I started speaking in publicly in 2001 and I received an award that year from the Board of Suicide Prevention for helping to give teenagers an alternative to suicide by sharing my experience. It is interesting to note that I became a suicide prevention speaker because of two clergymen who guided me to do so. One was Franciscan Brother Goerge Cherry and Monsignor Mike Harriman from St. Cecilia’s Church. Both mentors guided me to “give back that which I have received.” To all you parents out there, if your child ever hints about suicidal ideation, or says anything like, “I don’t want to be here anymore,” or “I don’t like this life,”

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or “I don’t belong here,” take them seriously and get help. Also if your child begins to seclude him- or herself from family and friends, let your child know you are there and that you understand and care. Remember to be a friend, not just a parent. I am grateful to be alive. John Kevin Hines works at School of the Arts in San Francisco. He is on the Psychiatric Foundation of Northern California’s task force to build a suicide barrier on the Golden Gate Bridge. He also holds a member seat on the Mental Health Board of San Francisco. He speaks to schools, foundations and hospitals about mental illness, his survivor story, and erecting the barrier on the bridge. He cares deeply about suicide prevention and loves life to the fullest degree. sfm

Calendar of Events SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: FINANCE THURSDAY, NOVEMBER 3

1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration) Call Posi Lyon at (415) 561-0850, ext. 260. SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: OPERATIONS THURSDAY, NOVEMBER 10

1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration) Call Posi Lyon at (415) 561-0850, ext. 260. SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: PERSONNEL THURSDAY, NOVEMBER 17

1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration) Call Posi Lyon at (415) 561-0850, ext. 260. sfm

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CHILDREN’S HEALTH CARE

Autism Biology and the Environment Martha R. Herbert, MD, PhD

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utism is a severe disorder of communication and emotional attachment. Once thought rare, it is now recognized as a significant cause of chronic illness in childhood. Autistic children are caught in the middle of an intense debate about whether or not their numbers are increasing—that is, whether or not there is an autism epidemic. Hanging in the balance are the nature of the treatments and services available to them, the funding levels for providing these, and the urgency with which their problems are addressed. And for these children, time is a pressing concern, as everyone agrees that interventions work far better for autistic children when they are begun early and pursued intensively. Parallel and intertwined with the debate about whether there is an autism epidemic under way are a series of other areas where we can see also substantially different points of view. These include different framings of the way genes influence autism, the way the brain produces autistic behaviors, the relationship of physical symptoms to the core defining behaviors in the autism syndrome (impaired language, social reciprocity and behavior), and the levels at which treatment targets should be sought. In addition, because autism appears to be markedly heterogeneous, the question arises of what it is that “autisms” of different etiologies have in

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common to produce a common behavioral syndrome. It is not surprising that autism should engage discussion at all of these levels, because while autism is defined behaviorally, it is clearly a biologically based disorder. The difficulty at this time is that the biological basis for the autism syndrome has not been established. This uncertainty about both cause and disease mechanisms also has great significance for autistic children, because while we are waiting for clearer science, we are operating on the basis of provisional models that shape how we choose and prioritize care regimens for these children. The positions in the parallel sets of debates tend to cluster into two provisional models, each of which links clinical and research data into a different gestalt. 6 One model sees autism as a strongly genetic brain-based disorder, with a constant prevalence but a recent increase in awareness that has led to the appearance—but not the reality—of an epidemic. The other model sees autism as a genetically influenced but environmentally modulated condition involving multiple systems of the body, with increased numbers being real and related to changes in environmental factors. The model of autism as strongly genetic and brain based is associated with a set of hypotheses about the relationships between genes, brains and behavior.

Autism is defined by a cluster of three specific behaviors, though there is a lot of heterogeneity in how these behaviors manifest. The specificity of behaviors is assumed to rest on alterations of specific brain regions or discrete neural systems that are genetically based. 3 These behaviors and brain changes are often construed to be due to a set of independent genes and brain alterations that aggregate to yield autism. This model has led to a research program seeking to identify autism genes, and to choose candidate genes from regions in the genome on the basis of their relevance to brain or behavior. It has also led to investigations of brain regions associated with the behavioral domains altered in autism. However, the yield of this program has been more modest than had been hoped. Genetic investigations have been inconclusive and regional brain findings in the brain have been intriguing but variable. On the other hand, a series of unexpected findings have emerged that challenge the expectations of the strongly genetic, brain-based model. These include: • A tendency toward large brains, the most strongly replicated brain finding in autism. Brains of children (though not adults) in autism are upwardly shifted in their size distribution—about 20 percent

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of autistic individuals have head circumferences over the 97th percentile, while most have head circumferences that are above average, while volumes measured by MRI in adults are not increased over controls. This finding needs further specification but it does not fit into localization-oriented models of brain-behavior correlation.5 • Widespread reductions in “functional connectivity”—the tightness of signaling coordination across the brain—that are also not strictly localized. Impaired connectivity could preferentially impact functions requiring the highest degrees of brain networking—such as autism’s three defining behavioral domains.9 • Evidence of inflammation and oxidative stress in autistic brain tissue from individuals ranging from childhood to middle age,11 as well as in peripheral blood and urine samples.8 These changes are signs not of inborn alterations of brain architecture in otherwise healthy tissue, but rather of chronic and ongoing disease processes in the same class as those found in conditions such as Alzheimer’s disease, Parkinson’s disease or HIV. • Common patterns of nonnervous system somatic illness, particularly involving the gastrointestinal and immune systems. These organ systems are both on the front lines of encounters with the environment.1 • Mitochondrial abnormalities milder than would be expected from clear genetic etiology. Environmental toxins are known to inhibit mitochondrial metabolism.4 • A higher relative risk associated with combinations of gene polymor-

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phisms in pathways associated with metabolic biotransformation of environmental chemicals. These involve environmentally responsive rather than brain- or behaviorassociated genes.7 • Evidence of an increased “excitationinhibition ratio” in the autistic brain. This could be a consequence of multiple genetic factors (e.g., GABA- or glutamate-related mutations) as well as multiple toxins (e.g., PCBs, heavy metals), which could interact to synergistically increase overall risk.10 It could also be related to metabolic changes that are not restricted to the brain but are systemic, including inflammation and oxidative stress. Indeed, the degree of environmental exposures may affect both whether genetic vulnerability turns into disease and how severe this disease becomes. It can be argued that these are just the types of findings that one would predict from a gene-environment interaction model, where the environmental exposures are subtoxic, persistent and multiple. These levels of exposures alter the body’s signaling mechanisms without killing cells. In the brain, impacts may include subtle but pervasive changes in brain volume detectable only through volumetric measurement, as well as modest but systemic degradation of connectivity— just what we see in autism. And in the body, modest shifts may lead to a bias toward different disease patterns—e.g., autistic children appear to have reduced ability to fight infections but greater vulnerability to immune and autoimmune problems. These findings raise a further question. Could common underlying mechanisms underlie both brain and body symptoms in autism? This question would probably not be asked from the “strongly genetic, brain-based” disease model vantage point, but it is central within a “systemic, gene-environment interaction” approach. If there are indeed such

common mechanisms, it has enormous implications for autism treatment targets. It would mean that instead of treating autism symptomatically (one set of treatments for behaviors, another for seizures, further medications for gastrointestinal disease and still others for the commonly seen allergies and recurrent ear infections), there might instead be a few underlying but strategic treatment targets that would address the basic causes driving inflammation, oxidative stress and the increased excitatory chemistry that may underlie both the defining behaviors and many other “comorbid” features. This argument is supported by the Fragile X mouse model, which has a glutamate receptor deficit; these animals show a spectrum of features ranging from repetitive behaviors and poor socialization to anxiety, sleep disorders and even gut dismotility, all frequent in autism.2 Moreover, we may be able to target certain final common pathways as treatment targets even though they are downstream of heterogeneous causal mechanisms. We thus come around full circle, back to the children. How can we best help them? It appears that the “systemic, gene-environment” model for autism not only has support from research findings, but also opens a range of new avenues toward potential treatment targets that may give us fresh ways to improve quality of life and even level of functioning. While the idea of an autism epidemic is certainly disturbing, no one has definitively explained it away. Now we need to forthrightly look at the mechanisms such a phenomenon would imply, because they may contain keys not only to understanding autism but also to treating it. Dr. Herbert is a pediatric neurologist at the Center of Morphometric Analysis, Massachusetts General Hospital. She can be reached at mherbert1@partners.org.

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Autism Biology and the Environment Continued from page 15

REFERENCES

1. Ashwood P, Van de Water J. A review of autism and the immune response. Clin Dev Immunol 11: 165-74; 2004. 2. Bear MF, Huber KM, Warren ST. The mGluR theory of fragile X mental retardation. Trends Neurosci 27:370-7; 2004. 3. Dawson G, Webb S, Schellenberg GD, et al. Defining the broader phenotype of autism: genetic, brain, and behavioral perspectives. Dev Psychopathol 14:581-611; 2002. 4. Filipek, PA, Juranek J, Nguyen MT, et al. Relative carnitine deficiency in autism. J Autism Dev Disord 34:615-23; 2004. 5. Herbert MR. Large brains in autism: the challenge of pervasive abnormality. Neuroscientist 11:417-40; 2005. 6. Herbert M. Autism: A brain disorder or a disorder that affects the brain? “Clinical Neuropsychiatry” In press. 7. James S, Melnyk S, Jernigan S. Low plasma methionine, cysteine, and glutathione levels are associated with increased frequency of common polymorphisms affecting methylation and glutathione pathways in children with autism. Abstract # 59.14. FASEB Experimental Biology 2005 19:A51A522005. 8. James SJ, Cutler P, Melnyk S, et al. Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism. Am J Clin Nutr 80:16117; 2004. 9. Just MA, Cherkassky VL, Keller TA, Minshew NJ. Cortical activation and synchronization during sentence comprehension in high-functioning autism: evidence of underconnectivity. Brain 127:1811-21; 2004. 10. Rubenstein JL, Merzenich MM. Model of autism: increased ratio of excitation/inhibition in key neural systems. Genes Brain Behav 2:25567; 2003. 11. Vargas DL, Nascimbene C., Krishnan C, et al. Neuroglial activation and neuroinflammation in the brain of patients with autism. Ann Neurol 57:67-81; 2005. sfm 16

Fact Sheet on Interventions for Autism Spectrum Disorders (ASD) The National Academy of Sciences of the United States has conducted the most comprehensive, impartial review of comprehensive interventions for children with ASD currently available (Committee on Educational Interventions for Children with Autism, 2001). The academy report cites ten programs that have some research support behind them, including the three most widely used approaches—ABA Discrete Trial, TEACCH, and the Developmental, Individual-Difference, Relationship-Based (DIR-Floortime) model. The academy report points out, however, that “although there is evidence that interventions lead to improvement, there does not appear to be a clear, direct relationship between any particular intervention and children’s progress” (page 5). The report also states that while the majority of children participating in comprehensive programs make significant progress in at least some developmental domains, “methodological limitations preclude definitive attribution of that progress to specific procedures” (page 172). Furthermore, it points out “there are no adequate comparisons of different comprehensive treatments” (page 8) and “virtually no data on the relative merit of one model over another” (page 171). In examining the research on the cited programs that have some evidence supporting them, the academy report further elaborates: With regard to the ABA Discrete Trial Approach, an intensive behavioral intervention, the report indicates that the original 1987 Lovaas study showing 9 of 19 children with very good outcomes was limited by a number of methodological problems. The Academy report indicates that while there have been a number of studies on Discrete Trial approaches, only one followed strict scientific methods and used a clinical trial design: “Only one of the studies (Smith, Groen, & Wynn, 2000) practiced random assignment of children to conditions” (page 172). This more recent replication of the 1987 Lovaas study dealt with the original study’s limitations. It showed, however, only modest educational gains (compared to the original study) and little to no emotional and social gains: “There were no significant changes in the children’s diagnoses or their adaptive or problem behaviors” (page 171). With regard to the TEACCH program, which combines developmental and behavioral elements, a number of studies are cited, including follow-up studies, and in one study comparing a home-based TEACCH program with an ABA Discrete Trial classroom, after four months, “The TEACCH home-based program showed more improvement…on imitation, on fine and gross motor skills, and on tests of nonverbal, conceptual skills” (page 170). With regard to the Developmental, Individual-Difference, Relationship-Based (DIRFloortime) approach, referred to in the academy report as the Developmental Intervention Model, it works on the building blocks of relating, communicating and thinking. The academy report cites a detailed review of 200 children with ASD receiving this approach (Greenspan & Wieder, 1997; Greenspan & Wieder, 1999) that shows that more than half the children had good to outstanding outcomes on the “Functional Emotional Assessment Scale” (high levels of language, creative and reflective thinking, and social interaction). A more in-depth examination of 20 of the highest functioning children detailed marked gains on the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984) and the CARS autism rating scale (Schopler, Reichler, & Renner, 1988) (page 168). Given that there is no definitive evidence for any one approach and no adequate comparisons of the different comprehensive approaches, the academy report recommends that “effective services will and should vary considerably across individual children, depending on a child’s age, cognitive or language levels, behavioral needs, and family

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CHILDREN’S HEALTH CARE

THE GROWING EPIDEMIC: Child Overweight Rates on the Rise in California Assembly Districts Harold Goldstein, MD, and Stefan Harvey

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uring the past three decades, the prevalence of overweight among young people in the United States more than tripled among children 6 to 11 years and more than doubled among adolescents ages 12 to 19 years.1 These figures are particularly alarming because of the health problems associated with children being overweight. Children and adolescents who are overweight are at increased risk for type 2 diabetes mellitus, asthma, and orthopedic problems; they are more likely to have risk factors for cardiovascular disease (such as increased blood pressure and cholesterol); and they are more likely to have behavioral problems and depression.2,3 In addition, children and adolescents who are overweight are more likely to remain so as adults,4,5 with an estimated 75 percent of overweight adolescents being obese as young adults.5 The increasing prevalence of overweight is a reflection of critical and fundamental health problems that plague our children: poor diet and a lack of regular physical activity. These problems are the result of a variety of individual, social and environmental factors. THE STUDY

The California Center for Public Health Advocacy (CCPHA) analyzed data collected in the 2004 California Department of Education Physical Fitness

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Test from almost 1.4 million children to determine the number of children enrolled in grades 5, 7, and 9 who were overweight. 6 The California Physical Fitness Test evaluates children using the FITNESSGRAM assessment tool, which consists of six measures of physical fitness.7 The Healthy Fitness Zone is the FITNESSGRAM term used to describe the minimum level of fitness (that is, the level thought to provide some protection from health risks imposed by a lack of fitness) in each component of the test. Each Healthy Fitness Zone is based on criterion-referenced standards that have been tested and shown to be valid and reliable. CCPHA analyzed one of these measures, body composition, as an indicator of whether or not children were overweight. Each student’s body composition was assessed based on either body mass index (BMI) calculated from measured height and weight, triceps skin fold thickness, or bioelectrical impedance.8 Children who exceeded the Healthy Fitness Zone were considered to be overweight. In this study, overweight is generally equivalent to the 90th percentile of BMI-for-age, and is slightly lower than the commonly used Centers for Disease Control and Prevention (CDC) definition of overweight as a BMIfor-age at or above the 95th percentile.9

CCPHA used data from the California Senate Office of Demographics to assign children to the 80 Assembly districts in California based on their school zip codes.10 The percentage of overweight children was determined for each Assembly district by gender, grade, and race/ethnicity. The percentage of children who were overweight in 2004 was compared to the percentage of children who were overweight in 2001 as determined by CCPHA’s prior analysis.11 RESULTS: STATEWIDE PERCENTAGES OF OVERWEIGHT CHILDREN

Overall, more than one in four (28.1 percent) children enrolled in grades 5, 7 and 9 in California were overweight in 2004. Boys (33.9 percent) were more likely to be overweight than girls (22.0 percent). The percentage of children who were overweight decreased with increasing grade level, from almost one out of three in grades 5 and 7 to one out of four in grade 9. The percentage of children who were overweight was highest among Pacific Islanders (35.9 percent), followed by Latino (35.4 percent), American Indian/ Alaskan Native (31.7 percent), and African-American (28.7 percent) children. Lower percentages of overweight

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Childhood Overweight Rates Rising in California Continued from page 19

were found among non-Latino white children (20.6 percent) and Asian children (17.9 percent). CHANGE IN PERCENTAGE OF OVERWEIGHT CHILDREN FROM 2001 TO 2004

Statewide, the percentage of children enrolled in grades 5, 7, and 9 who were overweight increased from 26.5 percent in 2001 to 28.1 percent in 2004. The percentage of overweight children increased among both boys and girls, among children in all three grade levels, and among children of all racial/ethnic backgrounds. PERCENTAGE OF OVERWEIGHT CHILDREN BY ASSEMBLY DISTRICT IN 2004

Across all 80 Assembly districts, the percentage of children enrolled in grades 5, 7 and 9 who were overweight in 2004 ranged from 18.2 percent to 39.1 percent. In 55 out of 80 (69 percent) Assembly districts, at least one out of four (25 percent) children was overweight. Between 2001 and 2004, the percentage of children enrolled in grades 5, 7 and 9 who were overweight increased in 71 out of 80 (89 percent) Assembly districts. POLICY RECOMMENDATIONS

The epidemic of childhood obesity will not be solved by calling for individual behavior change alone. To address this health crisis, state and local leaders must address the conditions in schools and communities that contribute to the epidemic and undermine parents’ efforts to protect their children’s health. The following recommendations are based on those made by a national Scientific Panel brought together by CCPHA and on recommendations developed by the

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Strategic Alliance for Healthy Food and Activity Environments.12 1. Institute healthy food and beverage standards for all items available in pre-school, school, and after-school programs. Standards should address levels of fat, sugar, and calories. 2. Ensure that all children receive physical education that meets minimum standards for quality, duration and frequency. Students should be active, classes should be of appropriate size, and teachers should be credentialed and well-trained. 3. Establish grocery stores with produce and other fresh, healthy items in all underserved neighborhoods. 4. Eliminate advertising of unhealthy foods and beverages to children and youth. 5. Provide health plan benefits that cover age-appropriate nutrition counseling and education as well as physical activity programs. 6. Make school recreational facilities available for after-hours use by children and families, especially in neighborhoods that lack adequate, safe and accessible park and recreational facilities. 7. Adopt and implement “complete streets” policies to provide safe and convenient roadway access for people who walk, bicycle, or use wheelchairs. 8. Provide financial incentives for establishing physical activity facilities, grocery stores, and farmers markets, and improving walkability, particularly in low-income communities. Dr. Harold Goldstein is the founder and executive director of the California Center for Public Health Advocacy. Stefan Harvey is the assistant director. CCPHA is a nonprofit organization that raises awareness about public health issues and mobilizes communities to promote the establishment of effective health policies.

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REFERENCES

1. National Center for Health Statistics. Health, United States, 2004 with chartbook on trends in the health of Americans. Hyattsville, MD: 2004. Available online at http:// www.cdc.gov/nchs/data/hus/hus04.pdf. Accessed on May 11, 2005. 2. Reilly JJ, Metheven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child. 2003; 88:748-52. 3. Institute of Medicine (United States). Preventing childhood obesity: health in the balance (Committee on Prevention of Obesity in Youth, Food and Nutrition Board, Board on Health Promotion and Disease Prevention). 2005. Washington, DC. 4. Freedman DS, Khan LK, Serdula MK, et al. The relation of childhood BMI to adult adiposity: the Bogalusa heart study. Pediatrics. 2005; 115:22-7. 5. Guo SS, Wu W, Chumlea WC, Roche AF. Predicting overweight and obesity in adulthood from body mass index values in adolescence. Am J Clin Nutr. 2002; 76:653-8. 6. Additional information about the California Physical Fitness Test is available online at http:/ /www.cde.ca.gov/ta/tg/pf/index.asp. 7. Additional information about FITNESSGRAM is available online at http:// www.fitnessgram.net. 8. Body mass index is a ratio measurement of weight to height, reported as kg/m2. For most persons, the body mass index is a reliable proxy for fatness. Skinfold thickness and bioelectrical impedance are both estimates of body fatness. 9. Centers for Disease Control and Prevention. BMI for children and teens. Atlanta, Georgia, 2005. Available online at: http://www.cdc.gov/ nccdphp/dnpa/bmi/bmi-for-age.htm. 10. Additional information about the Assembly district zip code files is available online at http://www.senate.ca.gov/ftp/sen/ offices/demographics/_HOME/. 11. California Center for Public Health Advocacy. An epidemic: overweight and unfit children in California Assembly Districts. Davis: California Center for Public Health Advocacy; 2002. 12. Strategic Alliance for Healthy Food and Activity Environments. Taking action for a healthier California: recommendations to improve healthy food and activity options, 2005. Available online at: http://www.eatbetter-movemore.org. sfm

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CHILDREN’S HEALTH CARE

Adolescent Obesity: A Local Solution Charles J. Wibbelsman, MD

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hose of us in adolescent throughout the city. This innovative to address the nutrition and fitness crisis medicine are well aware of collaboration aims to teach good eating among young people,” says Virginia Witt, the epidemic of obesity habits and the importance of fitness to kids executive director of the San Francisco among children and adolescents. National between the ages of 11 and 15 who are at Beacon Initiative. “That was the catalyst statistics on childhood obesity are certainly risk for being overweight. that brought us all together.” alarming. Sixteen percent of Beacon Initiative centers are American children—or one in six located at elementary, middle and kids—are seriously overweight. And high schools throughout the city obesity leads to a host of other health including Chinatown, the Sunset, issues, including diabetes and sleep Visitacion Valley, the Excelsior, the apnea. Even more serious, though, Richmond, and Bayview Hunters studies show that overweight kids Point. The centers serve thousands of tend to become overweight adults, children and teens primarily from lowwho are at risk for heart disease and income neighborhoods. other life-threatening conditions. “Because the Beacon Centers We are seeing type II diabetes in already serve an existing population, children now when 20 years ago we this is a great way to reach kids whom only saw it in adults. we wouldn’t necessarily reach any The explanation for this change other way,” said Witt. “That’s why this is complex and involves many is a positive ongoing effort. It’s not a Teenage participants of the Beacon Initiative get lifestyle factors. To change this one-shot deal.” The Gateway to in shape during an after school program. pattern, we need to educate kids Fitness program is available at seven about diet and nutrition. We need centers to all kids who meet the The program is a partnership between criteria of being in the 85th to 95th to get them enthusiastic about being more active. And if there is going to be a change, the Beacon Initiative, which runs after- percentile for weight. Physicians at Kaiser now is the time to do it. It’s much easier to school programs at San Francisco public Permanente can also refer patients to the get an overweight 15-year-old to make schools, and Kaiser Permanente, which Gateway to Fitness program. lifestyle changes than it is to change adult provided health expertise in devising the The six- to eight-week program offers behavior. At Kaiser Permanente we are components of the program. Additional fun opportunities for physical fitness such looking for new programs and solutions partners were Team Up for Youth, a as kickboxing, karate, yoga, tae kwan do, because we need lots of options to reach nonprofit that supports after-school sports, and hip-hop dance in addition to traditional these kids. We have a chance to help them and the California Endowment, which sports and exercise. As school budgets have provided funding for planning and gotten tighter, physical education has been change their whole lives. One such program is the Gateway to coordination. cut back, giving kids fewer opportunities to “The key issue here is the urgent need Fitness program, which launches this fall

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A Local Solution to Adolescent Obesity Continued from page 19

exercise. The Gateway to Fitness program will address this imbalance. Those enrolled in the program make a commitment to maintain a minimum requirement of three days of physical activity each week. “What our centers are really good at is making exercise fun,” says Witt. “We find all sorts of ways to get kids moving.” In addition to exercise, the program includes nutrition classes that focus on developing healthy eating habits.

Middleschool boys participate in the Gateway to Fitness program. Participants learn how to eat a balanced diet using the new food pyramid and nutritional guidelines released in 2005 by the Department of Health and Human Services. At some centers kids will have the opportunity to go on shopping trips to learn how to buy healthy food and take cooking classes to learn how to prepare it. Because each Beacon Center has its own staff and resources, the components of the program are flexible and each center can decide how to implement them. “We focus on simple changes that can make a big difference, such as choosing

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whole grains over white carbohydrates and drinking water instead of juice or soda,” says Juggy Jaspal, a Kaiser Permanente San Francisco health educator, who helped develop the curriculum for the program. “Kids are really surprised when we tell them how much sugar is in Gatorade or Jamba Juice, drinks they think of as healthy.” The curriculum focuses on simple, straightforward messages such as the importance of cutting down on fast food and eating more fresh fruits and vegetables. The program requires parental involvement, so the whole family supports the teenager in making healthy lifestyle changes. Kids who complete the program will receive a one-year membership in the YMCA, an impressive incentive and one that will help them maintain their new enthusiasm for fitness. “We called the program Gateway to Fitness because we view it as a starting point for these kids,” says Witt. “It’s a gateway to making a longterm commitment to their own fitness and nutrition.” The Gateway to Fitness program is supported by the Kaiser Permanente Healthy Eating Active Living Initiative (HEAL), which aims to address the obesity epidemic through community partnerships. “This program is an innovative new approach and we really appreciate the willingness that Kaiser Permanente has shown to work with us at the community level to really make a difference in the lives of these kids,” says Witt. The program will be held during the fall and again in the spring, and organizers hope it will become an ongoing offering, available to new groups of kids year after year. All those involved in creating the Gateway to Fitness program are very excited to see it launched. Hopefully it will become a model for similar programs in communities throughout the Bay Area. It was designed in such a way that everybody is a winner. Kaiser Permanente is a winner, the school system is a winner, and the adolescents are winners. Dr. Wibbelsman is chief of the Teenage Clinic, Kaiser Permanente San Francisco and member of the SFMS Board of Directors.

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Autism Interventions Fact Sheet Continued from page 16 priorities” (page 220). The academy report emphasizes intensive individualized approaches with the following priorities— “functional spontaneous communication, social instruction delivered throughout the day in various settings, cognitive development and play skills, and proactive approaches to behavioral problems” and “a setting in which ongoing interactions occur with typically developing children” (page 6). The academy report calls for more research to compare the different approaches and better understand their relative strengths. For more information contact the Interdisciplinary Council on Developmental & Learning Disorders, 4938 Hampden Lane, Suite 800, Bethesda, Maryland 20814, (301) 656-2667 or go to www.icdl.com, or email info@icdl.com. REFERENCES

1. Committee on Educational Interventions for Children with Autism, NRC (2001). Educating children with autism. Washington, DC: National Academies Press. 2. Greenspan SI, Wieder S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communicating: A chart review of 200 cases of children with autistic spectrum diagnoses. Journal of Developmental and Learning Disorders, 1:87-141. 3. Greenspan SI, Wieder S. (1999). A functional developmental approach to autism spectrum disorders. Journal of the Association for Persons with Severe Handicaps (JASH), 24: 147-161. 4. Schopler E, Reichler R J, Renner BR. (1988). Childhood Autism Rating Scale (CARS). Los Angeles, CA: Western Psychological Services. 5. Smith T, Groen AD, Wynn, JW. (2000). Randomized trial of intensive early intervention for children with pervasive developmental disorder. Am. J. Ment. Retard., 105:269-285. 6. Sparrow S, Balla DA, Cicchetti D. (1984). Vineland Adaptive Behavior Scales. American Guidance Service.sfm

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CHILDREN’S HEALTH CARE

George Mark Children’s House—A First in Pediatric Palliative Care Christy Torkildson, RN, PHN, MSN

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eorge Mark Children’s “When Children Die: Improving Francisco Bay Area there are a multitude House (GMCH) is the Palliative and End-of-Life Care for of resources, but not nearly enough to deal first and, to date, only Children and Their Families.”3 with all the issues facing a family with a However, we have only “just begun” child who has a life-limiting or terminal pediatric respite and end-of-life care facility in the United States. GMCH as noted in the National Consensus condition. With the increase of techopened in March 2004 in San Leandro, Project (NCP),4 “there is reason to be nology and better interventions many after almost a decade of planning and optimistic about improving access to children, approximately 1 million at any fund-raising. The vision of cofounders palliative care.… Improvements…have given time, live longer, continuing to Barbara Beach, MD, a pediatric require care and interventions oncologist, and Kathy Hull, for an indefinite time, and yet PsyD, George Mark Children’s respite is, at best, difficult to House is a community-based achieve. Many families find resource, built to serve themselves returning to the children—and their families— acute-care hospital for this facing life-limiting and terminal support, often tying up acuteconditions. care beds with non-acute care Pediatric palliative care in needs. While children are still the United States did not dying in the hospital when home become recognized as a might be a prefer-able option, subspecialty until the late 1990s, many children are dying at home although it began in the midwith families who are often 1980s in the United Kingdom. It overwhelmed and ex-hausted. Christy Torkildson (L), Dr. Barbara Beach (M), and a was only in the year 2000 that Many families are simply medical student (R) visit with patient Mikey Teare. the American Academy of stretched to their limits by not Pediatrics published its position only the needs of their sick child, statement on Pediatric Palliative Care.1 evolved through demonstration models, but also the effort to meet all the normal That same year several articles were development of pediatric palliative care demands of their family life, often with published dealing with pediatric palliative curricular materials, as well as increases no real break.5 GMCH is available for any child care and the symptoms and suffering of in federal and private funding for both children at the end of life.2 pediatric and adult palliative care facing a life-limiting or terminal condition These publications documented research.” for respite, transitional care or end-of-life different gaps in care and the need to George Mark Children’s House is not care. Respite visits can be up to 14 days at integrate palliative care in pediatrics. In an alternative, but an addition to the a time and up to 28 days per year. This is 2003, the Institute of Medicine published existing continuum of care. In the San

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George Mark Children’s House Continued from page 21

a time for families to get a well-deserved break, and families can either stay with their child at GMCH or not, as their needs dictate. Transitional care is goal-oriented care. Typically, this is a bridge between hospital and home when the child no longer needs acute interventions. Children may need to complete a course of treatment, or caregivers may need more training or experience before they are independent enough to take their child home. In these cases, transitional care admissions are not time limited, but goal oriented. End-of-life care is for children who are actively dying. Typically, these children have weeks or possibly months to live, but all too often they only have days. Families often move in with the child and the focus is on making every moment special, focusing on quality of life. Pain and symptom management are key to the quality of care and often our children outlive predictions of life their expectancy. All care at George Mark Children’s House is governed by the Precepts of Palliative Care for Children and Adolescents and Their Families6 and the Clinical Guidelines for Quality Palliative Care.6 GMCH is not a medical home, nor is it a long-term-care facility. It is licensed by the State of California Department of Health as a Congregate Living Health Facility, which is defined as “a more homelike environment with typically a more acute care patient than a skilled nursing facility.”7 What does this mean? It means that the children remain under the care of their primary care physicians. It means that GMCH staff work in concert with the primary health care team and home health agencies, as well as the family, to help identify goals and decrease the fragmentation of care for these

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children and families. It means that GMCH provides end-of-life care, with services that are not time limited. Admission eligibility is strictly based on medical eligibility, i.e., the child is not expected to survive childhood. Unlike adult hospice, our services do not have a time limit. We prefer referrals as soon as a diagnosis is made that indicates a child may not survive childhood. This allows time for the family to use us for respite care, which in turn allows us to establish a relationship with the child and family. Cost for services are billed to third-party payers and families are asked to determine for themselves what, if anything, they are able to contribute toward the cost of care. At no time is a family billed for services. At George Mark Children’s House all care is delivered by an Interdisciplinary Team headed by our medical director, Barbara Beach, MD, and our program director Christy Torkildson, RN, PHN, MSN. The team consists of an LCSW, Child Life Specialist, Spiritual Care Coordinator, Clinical Psychologist and Manager of Volunteer Services and our staff of Registered Nurses and Certified Nursing Assistants. In addition, GMCH has a pediatric hospice pharmacist on call 24 hours a day to assist with pain and symptom management. There is always, at a minimum, one registered nurse for every four patients with a maximum bed capacity of eight patients. Working together with the primary health care provider, we also maintain our own GMCH Medical Team that provides 24hour on-call coverage. While our emphasis at GMCH is on providing a homelike environment, we are equipped to care for any child who requires in-wall suction, oxygen, and medical air. Built into the house is a lift system so any patient can be moved about easily. There are also many specialty rooms and services such as school (for both the sick child and siblings), arts and crafts, computer room, multisensory room, soft or “volcano” room, music room, a spa and a huge playroom. Ruth’s Cafe is our family dining room where all staff, patients, and family members come together for meals

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and special activities. It is not unusual to see a child in her bed joining the fun! All this is on five beautifully landscaped acres leased to GMCH by the Alameda County Board of Supervisors for a dollar a year. Pets are also part of our active pet therapy program. Children can bring their pets from home, but the animals must meet requirements for temperament and physical status, including up-to-date vaccinations and clearance from their veterinarian. Physicians who would like more information or a tour of George Mark Children’s House are encouraged to call or e-mail Christy Torkildson, program director, or Barbara Beach, medical director, at (510) 346-4624 or ctorkildson@georgemark.org. The website is http://www.george-mark.org. Christy Torkildson is Program Director for George Mark Children’s House. Dedicated to pediatric palliative care, Christy comes with experience in education, administration and research. She has been a contributor to several publications emphasizing pediatric palliative care and presents nationally on these topics. Christy was a member of the advisory board for the Pediatric End-of-Life Nursing Education Consortium and served as faculty for the course since its inception. She is a member of the Board of Directors for the Hospice and Palliative Nurses Association and serves as vicepresident for the Board of Directors of Omicron Delta, one of the largest virtual chapters for the Nursing Honor Society Sigma Theta Tau. Active in several other professional organizations, she currently serves on the National Pain Care Forum and the Children’s Hospice and Palliative Care Coalition of California while raising her four daughters.

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In My Opinion

San Francisco Youth Center: In Dire Need of Guidance Ronel L. Lewis, MD

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ince my last article in this journal on the mental health services at San Francisco’s Youth Guidance Center (YGC)(in May 2003), which described occasions for hope, even in face of the overwhelming odds against it, subsequent administrative and operational changes have occurred that have left YGC mental health services staff depleted and uncertain about future direction. New managers and directors who have agendas that do not necessarily place a high priority on quality mental health service for the youth detained in our Juvenile Hall (JH) have been appointed. There has been a loss of key mental health staff without even a viable promise of replacements. The resulting increase in workloads is being absorbed by remaining mental health staff, further watering down the mental health services available, in spite of no decrease in the mental health needs of our population (same high risk youth, same high levels of depression with increased suicide potential, PTSD, conduct disorders, and ADHD, along with the occasional major thought and mood disorders) and no decrease in the requests from Juvenile Probation for hurry-up assessments on incarcerated youth. Because the new Juvenile Hall facility, currently under construction, will provide a separate housing unit for youth in need of more focused mental health

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intervention, it had been a hope that new mental health services in this new housing unit would qualify for Prop. 63 dollars. This might have provided innovative

â?? New managers and directors who have agendas that do not necessarily place a high priority on quality mental health service for the youth detained in our Juvenile Hall have been appointed. There has been a loss of key mental health personnel without even a viable promise of replacements.â?ž

mental health services (and new mental health personnel) that would stimulate new directions in mental health treatment for detained youth. However, we are now hearing that these hoped-for additional funds will not be forthcoming, and that we may have to proceed with our current and more and more depleted mental health staff. Given the needs and the

potential, this is a huge missed opportunity. A major change in the probation services/mental health service working relationship has taken place during the past year. In an attempt to speed up the probation services disposition process (which is good), mental health services has been tasked with providing a mental health assessment in the first 24 hours of detention; previously these assessments took place over the first 72 hours. Therefore, initial assessments are done more hurriedly and the real value of such assessments may be compromised as we try to sort out the acute and transient symptoms resulting from the detention process itself. In most cases, it is probably more desirable to obtain that more timely disposition/earlier release. However, those youth with more significant mental health needs may be shortchanged in this new process of rapid assessment, and opportunities for mental health intervention (in the YGC setting, or in the community after release) may be missed. Speeding up the assessment process also increases the workload of the dwindling numbers of mental health staff at YGC. The new director of the health services at YGC has a very different background and approach from that of the

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San Francisco Youth Center in Dire Need of Guidance Continued from page 23 director he replaced. While change is always stressful to some extent, that stress is usually buffered by hopes of new opportunities resulting from new ideas and new energy, especially when those changes are high up the managerial ladder. However, after a year under our new director, it has become more and more apparent that his lack of understanding and appreciation of the process of mental health assessment and intervention has left mental health staff at YGC feeling very destabilized. Our new director, being a direct service-oriented, hands-on, do-itnow physician, appears to have little time for, or appreciation of, the more measured and slower developing process of mental health assessment and intervention, especially in a detention setting, the complexities of which already include multiple adversarial systems that stress and destabilize even the most resilient youth. This latter more measured and slower developing aspect of mental health intervention is still quite valuable for those detained youth who will not be released immediately, who may spend up to a year and more in this stressful environment at YGC. Cost-saving changes in the system have resulted in the mental health staff reductions noted earlier. And “further changes” in the system, we are told, are expected. Information passed along (by word of mouth only at this point) is that a “new direction” in mental health services at YGC is desired by managers further up the hierarchy, and that these changes in direction are to be facilitated by eliminating the current mental health directors at YGC. Although this is only unpublished information, its implication sits like a heavy foot upon the necks of mental health staff at YGC, and morale maintenance is harder than ever, as

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mental health staff wonder who and how many will be sent packing. I have been asked the question, what is working in the current mental health services at YGC? Hard to say. Not much beyond the few success stories that individual mental health staff are able to report in the few mutual supervisory meetings that we can still find time for. The needs of the detained youth remain great, and most of them are still hungry for and appreciative of the individualized attentiveness that can come when they have time (lots of that when you’re locked up) and when the current staff (and not just the currently beleaguered mental health staff) can find the time. What is different is that staffing changes are shifting in the direction of more medical and pediatric personnel and fewer mental health staff. Much of the individualized care that the youth thrive on is now coming more from nursing/ pediatric clinicians (and these nonmental health staff are for the most part compassionate and skilled, and do a good job of caring for these needy youth) and less from the reduced numbers of mental health staff. Therefore, a superficial look at care delivery at YGC can give the impression of more, while a mentalhealth-oriented evaluation of care delivery for emotionally disturbed youth at YGC will show much less. And perhaps even less to come. If we are aware of the problems of transitions, as so poignantly pointed out in the book Internal Bleeding,1 we should be alarmed at the many transitions taking place currently in the San Francisco Juvenile Justice System. We are about to move into a new Juvenile Hall building, we have new leadership in probation, we have new leadership in health services at juvenile hall, we have new leadership in San Francisco child mental health (the deceased medical director was recently replaced by someone who, I am happy to report, has the full confidence of all the child psychiatrists in the San Francisco mental health system, as well as the mental health staff at YGC), and we are

about to see many more significant changes (if threats and promises are carried out) in the mental health delivery system closest to these high-risk detained youth themselves. These are the times when dropping the ball can hurt the most, and those most at risk for being hurt are the high-risk youth in detention at YGC. I hope that the next article about the mental health delivery system in San Francisco’s juvenile justice system published in this journal will be more positive and hopeful. At this point I cannot be sure who that author will be. My understanding is that s/he is being currently recruited. I plan to be around as long as allowed, hopefully long enough to help smooth out the process of whatever transitions may threaten the mental health of the high-risk youth detained at San Francisco’s YGC. Dr. Lewis is currently medical director of mental health services at SF YGC, has a parttime private practice of child, adolescent, and forensic psychiatry, is a part-time clinical faculty member of UCSF’s division of child/adolescent psychiatry, and is a member of SFMS’s Psychiatric Services Committee. REFERENCE

1. Wachter R, Shojania K. Internal Bleeding: The truth behind America’s terrifying epidemic of medical mistakes. New York, NY: Rugged Land; 2004. sfm

The SFMS Psychiatric Services Committee will hold its last meeting of the year on Monday, November 14 from noon until 1:30 p.m.

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CHILDREN’S HEALTH CARE

Working with Community Providers to Respond to Child Health Challenges Philip Ziring, MD

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he Maternal, Child and Adolescent Health (MCAH) unit at SFDPH has served the community for many decades by providing important, well recognized services such as Women Infants and Children’s Nutrition program (WIC), California Children’s Service for children with disabilities (CCS) and the Child Health and Disability Prevention program (CHDP). Recent years have brought new challenges to the children and families of our community, especially for our most vulnerable populations, and the MCAH program has developed a variety of new programs to meet these challenges. SCHOOL HEALTH PHYSICIAN LIAISON

The San Francisco Unified School District serves 60,000 children in more than 100 schools and Child Development Centers throughout the city. Children with disabilities in the special education program (including, for example, several who are ventilator-dependent and a rapidly growing number who have autism spectrum disorder) receive special services from the district’s Special Ed teachers, psychologists, speech therapists, OTs and PTs, and a group of specially trained nurses who, in cases of special medical need, may provide one-on-one care in the child’s classroom.

Other nurses in the district’s school health program provide health care coordination and health education in areas such as diabetes management, immunization and medication monitoring, asthma management, monitoring the community physician’s emergency care plans, and training in nutrition and physical activity. Other nurses and therapists provide services in several high school Wellness Centers, and in Child Development Centers for preschool children. For the last two years, I have served in the capacity of physician consultant to this complex system at the SFUSD and have assisted the district in a number of projects, including the recently revised guidelines for tuberculosis screening. I have also served to strengthen links between important DPH programs (such as communicable disease, immunizations, etc.) and assisted community physicians in gaining easier access to SFUSD health services through presentations at grand rounds and discussions at our MCAH Pediatrics Advisory Committee. I remain available to assist community physicians as needed. Please contact me at philip.ziring@sfdph.org or by telephone at (415) 575-5709. CHILD CARE HEALTH PROJECT

A group of dedicated MCAH public health nurses have been providing child

health and safety services in a number of child care centers for several years. Designed to enhance child care staff’s knowledge of child health (nutrition, immunizations, infectious disease, disaster preparedness) in centers located in some of our most economically challenged neighborhoods, the nurses also carry out screening of young children’s vision, hearing, dental and, more recently, developmental needs. It is anticipated that they will be starting to measure children’s BMI at some centers and offer training in child nutrition and physical activity to carry out primary prevention and early intervention efforts in this childhood obesity epidemic. FOSTER CARE NURSING AND UNIVERSAL HOME VISITING PROGRAMS

Public health nurses and a medical consultant from the MCAH program have provided health consultation to Department of Human Services staff in the foster care program for several years. Of the thousands of children in foster care in the city, a substantial number have significant health care needs and the staff assures that these children have access to a medical home and a wide range of other health services. The Universal Home Visiting staff of public health nurses visits the home of new parents and their babies to assist with breastfeeding, general

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CHILDREN’S HEALTH CARE

Adolescent Substance Abuse: A Public Health Priority David. C. Lewis, MD, and Kathryn Cates-Wessel

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s many as 1 in every 5 children and adolescents in the U.S. has a behavioral or emotional disorder. One in 10 adolescents who need substance abuse treatment receive it, and of those who do receive treatment, only 25 percent get enough. Twenty-three percent of adolescents who need mental health services receive them. Forty-four percent of adolescent substance abuse treatment referrals come from the criminal justice system; just 5 percent come from health care providers. WHAT CAN YOU DO?

Responding to a major opportunity for intervention by health professionals, Physician Leadership on National Drug Policy’s goal is that every primary care medical practice in states with adolescent patients will: 1. Screen all adolescent patients for substance abuse, mental health, and/or family psychosocial issues. 2. For positive screens, identify and contact a local social worker, therapist, or health care professional who is certified and experienced in working with adolescents with substance abuse and mental health problems to conduct a comprehensive assessment (see provided list). 3. Communicate with the social worker, therapist, or health care professional regarding whether the adolescent needs substance abuse, mental http://www.sfms.org

health, or other services, coordinate referral, and follow up on progress. Adolescent substance abuse is a major national public health problem. Research indicates that despite a recent levelingoff of substance use by adolescents, the current levels remain high. Studies suggest that the younger an individual is at the onset of substance use, the greater the likelihood that a substance use disorder will develop and continue into adulthood. In fact, more than 90 percent of adults with current substance use disorders started using before age 18; half of those began before age 15.1 In the area of prevention, researchers have established a list of risk and protective factors that are critical to the development and implementation of effective prevention programs. These risk factors include: the availability of drugs in the community, a family history of substance abuse, learning disabilities and other academic problems, and associating with friends who engage in problem behaviors, among others. Identifying and addressing these factors early is a critical step in the prevention and intervention of substance use problems and delinquency.2 Today, most youth who enter substance abuse treatment programs do so through the juvenile justice system. One study reports that up to 67 percent of youth involved in the juvenile justice system have a substance use problem.3

Many of these youth also have a mental disorder, which complicates the administration and efficacy of treatment. One national study found that 73 percent of youth in correctional facilities reported mental health problems during screening.4 If risk factors are discovered and treated early, adolescent substance use problems and delinquent behavior could be prevented. Unfortunately, many youth are not identified as being involved with substance use until it progresses to abuse or dependence. In the 1990s, as rates of frequent use of alcohol, marijuana and other drugs escalated, the number of adolescents entering the treatment system increased by more than 50 percent. 5 Despite this increase, this figure only represents one in ten youths who needed treatment.5 While it is clear that treatment benefits this population, adolescents present a unique challenge to the treatment community. Compared to adults, adolescents have greater problems with marijuana and alcohol, higher rates of binge use, and greater complications as a result of the developmental changes they are undergoing.1 Impulsive and risk-taking behaviors are more pervasive in this population as well, which complicates treatment. Treatment for adolescents must be tailored to these specific needs, as well as

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Adolescent Substance Abuse Continued from page 27

gender and race concerns. The largest insurer of children and adolescents in this country is Medicaid, covering 16.4 million children under the age of 22.6 Substance abuse treatment coverage varies greatly by state. In many states, services are limited to acute care of substance use problems. This limitation in coverage is in contrast to evidence that substance use problems require a comprehensive continuum of care. For adolescents covered by private insurance, a lack of comprehensive substance abuse coverage is a major barrier to accessing treatment. In order to better address adolescent substance use problems, health insurance coverage must be equal to that of other chronic diseases. The treatment sector is entering a “renaissance” of new research. “The number of studies evaluating formal substance abuse treatment programs for adolescents more than doubled from 1997 to 2001 and promises to double again within the next three years.” 7 This research has translated into advances in treatment methodology, with promising new approaches that are comprehensive and integrative and involve the families, schools, health care professionals and communities. Unfortunately, the promise of treatment is not always apparent to all health care professionals. This lack of knowledge is primarily due to the fact that physicians are not trained to recognize these problems in patients, as only eight percent of U.S. medical schools offer a specific required substance abuse component of their curricula, and this could range from a lecture course to a single grand rounds.8 The entire report from which this was excerpted is available at www.plndp.org/ Physician_Leadership/Resources/ resources.html.

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Dr. Lewis and Ms. Cates-Wessel represent the Physician Leadership for a National Drug Policy.

George Mark Children’s House Continued from page 22

REFERENCES

REFERENCES

1. Dennis ML. “Treatment research on adolescents drug and alcohol abuse: despite progress, many challenges remain (invited commentary).” Connection. Washington, DC: Academy for Health Services Research and Health Policy. May 2002. Available www.academyhealth.org/publications/ connection/index.htm. 2. Arthur MW, Hawkins JD, Pollard JA, Catalano RF and Baglioni AJ. Measuring Risk and Protective Factors for Substance Use, Delinquency and Other Adolescent Problem Behaviors: The Communities That Care Youth Survey. Evaluation Review. In press. 3. Dembo R, Williams L and Schmeidler J. Addressing the Problems of Substance Abuse in Juvenile Corrections. In Inciardi JA (ed.). Drug Treatment in Criminal Justice Settings. Newbury Park, CA: Sage. 1993. 4. Abt Associates, Inc. “Conditions of confinement: juvenile detention and corrections facilities.” Washington, DC: Office of Juvenile Justice and Delinquency Prevention. 1994. 5. Center for Substance Abuse Treatment. “Treatment episode data set (TEDS).” (And) National Institute on Drug Abuse. “Monitoring the future (MTF).” Available www.icpsr.umich.edu/SAMHDA/das.html. 6. American Academy of Pediatrics. “Improving substance abuse prevention, assessment and treatment financing for children and adolescents.” Pediatrics. 108. October 2001. Pages 1025-29. Available www.aap.org. 7. Fleming M, Barry K, Davis A, Kropp S, Kahn R and Rivo M. “Medical education about substance abuse: changes in curriculum and faculty between 1976 and 1992.” Academic Medicine. 69. 1994. Page 366. 8. Fleming M. “Competencies for substance abuse training.” Training About Alcohol and Substance Abuse for All Primary Care Physicians. New York, NY: Josiah Macy. Jr. Foundation. 1994. Page 213.sfm

1. The American Academy of Pediatrics Committee on Bioethics and Committee on Hospital Care Position Statement “Pediatric Palliative Care,” Pediatrics August 2, 2000. 2. Wolfe J. Suffering in children at the end of life: recognizing an ethical duty to palliate. J Clin Ethics 2000;11(2):15763. Wolfe J, Grier HE, Klar N, Salem-Schatz S, Ellenbogen JM, Levin SB, Emanuel EJ, Weeks JC. Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000;342:326-33. Wolfe J, Klar N, Grier HE, Duncan J, Salem-Schatz S, Emanuel EJ, Weeks JC. Understanding of prognosis and treatment goals among parents of children who died of cancer: impact on palliative care. JAMA 2000;284:246975. 3. Institute of Medicine. When children die: improving palliative and end-of-life care for children and their families, National Academies of Sciences, 2003. 4. National Consensus Project for Quality Palliative Care, Clinical Practice Guidelines for Quality Palliative Care; May 2004. 5. Hilden and Tobin with Lindsay. Shelter from the Storm: Caring for a Child with a Life-Threatening Condition. Perseus, 2003. 6. Last Acts, APON, National Association of Neonatal Nurses. Precepts of palliative care for children and adolescents and their families. Last Acts June 2002. sfm

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CHILDREN’S HEALTH CARE

The Advent of a Childhood Immunization Registry in San Francisco Andrew J. Resignato and Che Waterman

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accines have come a long way since the polio vaccine was first given to children 50 years ago. Vaccines are more effective, safer, and used to prevent more diseases than ever before. While immunization technology has improved tremendously, our ability to successfully track an individual’s immunization history still remains a challenge. Many health care providers do not have a consistent method for assessing accurately the immunization status of their patients. “Without an effective system in place, some health care providers have frequently overestimated the proportion, of their patients who are fully immunized, says Path Fu, Pediatric/Adolescent Immunization Program Coordinator for the city of San Francisco. “Parents often do not know the immunization status of their children, and most parents do not know when an immunization appointment is missed or due.” One of the most effective ways to deal with the issue of systemized vaccine tracking is through the use of populationbased computerized childhood immunization registries. Childhood immunization registries are confidential, computerized information systems that collect vaccination data about all children within a geographic area. In a population-based immunization registry, children are entered into the registry at birth, often

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through a linkage with electronic birth records. A health care provider also can initiate a registry record at the time of a child’s first immunization. If a registry includes all children in a given geographical area and all providers are reporting immunization information, a registry can provide a single data source for all community immunization partners. A population-based immunization registry can make it much easier to carry out the demonstrably effective immunization strategies that prevent disease and decrease the resources needed to achieve and maintain high levels of immunization protection. One of the national health objectives for 2010 is to increase to 95 percent the number of children under six years of age whose immunization histories are in fully operational population-based immunization registries. The concept of immunization registries is not new. Many individual practices and health plans administer immunizations to their patients. Records of these immunizations often are based on computerized information systems designed for other purposes such as billing. The fact is that diseases and patients move from one location to another, rarely remaining in the system of just one health care organization. A population-based system creates a seamless network allowing access to patient’s immunization histories regardless of the health care

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provider. If a child receives vaccines from the Santa Clara Public Health Department, and then the Mission Neighborhood Health Center in San Francisco, and then La Clinica de la Raza in Oakland, with the help of a populationbased immunization registry the child’s updated immunization history can be easily accessed by all of these providers. Private practices and large clinics that provide immunization can benefit from the systemized approach that a registry affords. Benefits include: • Easy access to patient immunization records, including immunizations that were given by other practices and clinics. • Precise tracking of contraindications and precautions for each patient. • A reduction in staff record-keeping and handwriting errors by printing the California Immunization Record (yellow card), the immunization section of the Child Health and Disability Prevention (CHDP) form, and a patient’s complete immunization history, including lot number and Vaccine Information Statement (VIS). • The automatic tracking of new

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vaccines and changing immunization schedules and recommended vaccines that patients need, based on current American Academy of Pediatrics (AAP) and Advisory Committee on Immunization Practice (ACIP) recommendations. • Simple generation of practice data needed for Health Plan Employer Data and Information Set (HEDIS) reporting, vaccine usage reports, immunization rates, and lists of patients who are overdue for immunizations. • A reduction in malpractice insurance as registries reduce the number of shots administered, and readministered, reducing the possibility of adverse events. • Allowing users to print postcards to notify patients of immunizations they need, and the tracking of vaccine inventories by lot number and manufacturer. “The immunization registry in Santa Clara County has been operative in my practice office almost since its inception,” says Waldemar Wenner, MD, a privatepractice physician. “In prospect, it appeared to have many advantages; in practice, it has repeatedly shown its worth. We can check on prior shots, we can easily provide records for families and schools, etcetera.” By tracking who in a given population is vaccinated, a registry also provides a precise instrument for public health workers to monitor disease outbreaks and provide for better control of vaccine-preventable diseases. Eventually, this immunization data will be rolled into a national electronic medical record for each patient. In most registries, patients can opt out of having their records shared, honoring their right to medical privacy. The majority of individuals in states and cities with well-populated operational immunization registries choose to share

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their own or their children’s immunization histories as it is more convenient and can better protect their health. The San Francisco Immunization Coalition is working closely with the San Francisco Department of Public Health to install the California Automated Immunization Registry (CAIR) software throughout private and public medical offices in San Francisco that provide childhood vaccinations. CAIR is a webbased software application with multiple functionalities designed to systematize the delivery and tracking of vaccines. The software hooks into a regional database called the Bay Area Regional Registry (BARR), which links the immunization histories of patients from several counties including Alameda, Marin, San Mateo, San Francisco, Solano, San Benito, Santa Clara, Sonoma, and Napa and the city of Berkeley. San Francisco has been a member of the BARR group since November 2003 and currently has over 23,000 patients in the registry database, representing 15 percent of children less than five years of age. The challenge lies in the implementation of immunization registries. In San Francisco, the San Francisco Immunization Coalition has a registry consultant who assists providers with integrating the CAIR system into their practice. Providers who wish to participate only need a computer workstation, DSL Internet connection, and a printer. In many cases providers are unaware of the aggregate benefit an immunization registry will provide for their practice. Dr. Ruiz, lead pediatrician at the San Francisco Mission Neighborhood Health Center, was one provider who was skeptical about the registry. “Before integrating the registry into our pediatric practice, I thought it was going to be more work for my staff. After implementation I realized that the registry actually saved staff time and had many other benefits I did not anticipate.” In San Francisco local participation

in BARR currently includes the Saint Anthony Free Clinic, the Mission Neighborhood Health Center, Northeast Medical Services, and several other private practice providers. A goal of the San Francisco Immunization Coalition is to have all providers and school health systems in San Francisco using the CAIR software and BARR database. The BARR database will soon be HL7 compliant, meaning that all of the patient records will be in a nationally standardized format, allowing the BARR data to eventually be rolled into a national immunization registry. The San Francisco Immunization Coalition has invited the health care community to provide resources and input for the building of the registry. This includes attending coalition planning meetings and working with community partners in San Francisco. With the cooperation of providers and community partners, the dream of easily accessible, precise, electronic immunization record keeping is well within reach. To learn more about how to integrate the BARR into your practice or get involved in the building of the immunization registry, call the San Francisco Immunization Coalition at (415) 554.2567 or email andrew @sfimmunize.org. Andrew J. Resignato is the Director of the San Francisco Immunization Coalition, a community collaborative organization working to improve San Francisco’s immunization infrastructure and educate all San Franciscans about immunization. Che Waterman is a nursing student at San Francisco State University and an intern with the San Francisco Immunization Coalition. sfm

Best Wishes for a Peaceful and Happy Holiday Season from the San Francisco Medical Society

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CHILDREN’S HEALTH CARE

Kiss It Better—A Systems Approach to Treatment of Delinquency Ray Curtis, LCSW, BCD

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nce, while working with a youngster, using the halffull, half-empty-glass analogy, I posed the question whether he was an optimist or a pessimist. His response was that perhaps the glass was just the wrong size. When challenged to discuss the issue of criminal vs. mental illness as the source of behavior that we call delinquent, I have found myself struggling with what seemed like an attempt to seek answers when we had incorrectly stated the question. One issue we may want to consider is that the prevalent paradigm used in medical care today is the use of the disease model. The model has been highly successful when there is a clearly identified causative component (e.g., virus or bacteria) and a clear outcome (such as such death or disability) and when there is an effective remedy such as a medication (penicillin). When we look at a behavior, such as delinquency, the causes, outcomes and treatments are numerous and complex. Our awareness of that complexity suggests that we are better to adopt a systems approach to the issue. A systems approach would suggest that we should address both the systemic causes of the problem and a systemic approach to their treatment. CAUSES OF DELINQUENCY

Emotional, physical and sexual abuse and/or neglect results in many youth who

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externalize their pain through antisocial behaviors. Often, children use aggressive behaviors to protect themselves from the pain and risks of closeness. Many youth “self-medicate” with street drugs. (Watch television if you want to see the promise of a better life through medication.) They also participate in a subculture and economic system built around drugs. (How many delinquents get an allowance? Where do they get their money?) Our social services and mental health systems are underfunded and overwhelmed. Because all of these issues have been considered a medical problem, care is now managed and severely limited. In the words of one policeman, “When cops are called because a guy is acting crazy, the only option is to bring him to jail where he is caught up in the whirlpool of the justice system.” Instead of treatment, we have shifted the cost to the juvenile justice system. Should we consider our prisons a part of the continuum of care? (Imagine a managed care system deciding lengths of stay in our prisons!) TREATMENT OF DELINQUENCY

The disease model says, “Diagnose, stabilize, medicate and discharge.” Discharge usually means, return the child to the environment that disturbed him or her. Once the child is there, the medication that at least kept the child tranquil is no longer affordable or available. More critical

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is the fact that the medication has not taken away the sadness/fear/rage that comes from trust betrayed. Behavioral approaches have emphasized punishment and rewards over relationships, and relationships are the foundation upon which conscience is built. Even though there are changes in behaviors, they are not internalized and the punishment and rewards (especially rewards) are not sustained in the real world. Good treatment provides an environment where children know they are safe, that they will not be hurt or allowed to hurt others. Adults must provide care that the children can learn to trust. We will only learn from and emulate those we trust. All of us can name someone, a parent, relative, mentor or teacher, who changed our life and whom we still honor with our efforts. Good treatment requires sufficient time for relationships to form and views medication as a means to make children available for the forming of those relationships and never as an end of treatment. Trust can be challenged when they must leave our care when we, and they, know they are not yet ready. OUTCOMES OF TREATMENT

Behavioral and medication approaches can achieve rapid changes that are not sustained when the tools of those methods are withdrawn as a child leaves care, with a

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resultant high recidivism rate. Punitive programs toughen the defenses of delinquents and even teach them more sophisticated antisocial skills. The disease model allows patients to escape from the inevitable dilemmas of real life. It can also keep us from facing our responsibility for the welfare of the children and families that we serve. There is a great risk that we can allow managed care, limited resources and neglectful care to be the excuse for our failure to heal those children. We must become not only healers, but also advocates for what they truly need. We must stop building prisons and start building children. Finally, we need to remember that wonderful time (at least for many of us) when the magic of a healing mother whom we loved and who loved us could heal us by kissing it better. We need to always consider love as the catalyst that makes all of our techniques healing.

Ray Curtis, LCSW, BCD, was social service director from 1973, until his retirement in 2003, at Forest Heights Lodge (a psychiatric facility for children and adolescents) in Evergreen, Colorado. He received a BA degree in psychology from Arizona State University in 1960 and a master’s in social work from the Denver University Graduate School of Social Work in 1963. He was a therapist in individual, family and group settings and a field instructor for graduate student social workers and psychology interns. He continues as a part-time therapist and consultant at Forest Heights Lodge. He also continues to conduct trainings throughout the U.S. and Canada using the attachment model for addressing the needs of emotionally disturbed children. He is best known for his workshop on “Discipline and Control as Nurture.”sfm

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SFDPH Responds to Child Health Challenges Continued from page 26 medical and mental health assessment and other needs to assure that newborns get off to the right start in life. SHAKEN BABY SYNDROME PROJECT

MCAH staff have become increasingly alarmed by the increasing numbers of infant victims of Shaken Baby Syndrome and are working to develop an education and intervention program for the newborn nurseries of the five delivery hospitals in San Francisco. An interdisciplinary committee that includes members from these hospitals has been reviewing materials currently in use in successful programs in other parts of the U.S., and has started adapting them for use in this culturally diverse community. Child health care providers in our community who would like to know more about this effort or assist in this work can contact Ms. Carol Schulte, MSW, at carol.schulte@sfdph.org. These are some of the projects currently under way in the MCAH program. We would be interested in hearing from the medical community regarding these and other SFDPH projects of particular interest to them. Dr. Ziring has been medical director of the Child Health and Disability Prevention program and physician liaison to the San Francisco Unified School District for the San Francisco Department of Public Health since 2003. He graduated from the NYU School of Medicine in 1962, trained in Pediatrics at UCSF and NYU, served for two years with the U.S. Army, and embarked on a long career in academic medicine in New York, New Jersey, San Francisco, and Chicago. Before returning to the Bay Area and accepting an appointment to the SFDPH, he was Professor and Chairman of the Department of Pediatrics at the Chicago Medical School and Cook County Hospital.sfm

All SFMS members are cordially invited to the Annual Dinner Celebrating the installation of our 2006 President Gordon L. Fung, MD and the 138th year of the San Francisco Medical Society Thursday, January 26, 2006 Delancy Street Catering, Town Hall 600 Embarcadero Cocktails: 6:30 pm. Dinner and program: 7:30 p.m. Black Tie Optional Parking Available Mail Your RSVP back by January 16, 2006. Call Posi Lyon at (415) 561-0850, ext. 260 with any questions. Come join your colleagues and mentors for a night of history and fun.

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Perspective: Children as Ancestors Mike Denney, MD, PhD

Now I lay me down to sleep, I pray the Lord my soul to keep. If I should die before I wake, I pray the Lord my soul to take. —children’s bedtime prayer, 18th century

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raditionally, human beings have honored the souls of their ancestors. In ancient tribes the elders often called upon the ancestors to provide wisdom and guidance for their living progeny. Today, such rituals continue in the form of fond memories of bestowed wisdom from departed parents and grandparents, lore about the feats and the foibles of adventurous deceased relatives, and nostalgic genealogy to reveal accomplished, revered, and sometimes famous ancestors within the family tree. How, then, do we remember the souls of babies and children who so sadly die before they wake? How can we acknowledge their fervent bedtime prayer for the Lord their souls to take? These children die before they achieve an age of knowledge, before they can offer guidance to others, before they can engage in adventurous feats or careers of accomplishment, before they have a chance to become famous, and before they can produce offspring, thereby denied even a quiet niche on a genealogy chart. In the face of this most grief-laden event in human experience—the unfulfilled potential, the lost dream of a life well lived, the vanished hope for the future—what in our traditions and mythology can guide us as we seek to honor and revere those who die young? What wisdom might we ask from these childrenancestors who have been so rudely deprived of so much of the experience from which to respond? In a world in which before the 20th century one out of every three children died before the age of five, we might expect to find a rich mythology surrounding these tragic events. But the stories about the souls of deceased children are very mixed in their meanings. In The Parable of the Mustard Seed from India, a woman carries her dead child from house to house, ending her grieving only after learning from the Buddha about the impermanence of all things. The Hopi creation story includes an event in which tribe members see a deceased little girl playing in a deep hole in the earth and thereby learn about souls and an afterlife. In an old Japanese myth, as punishment for causing sorrow to their parents, children who die are sent to Sai no Kawara, the river of souls, and forced there to pile stone upon stone. They are then saved by the god Jizo, who hides them in the sleeves of his robe. In European lore, children who have died return to tell their

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parents to stop grieving. In a Grimm’s fairy tale, for example, a deceased child complains to his mother that he cannot sleep because his burial shirt is soaking wet with her tears, and other stories tell of departed children returning to exhort their parents to stop crying and let them rest! Our tradition seems wanting for a definitive cultural mythology about the deaths of children. We are left with images of little cherubs in heaven, and even those are mixed blessings—some religions teach that children who die go directly to heaven, even may become angels, while others note that because of original sin children who die before they reach an age of choice must remain forever in Limbo. As in this issue of San Francisco Medicine we review treatment of illnesses in children and adolescents, even reflect upon a first in pediatric palliative treatment—a hospice for respite and end-oflife care for children and teens—where might we turn for deeper understanding of our soulful Children’s Bedtime Prayer? Perhaps we must turn directly to the child who has died. In Antoine de Saint-Exupery’s great novel, the Little Prince doesn’t exactly die, but he has been forced to leave his own planet, and, like children who die, he will remain forever a youth. The Little Prince admonishes, “Grown-ups never understand anything for themselves, and it is tiresome for children to be always and forever explaining things to them.” Looking out of his window at a child’s grave surrounded by green fields brushed by the summer wind, the clouds overhead, the sunshine, and the flowers, the British journalist and poet Leigh Hunt reflects, “The sight of this spot does not give us pain. So far from it, it is the existence of that grave which doubles every charm of the spot; which puts a hushing tenderness in the winds, and a patient joy upon the landscape; which seems to unite heaven and earth, mortality and immortality, the grass of the tomb and the grass of the green field; and give a more maternal aspect to the whole kindness of nature.” And, as for that wisdom we can glean from departed children, we might turn to the great poet Rainer Maria Rilke: Listen to the voice of the wind and the ceaseless message that forms itself out of silence. They sweep toward you now from those who died young.

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In Memoriam Nancy Thomson, MD, MPH

HILLARD J. KATZ, MD

Dr. Hillard J. Katz passed away April 2, 2005, at his home in San Francisco. He was nearly 87 years old. Born in Stockton, May 26, 1918, he graduated from UC Berkeley in 1939 and entered UCSF, with which he was associated for 66 years. He served his internship there and completed his residency in cardiology in 1945. In 1948, he opened a private practice in downtown San Francisco. He began teaching at UCSF in 1953 as an assistant clinical professor and was made clinical professor in the cardiovascular division in 1970. He was chief of staff from1964 to 1966, after which he developed and ran the Coronary Care Unit through 1973. He served as chairman of the National Committee on Coronary Care from 1974 to 1976. He was a fellow of the American College of Cardiology and the American Heart Association, where he received the Distinguished Service and Service Recognition awards. During his longtime membership in the California Heart Association, he served as director from 1956 to 1971. As a member of the San Francisco Heart Association, he served as president from 1955 to 1971. He also served as president of the California Academy of Medicine and president of the UCSF Alumni-Faculty Association. He was a member of the San Francisco Medical Society since 1948. After his family and medicine, Dr. Katz’s loves were wine and food. He was member and president of the Society of Medical Friends of Wine, and a member of the Wine and Food Society of San Francisco, the Commanderie de Bontemps de Modoc et des Graves and the Confrarie des Chevaliers du Taste-vin. He also belonged to the Club Culinaire Francais de California, the Cercle de L’Union and the Commanderie de Bordeaux in San Francisco. Dr. Katz supported a host of charities connected to UCSF, the San Francisco cultural community and the Cal Band. He was a member of Phi Beta Kappa and Alpha Omega Alpha. He held season tickets to the 49er games since the team was formed in 1946. He is survived by his wife of 56 years, Jeanette Lillian Gordon, his sister, Marjorie Adasleweiz, his son, Stephen, daughters Stephanie Katz and Hilary Hausman, and three grandchildren. S. WILLIAM LEVY MD

Dr. S. William (Bill) Levy passed away at his home in Kentfield, Marin County, on May 6, 2005, at age 84, after a brief illness. He was born September 28, 1920, in the Mission district of San Francisco. He helped his family during the depression years by selling newspapers at the corner of 16th and Mission. As a teenager, he was president of the student body at Lick-Wilmerding High School and earned the rank of Eagle Scout in 1936.

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Dr. Levy initially attended the College of Marin, traveling from San Francisco by streetcar, ferry and interurban railway. In his sophomore year he transferred to UC Berkeley, receiving his bachelor of science degree from UCSF College of Pharmacy in 1943. After working two years as a pharmacist, he attended UCSF Medical School and simultaneously enlisted in the Navy V-12 program. While giving medical care at San Francisco General Hospital, he contracted tuberculosis. Despite this medical setback, he graduated from medical school in 1949. He interned at San Francisco General Hospital, Massachusetts General Hospital in Boston, and Bellevue Medical Center in New York City. After completing this training, he was chosen as chief resident in dermatology at UCSF. He opened his practice of dermatology at 450 Sutter Street in San Francisco in 1953. During his 35 years of practice, he served patients from San Francisco and around the Bay Area, the United States and many other countries. He served on the staff of UCSF, Mt. Zion, San Francisco General and CPMC (Pacific campus). His present wife, Elisabeth, had come to work for him as his office nurse. Born in Switzerland, she had a knowledge of German and French that helped greatly in communicating with some of his patients. Dr. Levy became interested in skin problems of amputees and joined the biomechanics laboratory at UCSF to make it possible for them to wear their prostheses comfortably. This work led him to publish a pamphlet “Stump Hygiene” in 1961, which has been distributed in 19 countries and is still in print. He also wrote a book, Skin Problems of the Amputee, in 1983. This outlines successful methods of treatment and is widely used by dermatologists, orthopedic surgeons, prosthetists, rehabilitation workers, physical and occupational therapists, family practitioners and nurses. Dr. Levy also wrote the first paper on dermabrasion on the West Coast. This proved effective for removing acne scars and people born with certain defects of the facial skin. What began as an experimental technique that Dr. Levy brought from his practice in New York is now a routine procedure. In recent years, Dr. Levy maintained an office in Greenbrae close to his Marin County home. His compassion for patients and quality of care were widely recognized. He commonly visited the homes of patients who were too sick to visit his office and also saw patients in his own home outside his regular office hours. During his 52 years of practice, he and his wife enjoyed traveling to countries all over the world where he gave educational lectures and attended meetings with colleagues. He is survived by Elisabeth, his wife of 31 years; son David with his wife, Rita, of Roslyn, New York; daughter Ann Rhoads and her husband Jeffrey, of Las Vegas; his brother Mike and wife Beverly of

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HOSPITAL NEWS ■ Chinese

■ CPMC

■ Kaiser

Fred Hom, MD

Damian Augustyn, MD

Bruce Blumberg, MD

Preliminary data analysis has begun for the six- and 12-month follow-up of participants in the Chinese Community Smoking-Cessation Project. According to Dr. Candice Wong of UCSF and principal investigator, the difference in abstinence rates was much higher among the outpatient participants, rather than between inpatients who received intensive counseling compared to outpatients who only received minimal counseling. I am working as coinvestigator with Diana Lau, to see that these final analyses will be forthcoming. The project presented two abstracts at last year’s 12th Conference on Health Care of the Chinese in North America. I presented “Nicotine Dependence and Readiness to Quit among Chinese Patients.” Although a majority of Chinese smokers were found to be light users, their smoking behaviors indicated high nicotine dependency. Substantial numbers were not ready to quit within the next month, but many had a goal of “slowly cutting down” on smoking. Dr. Wong spoke on the “Differences in Tobacco Use, Nicotine Dependence and Readiness to Quit Between Inpatient and Outpatient Chinese Smokers.” Inpatient Chinese smokers were significantly older, were light smokers, had a lower nicotine addiction score, and were more confident of becoming successful quitters compared to outpatients. Smokers of Chinese nationality can still be enrolled; call (415) 719-3900. This month’s JCAHO reminder: Sign, date and time all orders, and cosign, date and time all phone and verbal orders within 48 hours! sfm

On September 9, the Department of Orthopedic Surgery at CPMC hosted its First Annual Orthopedic Surgery Education Day at the Cathedral Hill Hotel. The program, which was attended by almost 100 physicians, focused on advance shoulder surgery techniques and concepts. The goal of the meeting was to present clinically proven information regarding a full spectrum of treatment options for shoulder surgery. A distinguished faculty including members from our own Department of Orthopedic Surgery presented their extensive experience in shoulder arthroscopic diagnostic techniques, shoulder arthroplasty and treatment options for arthritis and trauma. Questionand-answer sessions were interspersed during the event, enabling participants to actively engage leading practitioners in all aspects of shoulder surgery. The Third Annual CPMC Pain Management Symposium was held on Saturday, October 1, at the Cathedral Hill Hotel. The half-day conference, attended by almost 250 physicians, explored various topics in pain management and end-oflife care in the hospital and outpatient setting. Attendees will receive up to four CME credits that can be applied toward the 12 hours required for license renewal by December 2006. Early feedback from attendees suggests that it was one of the best programs sessions held to date. The last in our series of four symposiums is tentatively scheduled for May 2006. Next year’s conference will feature a full day of presentations with a focus on complementary and integrative medicine. Physicians attending the course will be eligible for 8 hours of pain management CME.sfm

Obesity is an epidemic among children and young adults in this country. Overweight children are at risk for diabetes, sleep apnea, orthopedic problems and fatty liver. At Kaiser Permanente San Francisco, our pediatricians and specialists have developed innovative programs to help children lose weight safely and make healthy lifestyle changes. Key to the success of the programs is our commitment to work with the whole family, to encourage them to incorporate exercise into their daily routine, and to change eating habits so they are cutting down on sugar and eating more vegetables, fruits, protein and whole grains. Three years ago, Scott Brown, manager of Health Education, and Louise Greenspan, MD, a pediatric endocrinologist, started the pediatric weight management program, an intensive 19week regimen. The five-month program is designed for overweight and obese children—those at risk for related health problems such as diabetes, high blood pressure and heart disease. Participants, ages 8 to 16, have lost an average of 20 pounds; typically, the reduction in body mass index is four or five points. The children work with a team of experts including a pediatric endocrinologist, a dietitian, a physical therapist and a social worker. The kids learn a whole new way of eating and they commit to a regular exercise schedule. Another program, called the Passport Clinic, is designed for children who are obese and have at least one additional health problem. Again, a team of experts— a pediatric endocrinologist, a nutritionist, a health educator and a pediatric behaviorist—helps kids control their health issues by making lifestyle changes, like agreeing to give up sweet drinks. One change can make a big difference. sfm

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HOSPITAL NEWS ■ Saint Francis

■ St. Luke’s

■ St. Mary’s

Guido Gores, MD

Jerome A. Franz, MD

Kenneth Mills, MD

At its Centennial Gala held in September, Saint Francis Memorial Hospital presented San Francisco with a Gift to the City in honor of its 100th anniversary: $500,000 in grants to six community organizations that will address local health issues from a variety of standpoints, including planting 100 trees in neighboring communities in honor of the centennial. The Gift to the City contributions were awarded to Glide Health Clinic; St. Anthony’s Free Medical Clinic; South of Market Health Center; Curry Senior Center; Bay Area Women’s and Children’s Center; and Friends of the Urban Forest. “These gifts are a reflection of our commitment to improve the quality of life in our community,” says Saint Francis President/CEO Cheryl A. Fama. “The funds will support facility and program expansions that tie directly to the needs and priorities identified in our Community Benefit Plan, while also ensuring that primary care will be delivered both at a more appropriate level of care and in a more appropriate setting than the Emergency Department.” The Gift to the City was not the only surprise at the gala event. Proclamations from House of Representatives Democratic Leader Nancy Pelosi, Governor Arnold Schwarzenegger, Lieutenant Governor Cruz Bustamante, State Senator Jackie Speier, and San Francisco Mayor Gavin Newsom were presented to Board of Trustee President James Woolwine and Board of Trustee Secretary Caryl Ito. A special video was shown including acknowledgements from U.S. Senator Dianne Feinstein, Mayor Newsom, Board of Supervisor President Aaron Peskin, and Reverend Cecil Williams, just to name a few. More than 900 physicians, staff and friends of Saint Francis enjoyed the evening’s festivities. But we are not finished yet with our Centennial Celebration. Beginning this month, San Franciscans are invited to enjoy the Saint Francis Memorial Hospital historical exhibit at City Hall’s South Light Court. The exhibit includes memorabilia from our early days and intertwines the hospital’s history with San Francisco’s. I invite my colleagues from the SFMS to stop by and take a glimpse of our history. sfm

St. Luke’s is in mourning. As many of you already know, Ernesto Puletti died of a cerebral hemorrhage on October 8. As vice-chief I shall take his place until July. Hundreds of people filled St. Paul’s Church on October 12 for his funeral and came to the hospital afterward for a reception. We heard a eulogy read by William Miller, MD, which emphasized Dr. Puletti’s devotion to his patients and to the mission of St. Luke’s as a hospital for people of all economic and cultural backgrounds. Ernesto served the community for 39 years. He is survived by his wife, Maria Cristina, who was the head of social services at St. Luke’s for many years and is now a leader of the hospital auxiliary. On the day of the funeral we also lost David Haskin, MD, after a five-year battle with colon cancer. David retired at the end of June. As a pediatrician he had worked at St. Luke’s since 1952, chaired his department, and served as both chief and vice-chief of staff. I was honored to be his physician. His patients became very attached to him and stayed with him long after their childhood years. He occasionally sent me new patients in their thirties. He was a vocal critic of our previous administration and a strong advocate for improvement at St. Luke’s. Along with the Episcopal Diocese we are bidding farewell to Reverend William Swing, Bishop of California, who has been on our board of directors since 1980 and will retire at the end of the year. He has been highly respected and loved by all who know him. Still hale and young for his years, he will continue his work to bring people of different faiths together for peace and social justice. sfm

In keeping with the theme of pediatric and adolescent medicine, St. Mary’s continues its commitment to the community with our Adolescent Psychiatric Services as part of McAuley Behavioral Health. McAuley is the only nonprofit inpatient psychiatric care provider for adolescents in San Francisco and the city’s youth, families, courts and child crisis workers have come to depend on its services. Founded in 1954, McAuley has a history of providing high-quality, accessible mental health services to an underserved population with wide-ranging psychiatric needs. While some children have private insurance, 30 percent have only Medi-Cal coverage. Grants and private contributions ensure that we can serve any child in need regardless of ability to pay. An estimated 55 percent of the adolescents in the inpatient unit are victims of sexual or physical abuse. Many have been in chaotic home environments since birth and some have been living on the street. Others have experienced a mental health crisis despite a stable home life. Many exhibit behaviors that pose a danger to themselves or others. McAuley offers a full continuum of care for adolescents ranging in age from 12 to 18 years. In addition to the inpatient unit, we provide partial day hospitalization, transitional services and our Adolescent Day Treatment Center. Our goal is compassionate care for kids in crisis and helping young people regain a sense of stability and self-sufficiency in their lives. And because we operate within the structure of the medical center, we can also address the complex needs of patients with combined medical and psychiatric problems. We consider these essential services to our adolescents as an investment in the future. sfm

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HOSPITAL NEWS ■ SFGH

■ UCSF

■ Veterans

Andre Campbell, MD

Linda M. Reilly, MD

Diana Nicoll, MD, PhD

Hurricane Katrina and now Hurricane Rita have had a devastating impact on the people in Louisiana, Mississippi, Alabama and Florida. As medical care provider, you must have had feelings of outrage and anger when you heard and read about 30 patients who died in a flooded nursing home in Chalmette, Louisiana, when staff members left behind the elderly residents in their beds. There are a number of other stories where the very young and very old suffered from various complications or death because of problems with resources. The question we are all asking ourselves here in San Francisco is, “Are we ready to deal with a large earthquake that is predicted to strike our region in the near future?” The SFGH hospital disaster planning committee, which is chaired by William Schecter, MD, has been looking at ways to improve how we respond to natural disaster or a potential terrorist attack. Hurricane Katrina and Rita should serve as a wake-up call for all of us to take disaster drills and disaster preparedness more seriously. As a medical staff, we need to be mobilized, sometimes on short notice. The Mayor’s Blue Ribbon panel on the SFGH future location had its concluding meeting and the final decision was that the hospital should be built at the Potrero site location. The mayor has already gone on record stating the bond issue will need to be $1 to $1.2 billion for this project. The SFGH medical staff felt very strongly that the hospital should be located at Mission Bay. The finances made it an impossible option given the city’s current economic climate. In addition, UCSF has already purchased most of the land in Mission Bay for the future Children’s hospital, Women’s Hospital and possibly future Cancer Center.sfm

A series of six clinical trials starting this fall at UCSF Medical Center and UCSF Children’s Hospital will investigate the promise of immunomodulatory drugs to postpone further destruction of insulin-producing beta cells in those with the recent onset of type 1 diabetes. Pediatric diabetes clinic director Stephen Gitelman, MD, is principal investigator of the trials, which are open to newly diagnosed type 1 diabetics ages 8 to 35, and within six weeks to 12 months from diagnosis. These NIH-sponsored trials are part of either the Immune Tolerance Network (ITN), headquartered at UCSF, or TrialNet. There are also studies under way to screen unaffected family members to determine their risk for progression to type 1 diabetes, and prospective trials that will attempt to block this progression in those found to be at risk. The current trials follow up on the promising results with a humanized monoclonal antibody against CD3 (hOKT3g1 (ala-ala). A two-week treatment with this drug has been shown to protect beta cells from further autoimmune destruction up to two years later. As a result, the treated group maintained significantly better metabolic control over time. A recent study in Europe with a related drug has corroborated these findings. Several of the new trials will further investigate the use of hOKT3g1(ala-ala) in new onset diabetes, either alone or in combination with other agents. This includes plans to use this drug prior to the onset of diabetes, to determine if it can prevent diabetes. The investigators are also evaluating other agents to determine if they may be even more beneficial in prolonging the honeymoon period. For more information about the trials, go to www.diabetes.ucsf.edu/clinical_trials. sfm

The San Francisco VA Medical Center (SFVAMC) opened the VA San Bruno Outpatient Clinic located at 1001 Sneath Lane in San Bruno on August 23, 2005. The new clinic serves the primary-care needs of veterans in the northern San Mateo County area. The clinic director is Ronald S. Strauss, MD. The secretary of the Department of Veterans Affairs, R. James Nicholson, was the scheduled guest speaker at the clinic dedication ceremony on October 26, 2005. Virtual colonoscopy (VC) uses the data acquired from helical CT and combines it with advanced graphical software to generate twodimensional and three-dimensional views of the colon. Not only can VC detect colorectal polyps and cancers but it can also find cancers and other clinically important conditions outside of the colon that would be missed with standard colonoscopy, as reported in a large study led by Judy Yee, MD, chief of radiology, in the August issue of Radiology. Dr. Yee and her colleagues performed VC on 500 men (mean age of 62.5 years), including 194 (39 percent) considered to be an average risk and 306 (61 percent) at high risk for colon cancer. Of the 500 patients in the study, 315 (63 percent) had extracolonic findings. Fortyfive (9 percent) patients had clinically important extracolonic findings such as renal cell carcinomas and aortic aneurysms. The mean additional cost per VC exam to work up the important findings was $28.12. It was concluded that a substantial number of both average and high-risk patients undergoing VC had clinically important extracolonic findings. No increase in morbidity or mortality was associated with the additional evaluation of extracolonic findings. The cost of evaluating these lesions was low given the potential for positive impact on patient care. sfm

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In Memoriam Contnued from page 35 (S. WILLIAM LEVY, MD)

Novato; four grandchildren, and numerous nieces and nephews. All were close to him and will miss him greatly. EDWARD ALBERT SMITH JR, MD

Dr. Edward A. Smith Jr. passed away August 23, 2005, at the age of 85. Born in New York City, May 1, 1920, he graduated from the University of North Carolina and the University of Pennsylvania Medical School in 1944. He interned the following year at the Naval Hospital in Philadelphia and served in World War II in the Pacific Theater as a Lt. JG. He finished his residency in pediatrics and, with his wife of 56 years, Hope, whom he had met as a wartime volunteer for the deaf and blind unit at the Naval Hospital, moved to San Francisco. He served on the pediatric staff of the then Children’s Hospital for over 40 years. His practice also included service as a medical adviser to the San Francisco Juvenile Justice Commission, work with various public health agencies and at the student health clinic of Hastings College of Law. During the Korean War he had been called back into the Navy and served as a medical officer on troop ships crossing the Pacific. Dr. Smith and his wife were avid sports fans, 49er season ticket holders from the first game at Kezar Stadium, and later, supporters of ice hockey in San Francisco. They treasured the companionship of their many Labrador and Golden Retriever dogs. After retirement in 1982, they moved to San Rafael. His wife and many loving neighbors and friends will miss his charm, wit and compassion. PHILIP R. WESTDAHL, MD

Dr. Philip R. Westdahl, a pioneer in breast cancer surgery, passed away September 16, 2005, at the age of 93. He was visiting his daughter and son-in-law in Washington State when he fell two weeks earlier, breaking his hip, and failed to recover from pneumonia surgery. One of three brothers, Dr. Westdahl was born February 11, 1912, in San Francisco, http://www.sfms.org

where he completed elementary school and was class president and crew captain at Galileo High School. He graduated from UC Berkeley and attended Stanford Medical school graduating in 1939. He began his surgical residency under Dr. Emile Holman at San Francisco General and Stanford Hospitals. He joined a reserve unit, the 59th Evacuation Hospital of the Army Medical Corps, and he and many of his colleagues were called to active duty in 1942. The Westdahl family had a family home on the Russian River. Visiting there when he was 24, he met 16-year-old Georgia Richardson, whose family also had a home there. He invited her to a picnic he had planned for a group of local children and five years later they were married at St. Luke’s Episcopal Church in San Francisco. After training for the South Pacific at Fort Ord, the unit was sent to Camp Pickett to wait for deployment. They were sent to Casablanca, Morocco, arriving on Christmas Eve. A few months later, he learned that his daughter Laurie had been born on his 30th birthday, February 11. It was hard for the young couple to be separated but they kept in touch by near daily letters and by weekly baby photos Georgia would send to her husband. He also kept notes of his experiences at the evacuation hospital which he later transcribed into a book which may be found in the Stanford Library. The unit followed the invasion of Sicily, Anzio Beach, the Rhone Valley and finally Germany. One morning in Germany he had strolled up to the autobahn after his shift finished to photograph the sunrise. He heard a voice çalling “Kamerad, Kamerad,” from the other side of the road and a teen-aged German emerged with his hands up and head bleeding. After taking him prisoner, Dr. Westdahl promptly took an X-ray and, under local anesthetic, extracted a bullet from above his ear. The soldier survived and Dr. Westdahl kept that bullet on his key ring, even showing it to the paramedics who responded after his hipbreaking fall. Returning to San Francisco, he began his surgical practice treating his patients with the same empathy and compassion. He specialized in breast cancer and with the advent of mammography and the diagnosis of ductal carcinoma-in-situ, he pioneered the

lumpectomy rather then the more invasive mastectomy. He was a member of the San Francisco Medical Society, the CMA, AMA, the San Francisco Surgical Association, past president of the Pacific Coast Surgical Association, and the American College of Surgeons. He also had a mischievous side, creating fun and having fun with others. The Westdahl home on Seventh Avenue became a magnet for the neighborhood children, especially at Halloween (his favorite holiday). Dr. Westdal designed musical instruments like a “gut bucket” and a quasi-clarinet composed of leftover plumbing parts from the remodeling of the Russian River family retreat, Summerhill Park. He was a founding member of the Guardsmen, an organization dedicated to disadvantaged Bay Area Youth, and the San Francisco Boys and Girls Club, arranging for other colleagues to help him give medical examinations to the children attending the club’s summer camp. He was a member of the Family Club and Vestryman at his Episcopal Church. He is survived by his wife, Georgia, his daughters Laurie (Furia) of Bellevue, Washington, Paula Westdahl of Big Sur, and Georgia (Kuhn) who lives in France; two grandchildren, three step-grandchildren, two great-grandchildren and one step-greatgrandchild. He was preceded in death by his son, Philip. His memorial service, held at the Episcopal Church of St. Mary of the Virgin in San Francisco on October 15, was filled to overflowing in celebration of a meaningful life, well lived.sfm

Letters to the Editor Dear Editor: I just read the entire September 2005 issue. It was superb. I welcomed the variety and the content. I’ve been a member of the San Francisco Medical Society for 35 years. I wonder why not all San Francisco physicians aren’t members. I extend my kudos to your writers. Sincerely, Gerald A. Gellin, MD

NOVEMBER/DECEMBER 2005 / SAN FRANCISCO MEDICINE

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