Bronchiolitis is the leading cause of hospitalization for very young children in the USA. You’ll find various definitions of what bronchiolitis is, but a standard one is a viral illness that starts in the upper respiratory tract with runny nose, congestion, and cough. This is soon followed by symptoms in the lower respiratory tract — the lungs — such as rapid breathing, wheezing, and sometimes the need for extra oxygen. The culprit in half to three-quarters of cases is what we call respiratory syncytial virus, or RSV, but a variety of viruses can do it. Interestingly, 10-30% of children with bronchiolitis and RSV have another respiratory virus, too. Researchers aren’t sure if this combined infection contributes to how severe the symptoms are.

Any child can get bronchiolitis, but children who were born prematurely or who have some preexisting problem with their lungs are particularly susceptible to experiencing severe cases of it. But even otherwise normal children can get critically ill. I just cared for such a child, one who needed a week of a mechanical ventilator for it, and all pediatric intensivists have now and then had similar cases.

Because it’s so common, and because some of the symptoms of bronchiolitis resemble asthma, physicians for many years treated it with asthma drugs. Unfortunately, these drugs rarely help. But the urge to do something, anything, for this often frustrating illness is a strong one, and I still often see full-bore asthma treatment given for bronchiolitis. Indeed, in spite of multiple recommendations by panels of experts, more than a few American doctors seem reluctant to concede that little in the way of drug therapy helps. It’s hard-wired into our nature to treat things. The problem is that no drugs are risk-free, so we shouldn’t use them unless there is a reasonable chance they will do good.

What helps bronchiolitis? For a child at high risk of getting a severe case of RSV we can give a monthly shot of a drug called Synagis that can reduce the chances of getting RSV, or, if it happens, having a less severe case. For the rest, we use frequent suctioning of all the nasal mucus, oxygen if a child’s blood oxygen level shows it to be a bit low, and time. For now, that’s about it.

A recent article in the New England Journal of Medicine examines what would happen to our nation’s health statistics if we succeeded in reducing salt intake. Although I’ve always known, as all physicians do, of the connections between excessive salt intake and heart and blood vessel problems, I was surprised by the magnitude of the findings. An average per person reduction in salt intake of 3 grams per day would have dramatic effects on the incidence of these diseases. The authors estimate that the numbers of strokes and heart attacks would drop substantially: the annual number of deaths from all causes could easily drop by nearly 50,000. The greatest benefit would accrue, over time, to young persons, because the cumulative incidence of these chronic illnesses would fall. Even a more modest reduction in average salt intake — 1 gram per day — would still reap great rewards, since the relationship of salt intake to cardiovascular disease is a linear one.

And where does most of the salt in our diet currently come from? Not from the salt shaker — it comes from processed foods, those convenient boxes on supermarket shelves. The salt in these products can be reduced without consumers even noticing — a 10% reduction was accomplished in England over a 4 year period without complaints.

When I started training in pediatrics, nearly 35 years ago, it was common practice when an infant or child needed something done that was going to be painful, anxiety-producing, or both, the child was often merely held (or tied) down. Looking back on it now, it reminds me of the 19th century, a time when somebody might just be given a stick to bite down on. I wonder how we could have been in the same place with children a century later.

To be fair, there were several reasons we did things that way. Chief among them was the notion — one we now know to be false — that children (infants in particular) did not feel pain in the same way as older persons. The other reason was that we simply didn’t have available many of the medications we have now to counteract pain and anxiety, and the few that we had had not been studied much in children.

Things are much different now. We have a menu of things we can use to prevent pain, ranging from numbing cream we can put on the skin to lessen (or even eliminate) the pain of a needle stick to powerful, short-acting anesthetic drugs we can use to put the child into a deep (and brief) slumber. We have reliable ways of greatly reducing or eliminating both pain and anxiety when a child needs medical procedures as varied as an MRI scan or some stitches in the scalp.

Most doctors who do these procedures are well aware of these things. But if you run across one who doesn’t seem to be, don’t be shy about speaking up and asking what can be done to make your child more comfortable.

An interesting recent editorial in the New England Journal of Medicine asks that doctors be explicit about what they will support and what they won’t. In particular, would we agree to pay cuts? The essay points out that, at least early in the process, drug companies, insurance companies, device manufacturers, and hospitals all agreed to some limitation on their income. (If they still would, of course, is another question.) But doctors have made no such pledge. In fact, as a group, we’ve demanded more of the healthcare pie. Is that fair?

I don’t think it is fair. To me, the biggest problem with physician salaries is that they are so spread out from lowest to highest in a manner that doesn’t really reflect training or expertise — the variance primarily reflects custom. My own family’s experience with medicine spans well over a century, with my grandfather graduating from medical school in 1903 and my father in 1944. Some doctors have always made more money than other doctors, either from being busier or from getting more training. Surgeons and other doctors who do procedures have always made more than those who don’t do these things, but the huge variance in physician salaries we have seen emerge in the past several decades is a new phenomenon. To me it parallels the huge (and recent) disparities we see between what a CEO gets paid and what an the average employee gets paid. Things have gotten out of balance.

If you want to learn more about how medical practice, including how it is paid for, emerged in the last century, there is no better book about it than The Social Transformation of American Medicine, by Paul Starr. The book won a Pulitzer Prize in 1984. And if you’re wondering: yes, I’d give up some salary to get healthcare reform, so long as everybody else would, too. It’s only fair.

That’s the title of an interesting editorial in a recent issue of the New England Journal of Medicine. It’s interesting because how people think about, and act towards, an epidemic is in many ways as important as the medical aspects of the disease. So the emotional epidemiology is important

The H1N1 vaccine became a controversial subject, although not among medical scientists. There were some glitches in the vaccine supply, but these are easily explained by the lack of lead-time in vaccine manufacture. Generally the manufacturers get about a year to produce the next year’s vaccine; in this instance they only got half that time. The interesting thing is that, by the time the vaccine became available in large quantities, the same people who were clamoring for it in mid-2009 (and upbraiding the system for not have it ready) were now suspicious of it, even afraid of it.

Why did this happen? One culprit, of course, is the voracious 24 hour news cycle that demands extreme stories. The “swine flu plague” played right into that. Another is that we physicians lack an appreciation for “emotional epidemiology,” causing a subsequent lack of vigor in addressing influential, but misleading articles, such as this one. (This article has been demolished in many places, such as here specifically and here, more generally.)