Face it, not in the exam room!

We always ask our patients to bring in a list of their current meds. As I perused my patient's list this afternoon, I noticed that he had written 'face' by one of his prescription drugs given to him by another MD.

I asked him what that meant. He said that when he told me on his last visit that he was on that medication, I'd made a face. He wondered what the face meant.

While I couldn't recall making a face nor any reason why that particular medication should make me grimace or roll my eyes, I did think that I should keep my future opinions off my mug.

Who needs a Hepatitis A Vaccine?

Fecal fingers.

Yucko. But that's what they're called, the 'fomites' (vectors or vehicles of infection) that bring you hepatitis A. That occasional, unclean digit of the unwell worker who forgot to read the sign you've seen posted in restaurant restrooms, namely "Employees are required by law to wash their hands before returning to work." I'm sure the majority of kitchen- and wait-staff are law-abiding citizens, but what if they're stomach's upset AND they're in a bit of a hurry.

There are worse things than having hepatitis A (like having hepatitis B or C). Unfortunately, however, this disease which was formerly known as infectious hepatitis can take a chunk of days from your life and a chunk of points from your sense of well-being. While children can contract the disease with few or no symptoms, adults are generally nauseated, yellowish, and too exhausted to care, and may remain thus for weeks. Fortunately, hepatitis A virus (HAV), unlike B or C, cannot set up permanent housekeeping in your liver in a chronic sort of way and only rarely causes liver failure.

We have shots, a series of two to be exact spaced at least 6 months apart, that can raise your immunity to fecal fingers at least in a HAV sort of way.* As you ponder whether or not this shot's for you, consider that 1) I haven't seen a case of hep A for years (and I do check liver functions in persons with persistent nausea and GI upset), and 2) If you happen to have eaten in an establishment subsequently found to be the source of a HAV outbreak, we can administer hepatitis A immune globulin (IG) to you. This drug contains preformed antibodies to HAV and is 85% effective in preventing a hep A infection in persons exposed to the disease. Protection from an IG shot lasts for 3 months. It is made from blood products from paid donors, and while there are no reported cases of hepatitis B or AIDS from hep A immune globulin, this blood products from paid donors thing may seem a little unsavory.

The vaccination is made from HAV raised in cultures, then inactivated with formalin. You can't get hep A from the shot. Several different brands are available, and none are preserved with the controversial, mercury-based preservative thiomerisol. The shot is highly immunogenic meaning that nearly everyone who gets it quickly develops protective levels of antibodies within one month of the first dose. So if you've put off getting the hep A vaccine,and you are planning travel to a country known to be high-risk for HAV infection, chances are good that even a last-minute shot will afford you some protection. The shot is considered very safe.

Many school systems require the two-dose hep A series for children entering school. Remember that 85% of children do not develop symptoms of hep A, so an unvaccinated child who contracts the infection while traveling out of the country can bring the disease back to more vulnerable personal contacts at home. The incubation period for the disease is 2-6 weeks. Adults in high-risk groups for infections (say those who are in institutions or immuno-suppressed) or persons who work with high-risk groups, and anyone traveling to a high-risk country should consider receiving vaccination against HAV.
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*There are other infections leaping from the fecal fomites such as salmonella and shigella.

How much sleep do we need?

or how do I get my teenager up for work on a summer morn'?

Generally he gets his own darn self up, but this a.m. was an early start, and early start and summer and teenager are not necessarily part of the same sentence. When I first woke him up, it was clear that no one was home behind his eyes. After I poured water on his head, it was clear that an angry but wakeful human had taken charge.

Here are some observations from a recent article in ScienceNOW Daily News(1) about how much sleep animals need in the wild and why that may or may not apply to humans and the subset of humans known as teenagers:

1. "Animals sleep less if they need to graze extensively--as with herds of horses." This is a tough one, he already grazes extensively. The problem must be, however, that if all the grass...er food...is right there in the 'frig, he doesn't need to spend much time doing so. Note to self: Empty out 'frig.


2. "Animals that sleep in groups, such as herds of grazing animals, get less sleep than species that live alone." Scientists theorize that this is based more in eating habits of herd animals rather than the herdiness of it all. M. certainly has quite a sociable herd to graze with, but, again, the good grazing is apparently too close at hand.

Perhaps when he moseys back down the road to school, no more 'summertime, and the grazing is easy. This kid has a 9 a.m. class this fall; I hope the living is lean and dangerous at school. Or maybe not...
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(1)http://sciencenow.sciencemag.org/cgi/content/full/2008/722/2?etoc

Deplin testimonial

I posted some time ago about Deplin, a glorified B vitamin (methylated folate to be exact) that may supplement antidepressants by promoting the production of neurotransmitters in the brain. I've prescribed it to some people not on antidepressants and found that many of them have a positive response with respect to energy and focus. Check out this e-mail from a patient with MS who struggles with low energy and lack of focus:

This new addition to my Rx. closet has made an incredible difference. I feel human, actually went for a walk with my dog last night (1st time in 10 years), feel more alert, have terrific energy and life is suddenly colorful.

Who's the pain in the butt here?

My patient has a pain in the butt. Not 'is a' mind you, but 'has a'. I've never seen anything like it. Her sit bones (ischial tuberosities) are painful to sit upon. She's o.k. with standing or lying, but her sitting hours are intolerably painful so, therefore, seriously curtailed.

I didn't know what to do with her (my father's advice from my childhood regarding things medical that were problematic --"Don't look at it for three days and it will go away"-- didn't work). Ibuprofen and such made no difference. I had to send her to a specialist, and believe me, it was hard to know just what specialist to use.

The orthopedist ordered an MRI of her butt. It showed minimal inflammation of the spot where the hamstrings insert onto the butt bones, but treatment for tendonitis, including cortisone injections, was useless. The neurologist was clueless, the physical therapist energetic but likewise without results.

We finally sent her to a pain management specialist. If you can't beat it, treat it. She was frantic to travel (out of the question) or simply to read a book in the seated position (if you're like her, reading while lying down is a recipe for sleep).

He listened to her story. Don't know if he examined her butt. He suggested Tylenol (heavens, Doc, been there/tried that already!). When she asked him what else could she do to once again achieve comfort in her life, he answered "Just stand up!"

I kid you not, that's what our pain specialist recommended.

The ups and downs of being a doc

Life and a road trip recently took me through Rawlins, Wyoming. Hours of driving through the monotony of southwest Wyoming dictated the need for a pit stop; time to eat and rest glare-weary eyes.

We found a little restaurant, actually the only diner on Main St. that teemed with life and advertised breakfast served all day. Several stuffed animals graced the entryway, real stuffed animals including a bobcat caught for all eternity mid-leap as he brought down a fleeing pheasant. The women's room sported, of course, the title 'Cowbelles' and the men's merely 'Cowboys.'

The meal was so-so, they were out of blueberry muffins and I passed on the alternative biscuits and gravy. As we finished our meal, a tall and sunburned man strode by, balding head shaved close, a slight potbelly protruding over his turquoise studded belt buckle and a beeper hanging off the belt. Most heads turned as he passed, a wide variety of townfolk waved and called "Hi Doc."

Ah, a diner in a town where everybody knows your name. I longed to jump up too and yell "I'm a Doc" and have them all laugh with delight that this dusty aging hippie in coffee-spotted capris and a t-shirt was a colleague to their own dear Doc.

Anyway, Doc Rawlins got to the counter to pay his bill, and I waited to see if they would offer him a bag of blueberry muffins to add to the bag already on his waistline. But instead, the older woman at the register started in on a long story about her bowels and her trip to the regional hospital. Not that I was eavesdropping, but shoot, we were sitting nearby, and I was hoping, at least, for some wonderful tale about how the Doc had saved her aging aunt.

Then I remembered that I live in a neighborhood and shop at a grocery store where many know my name. Why one patient one day described her vaginal woes to me in produce, and another pulled down her lower eyelid in paper goods to ask me whether or not her bloodshot, oozing eye was conjunctivitis. It was. I called in a prescription right then and there to the pharmacy located just east of aisle 18.

On my second day back to work after our Wyoming tour, the nurse practitioner asked me to look at a cat bite, or rather a young woman's hand with four cat bites on it one of which had penetrated her thumbnail. In the day since the feline's attack, the hand had swelled some, the thumb turning pink and puffy. Cat bites are nasty affairs; think for a moment what sorts of fishy things go in that mouth. I told the NP to call a hand surgeon and confirm that oral antibiotics would suffice for a now.

Several minutes later, she returned, sadly shaking her head. "No go, Chief," she reported, "I couldn't get past the front desk with my question. They offered me an appointment for next Tuesday."

What sort of nonsense was that? I strode to the phone and pulled the officious "This is Dr. P, I need to talk to your on-call physician now about a patient."

"Just a moment, I'll get Dr. W," the receptionist said. A moment later she returned to ask "Would this be about a cat bite perhaps? We just had a patient call here for advice a moment ago."

The hand surgeon came on the line shortly thereafter and confirmed the NP's plan as a good one. I realized then, once again, the value of the title and the ease with which it takes me right to the top. Maybe someday it will get me blueberry muffins as well.

Payback time for moms

The female brain is a dynamic structure, which expresses its plasticity most readily following reproductive experience.
---from the Department of Psychology-Neuroscience, University of Richmond

According to research out of the University of Virginia(1), there may be psychological compensation for all those sleepless nights, saggy breasts, and stretch marks that accompany motherhood. Those tedious months of pregnancy, suckling, and pup-rearing...oh right, we're talking rats here.

Neuroscientist Dr. Craig Kinsley and colleagues proved that mother rats adapted better to the stress of confinement in a Plexiglas restraint tube than their female colleagues who'd not yet coped with the demands of ungrateful offspring. Did they consider that lady rats--married, with children--may have just been grateful for the relative peace and quiet afforded by those Plexiglas walls? Speaking from my current perspective of mom to one teenager on site for summer, I would easily adapt, right here, right now, to voluntary confinement at an air-conditioned hotel.

The researchers conclude: "The data suggest that reproductive (hormonal) and/or maternal (pup exposure) experience may inure a female and her brain to stress, rendering her less susceptible to the behavioral-or other-disruptions that stress sensitivity can produce."
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(1)Wartella, J et al. Single or multiple reproductive experiences attenuate neurobehavioral stress and fear responses in the female rat.Physiol Behav 2003 Aug;79(3):373-81.

Lab test for ovarian cancer

A friend/patient of mine was recently diagnosed with Stage IV ovarian cancer. That, of course, is one of the most difficult aspects of ovarian cancer, namely that it is relatively symptom-free until it reaches an advanced stage.

In retrospect, she identified certain vague abdominal symptoms in the months prior to diagnosis (constipation, bloating, the development of a small 'middle-aged' pouch in the midriff), most notable and puzzling to her through the winter and spring was the increasing agitation of her devoted dog. The dear but scruffy mutt would scarcely leave her side, and no sooner did my friend lie down, but the dog would lay paw or muzzle on her abdomen. Most dramatically, the dog would eye her directly with long and beseeching looks.

An article in the June, 2008 edition of Integrative Cancer Therapies(1) may explain her canine's consternation. Swedish researchers in collaboration with members of the Working Dog Clubs of Sweden and Hungary theorized that dogs could be trained to recognize the characteristic odor of ovarian cancer. They not only found that the scent of an ovarian tumor in a doggy sense is different from that of other gynecological cancers (e.g. cervical or uterine) but that these cancer-screening pooches correctly sniffed out early-stage and borderline tumors as well as big, advanced ones.

The authors wrote: "Our study strongly suggests that the most common ovarian carcinomas are characterized by a single specific odor detectable by trained dogs, and while we do not believe that dogs should be used in clinical practice, because they may be influenced during their work [now what, really, could distract a dog?]... still, under controlled circumstances, they may be used in experiments to further explore this very interesting new property of malignancies."
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(1)Horvath, Gyorgy, et al. Human Ovarian Carcinomas Detected by Specific Odors. Integrative Cancer Therapies Vol 7 Number 2 June, 2008.

It took all my education...

A man came in today worried about a red area on his arm. The spot was about the size of a quarter and had two raised bumps within its circumference. He told me that he'd had two similar areas recently, one on the other arm and one on his back, both now resolved. All of them itched.

And they pay me for this?

Tumor necrosis factor

This sounds like a good thing, right? Produced by cells of the immune system, this protein's name implies that it is a sort of cellular "ace-in-the-hole," inducing death in wayward cells and their mutant offspring before a cancerous tumor is formed.

When first discovered in 1975, tumor necrosis factor (TNF) was noted to induce death in malignant cells in laboratory studies. Unfortunately, it is most complex in its actions, proving toxic to healthy cells and actually promoting the growth of certain kinds of cancer. TNF in the wrong place at the wrong time causes unwanted inflammation. This little troublemaker is a destructive party crasher in the joints of persons with rheumatoid arthritis, It also has destructive, pro-inflammatory effects in Crohn's colitis, smoking-related lung disease, atherosclerosis, Alzheimer's disease, and doubtless much more of that which ails us. It contributes to the profound wasting of AIDS and induces fever and shock in the face of overwhelming bacterial infections.

TNF is a good thing if you happen to do battle with a saber-toothed tiger, accidentally drive a Folsom point into your leg, or fall off your bicycle and scrape your knee. TNF is known as an 'acute phase reactant'; as the body's own EMT, it is one of the first responders at the scene of injury or infection. Produced by activated white cells and the endothelial cells that line blood vessels, TNF attracts bacteria-killing white cells known as neutrophils, promotes the passage of these cells through the blood vessel lining into damaged tissues, alerts the liver to produce pro-inflammatory molecules such as c-reactive protein or CRP, suppresses appetite, and promotes fever.

If TNF and company are activated, however, by cigarette smoke, doughnuts, McDonald's french fries, or too much waisted fat, this same immune response sets off a world of trouble in our arteries. Likewise, auto-immune diseases such as lupus or rheumatoid arthritis cause TNF inflammatory responses in joint spaces and other body tissues.

Body balance or homeostasis depends on equilibrium between troubleshooters such as TNF and peacemakers such TNF inhibitors. Therapies directed against TNF have changed the long-term outlook for patients with rheumatoid arthritis. These new drugs include TNF antibodies such as Remicade and Humira, and proteins that fuse with TNF such as Embrel. Early suppression of the joint-destroying inflammation associated with RA can prevent skeletal deformities and pain, markedly improving a patient's quality of life. Unfortunately, blocking a bad actor such as TNF which also has essential immune functions is not without problems. For one thing, TNF has an active role in the body's response to mycobacterial infections. As a result, cases of active tuberculosis have been reported with the use of anti-TNF agents.

Optimal vitamin D doses

I thought everyone had heard the news about the widespread deficiencies in vitamin D, yet the majority of people whose D levels I check measure way, way low in this essential vitamin. Even those who take a daily multi-vitamin with 400 units of D per tablet (the current RDA) are failing to top 30 ng/ml, the lower end of the desirable range.

Doctors in Beirut studied two groups of adolescents over 16 weeks. Half took 1400 units of D3 per week (the RDA for this age group is 200 units) and the other half took 14000 units per week. By study's end, the high dose group had a significant upward change in their serum D levels, but, better yet, demonstrated "substantial increments in lean mass, bone area, and bone mass."(1)

Many of my patients take 400 units of D3 per day, the amount present in most multi-vitamin pills. Per Toronto's Dr. Reinhold Vieth and colleagues "Supplemental intake of 400 IU vitamin D/d has only a modest effect on blood concentrations of [vitamin D], raising them by 7–12 nmol/L [2.8-4.8 ng/ml], depending on the starting point."(2) So if you're skidding along in a pasty white fashion, no sun plus one multivitamin pill/day, and your vitamin D level is around 11 (like so many of my patients), adding one more 400 unit D tablet per day will only get you up to 15, still terribly deficient.

Experts recommend supplementation in the neighborhood of 2000 units per day. Studies suggest that fracture risk falls with D levels of 30 ng/ml, and the improved outcomes not only result from stronger bones but also from greater muscle strength.
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(1)Maalouf J, et al "Short term and long term safety of weekly high dose vitamin D3 supplementation in school children" J Clin Endocrinol Metab 2008; DOI: 10.1210/jc.2007-2530.

(2)Vieth, R et al. "The urgent need to recommend an intake of vitamin D that is effective" American Journal of Clinical Nutrition, Vol. 85, No. 3, 649-650, March 2007

Dr. Ed Hepworth, Denver, CO

Credit where credit's due. I know that people search for patient reviews of physicians, so here's one from a woman who had complicated sinus surgery with Dr. Ed Hepworth here in Denver:

This guy's incredible. Man, he's good!

Lipotoxicity

Here's the new lipocentric news! What is not news, of course, is how lipocentric we're all getting, our fat or lipid-filled midriffs featured front and center in a pregnant abdomen sort of way. Researchers now, however, are theorizing that the fat load we carry as a result of overeating and undermoving is the primary metabolic driver behind the current epidemic of type 2 diabetes. Dr. Roger Unger of the Touchstone Center for Diabetes Research concludes in a recent JAMA editorial that "If this is in fact the case, [high blood sugar] should be corrected by eliminating the lipid overload."(1)

Want the skinny on fat overload? Check out: Lipotoxicity for the details.
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(1) Unger, RH. Reinventing Type 2 Diabetes. JAMA, March 12, 2008, Vol 299, No 10.

Designated Listener, Part II

Seems like there's a run of bad health luck in the lives of those around me here recently. I found myself, once again, sitting in as designated listener for a loved one (LO) during an important consultation. This time, I noticed a few eye-openers about the way my colleague conducted the visit, so here's three rules for MDs in the consultation room:

1. Doctors who don't get appropriate touching should skip touching altogether.
   This guy often stood with hand on LO's shoulder or occasionally sat with hand on LO's knee. I prayed that LO would not haul off and smack him. Honestly, it was not the time or place for such touching, and, in any case, LO exudes 'don't touch me' from every pore of his body.
2. Explain your thoughts, but don't dither.
   The doc was clearly puzzled by the situation and was thinking on his feet. As he mused about the possibilities in a roundabout, back-and-forth, sort of way, he finally came up with what I thought were three appropriate theories. LO concluded, not inappropriately, that this physician was fairly clueless about LO's condition.
3. Explain, but don't over explain.
   The physician gave so many simplistic 'for examples' that he came off as patronizing. Patients may need simplification, but, here I completely agree with LO, this was WAY too much dumbing down.

As an aside, our consultant stood through most of the visit in a stance appropriate to a college defensive back. I assume that at some point in his career he was just that, but it was a little strange there in the examining room.

Blood vessels love grape juice

They're not just passive pipes anymore. Blood vessels, or rather the single layer of cells known as the endothelium that line these passages, actively regulate blood pressure, blood flow, clotting, inflammation, and the immune response. And endothelial cells love purple grape juice whether it's fermented or not.

Persons with arterial disease such as hypertension or atherosclerosis are known to have endothelial dysfunction. In other words, their blood vessels are unable to expand normally in response to such things as exercise and cannot, therefore, efficiently increase blood flow and oxygen delivery when needed. Researchers are able to measure the health of the endothelium and its ability to increase blood flow by a simple test called flow-mediated dilation (FMD).

This test uses ultrasound technology to measure the diameter of the brachial artery at the elbow. A blood pressure cuff is then inflated on the forearm to the point where blood flow through the area is stopped. When the cuff is released, blood surges back into the forearm. Ultrasound is again used to the brachial artery, and the state of blood vessel health can be judged by the post-test expansion of this artery.

Fifteen patients with proven coronary artery disease were hooked up with daily grape juice over the course of 2 weeks(1). Prior to being juiced, these patients, as expected, demonstrated impaired FMD. After 14 days of Welches (and this must be concord grape juice), their FMD tripled. No such changes were observed in other studies conducted with OJ or grapefruit juice.

Grape juice kind of makes my skin crawl, but I drink it anyway. Pair it up with dark chocolate and oatmeal, and your endothelium will be relaxed, your arteries surging with blood.
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(1)Stein, JH et al. Purple grape juice improves endothelial function and reduces the susceptibility of LDL cholesterol to oxidation in patients with coronary artery disease. Circulation. 1999 Sep 7;100(10):1050-5.

Designated listener

Unfortunately, I was the designated listener for a good friend yesterday. I sat through the doctor's appointment with her and took notes while she more or less heard the words that would change the course of the rest of her life.

The doctor did a wonderful job with a most difficult task. She started the conversation with "I am so sorry that you have to come see me today." She spent nearly an hour and a half with us, explaining and also doing a fair amount of listening herself.

Afterwards, we went out to lunch. Shortly after ordering, the waiter returned to the table. "I'm afraid I have some bad news," he said. "We're out of the foie gras."

She and I didn't know whether to laugh or cry. Bad news indeed!

The benefits of Deplin

I wrote about Deplin recently. Billed as a 'medical food,' it is an fancy new methylated version of folate that easily enters the brain. Being a good sport and an inquiring mind as well as a doctor, I thought I'd give it a try.

The downside of Deplin is that it does indeed interfere with sleep. On the plus side, however, I have noticed an increased ability to focus on loathsome tasks involving numbers. My theory is that I have been borderline low on norepinephrine, the lack of which makes me inattentive and anxious. This new source of methylated folate is, perhaps, hard at work promoting norepinephrine production in my aging brain.

I have not yet heard back from several patients whom I have started on Deplin. I hope that it will improve their response to antidepressants and decrease that lethargy that sometimes accompanies the use of SSRIs. This side effect may be due to a down-regulation of norepinephrine receptors in the brain.

I said...MOVE YOUR REINDEER!

You may be surprised to discover that reindeer herding is a hazardous, noisy profession, what with all those braying reindeer and roaring snow mobiles. However, Finnish researchers have found that hearing loss among the herders is not just about nerve damage from noise exposure. Those tundra hands who escaped job stress through smoking, particularly those indulging in more than 144,000 cigarettes (a pack a day for 20 years), had significantly more hearing loss than their non-smoking herd-buddies.

Lest you think this danger does not relate to your daily life, this finding was repeated in a study of 1,500 Japanese office workers exposed to nothing more than the ringing of phones and computer games, There, the risk of high-tone hearing loss among heavy smokers was more than two times greater than those who abstained.

No wonder our pleas to our smoking friends to quit sometimes fall on deaf ears.

"Etiquette-based medicine"

Patients ideally deserve to have a compassionate
doctor, but might they be satisfied with one who is
simply well-behaved? ...A doctor who has trouble feeling
compassion for or even recognizing a patient's suffering
can nevertheless behave in certain specified ways that
will result in the patient's feeling well treated..
---Michael Kahn, MD

Dr. Kahn calls for a good manners curriculum in medical education in the latest edition of the New England Journal of Medicine.(1) He provides an example of a behavioral checklist that clinicians should follow to promote civility and respect in our patient encounters, including:

1. Introduce yourself.
2. Shake hands.
3. Sit down.
4. Smile if appropriate.

I'm sure you've all had encounters with physicians who were less than polite. My Mom's first doctor at the nursing home, shortly before I fired him, spent five minutes in her room during which he never looked at her once nor addressed a single remark to her. I saw a dermatologist a few years back who walked in one door of the exam room, moved slowly past me looking closely if briefly at the area of concern on my forearm, then scurried out the door at the other end of the room. Period. End of encounter.

I agree with Dr. Kahn. If you can't teach all medical students compassion, pass along a few basic rules of etiquette, and train them to shake hands and sit a spell.
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(1)Kahn, MK. Etiquette-Based Medicine. NEJM. Volume 358:1988-1989.

Post-vaccination syncope

Early in my medical school career, some brave pediatrician rounded up a group of us to observe a circumcision. The mom among us (brave soul had a young son at home) turned white as a sheet mid-procedure and sank to the floor in a faint.

This loss of consciousness as a result of undergoing an unpleasant experience is called vasovagal syncope. Completely involuntary, changes in automatic body functions after an intense experience result in overactivation of the parasympathetic nervous system (drop in heart rate) and withdrawal of sympathetic tone (dilation of blood vessels with a subsequent drop in blood pressure). Blood flow to the head diminishes (thus white face), and down she goes.

Actually, she is not completely accurate. The most common vasovagal reactions we see at the office are young men swooning after blood draws. Per the May 2nd Morbidity and Mortality Weekly Report, however, there's a new trend in fainting--teenage girls going to ground after vaccinations.

Experts theorize that the upswing in adolescent girls getting shots due to the rise in recommended vaccines such as the Gardasil series against HPV has caused this surge in syncope. While sinking to a prone position restores blood flow to brain, the worry here is that the young lady will injure herself while sinking, or will take out others if she sinks and drives.

Last year, one of my neighbors, a girl of 15, came to my office from her nearby school to get her tetanus shot. No one likes to be needled, but K was particularly dramatic about her distaste for the task. Nevertheless, she finally received her shot, and fifteen minutes later, we headed for my car as I was done with work and had offered to take her home. Halfway there, K complained of dizziness, and when I looked over she was out like a lightbulb, twenty-some minutes post-vaccine.

Our experience underlines the importance of the Advisory Committee on Immunization Practices' (ACIP) recommendation: Keep the drama mamas and the papas under observation for 15 or more minutes after they twitch their way through their ordeal.