At the end of a long day

And here’s where we stand, at 11 PM on November 1, 2012:

The office at 690 Bay Street on Staten Island is open. (The tanker ship is in fact sitting on top of Bay Street but somewhat to the north of our location and so should not inconvenience our patients.) We are offering all the usual services at that office (though vaccine availability is limited due to lack of deliveries) and welcome all Brooklyn and Staten Island patients.For those able to travel to Staten Island, Drs Anna Shindelman, Arkadiy Sherer and Felix Fisher will do their best to help you.

The Staten Island telephone is 718-816-1010. The office will be open 7 days a week for the foreseeable future, to compensate for the difficulties we are experiencing in Brooklyn.

It was a long day in Brighton Beach, with some positive developments, and some welcome news about our office at 523 Oceanview Avenue: the “old” office is now open! Power came back on last night. Our staff did an incredible job of cleaning the office several times over (considering it had over 2 feet of mud and seawater over the floor at ground level), and intermittent Internet and phone service came back late today.

Dr Raisal Milman and Dr Terence Reynolds were able to begin seeing patients today, in difficult conditions and on an emergency basis only because of lack of phone service. None of the cell phones work reliably in the vicinity of the office, with intermittent text message capability at best. Our answering service is still underwater. Verizon only regained the capability of changing call forwarding today, and we only have one functional land line in the office, and that intermittently, with repair scheduled for Saturday, November 3.

The plan for tomorrow, November 2, is: We open at 523 Oceanview avenue at 10 AM, and see walk-ins as well as “scheduled” patients (those who can get through on a single line that loses the dial tone half the time, with little to no service on any of our cell phones anywhere in Brighton or Manhattan Beach), with Drs Milman and Reynolds continuing to hold the fort. (None of our doctors will cross the Verrazano bridge to work until the gasoline shortage is relieved.)

We have no vaccine, limited lab, no fax, limited Internet, and, what distresses me the most, the majority of our paper medical records are saturated with sea-bottom mud, making them inaccessible for the foreseeable future. We still have the same dedicated people we’ve always had working in the office, and we will continue to do our best for you. We will also continue to be grateful for the patience you’ve shown these last trying days, for the heartfelt messages of support, for your thoughts and prayers, and for your loyalty.

I will be wearing my “CEO” (Chief Everything Officer) hat for the next several days, trying to return the office to its best possible shape, while looking forward to taking care of patients again as soon as I possibly can.

Anatoly Belilovsky, MD

Chief, Belilovsky Pediatrics





Not our choice, the neighborhoods will be flooded. Staten Island office on Bay Street closed Saturday August 27, Sunday August 28 2011; Brighton office at 523 Oceanview Avenue open 9AM-noon Saturday for EMERGENCIES ONLY! and closed Sunday since it is expected to be inaccessible. Opening either office on Monday depends, again, on the accessibility of the buildings and of the neighborhoods in general.


Swine Flu 4.995: Back to the FLUture

OK, it’s not really about swine flu.  We have had a few febrile, sick children test positive for Flu A with our rapid in-office test; we don’t know if it’s H1N1 yet, but at this point it doesn’t really matter.

The CDC site is, as of now, still showing data from May 2010, including this plot which tells us that the cumulative pediatric mortality for H1N1 flu was on the order of seasonal flu mortality for the last 3 years combined.

I said this before and I’ll say this again: many of these fatalities were because of suboptimal guidelines for diagnosis and treatment of the flu — not so much because the guidelines were wrong, but because of our over-reliance on them.  There is no way a government agency can react quickly enough to new information, but individual physicians must use their best judgment at all times, and should not be discouraged from doing so by these agencies, and by our professional organizations.  Guidelines should not become straitjackets.

The initial guidelines said not to do in-office testing for flu.  Well, we did, and it took us maybe 2 days to realize that they did work well, and another 2 days to figure out that many children who were negative the first day of illness, became positive on the second. 

The initial guidelines said not to treat with Tamiflu except for high-risk and seriously sick individuals.  In two days it became clear that those we did not treat would become seriously ill in short order, and we began treating everyone, with excellent results.

The guidelines also did not allow us to suspend preventive care for the duration of the epidemic.  We partially solved the problem of exposure by offering an alternative location for well infant visits, but some patients came for checkups because HMOs sent them reminders and were exposed unnecessarily, and as for others –

The irony, of course, is that while we did a great job handling the epidemic, this very fact caused a drop in our quality indicators which are based almost entirely on preventive care measures.  Overlooking the fact that the best preventive measure for swine flu was staying away from the doctor’s office during the epidemic unless you were actually sick.

Except for suspending some preventive care visits (a sacred cow if ever there was one), all of our approaches were incorporated into guidelines, months later.

So what does this have to do with the flu that we are seeing now?  Just this: at any given time, your doctor will have the best information about the epidemics that are active in your community at that time.

If he or she is still allowed to see sick people, that is.

PS: Come get your flu vaccines!  They do work.    I did the study myself.   We’ll discuss that next time.


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WAKE up!

Much has been said about the Wakefield revelations, none more succinctly than here:

And, as the many comments have shown, some people STILL DON’T GET IT (such as this):

>Of course, if it isn’t MMR, where the hell are all these autistic kids coming from? I mean, I’ve got two.

That’s a very good question. Perhaps the poster should start with his own question: why does he have two, while the prevalence is (reportedly) 1 in 150? And why are both of them children of a man who can’t tell who is lying to him and who isn’t?


is so going on my office wall…


The Winter of our Discontent: Sun and the Seasonal Affective Disorder

I just did an interview with HealthRadio about the Winter Blues, also known as Seasonal Affective Disorder, and apparently there is great interest in this subject, so I’ll talk about it here in more detail.

SAD: Seasonal Affective Disorder. Kind of says it all: feeling sad in the winter. Think about SAD if your child starts acting like the Seven Dwarves:

Sleepy: a change in sleeping habits, inability to get out of bed, lack of interest, lack of exercise

Grumpy: Irritability, sadness, low self-esteem

Dopey: lack of concentration, difficulty in school

Bashful: lack of desire to be with other people, social isolation

Sneezy: unrelated to SAD, but it’s still flu season, isn’t it?

Happy is what you want them to be, and

Doc is who you take them to if you need help, right?

Oh, and craving for carbohydrates is a feature of SAD as well, but that’s more Sleeping Beauty, isn’t it, with the apple? And staying in bed and craving chocolates is what St Valentine’s day is all about.

And, just as in the summer, it’s not heat, it’s the humidity — with SAD, it’s not the cold, it’s the dark. When our eyes sense dim light or darkness, our brain makes more melatonin which acts like a sedative. In the winter, light may be dim all day. I’ve praised melatonin in the past as a natural replacement for sleeping pills, but in the winter the brain may be making it at a rate of a pill every hour between 4 PM and 11 AM, and that’s way too much sedation.

In addition, the light makes vitamin D in our skin; by winter’s end, almost everyone is Vitamin D deficient unless they are supplemented, especially children whose skin is dark.

The latest recommendations on Vitamin D are here:

An extensive review on vitamin D deficiency in children, with new recommendations for supplementation, was published in the August 2008 issue of Pediatrics by Misra and colleagues on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society.[16] This paper provides an excellent resource for pediatric health care providers on topics ranging from biomarkers of vitamin D deficiency to dietary sources and dosing of vitamin D products.

Based on a review of the literature, the group recommended that serum 25 (OH)D levels be maintained at least above 20 ng/mL and that daily supplementation with 400 International Units (10 mcg) of vitamin D be initiated within days of birth for all breastfed infants and in formula-fed infants and children who do not ingest at least 1 L of vitamin D-fortified milk each day. Premature infants, dark-skinned children, and children who live at higher latitudes may require larger doses of vitamin D, up to 800 International Units (20 mcg) per day. Supplementation for vitamin D insufficient or deficient children should be dosed according to the chart below:
Patient Age Dose (International Units/day)
< 1 month 1,000
1–12 months 1,000 to 5,000
> 12 months > 5,000

In addition to their recommendations, the authors also highlighted the need for additional studies to determine if higher levels of 25 (OH)D (> 32 ng/mL) should be considered, as well as to determine the appropriate balance of the benefits and risks of sunlight exposure.[16]

And the light ionizes the air. Remember walking outside, breathing in, and saying, “Ahhh, spring!”? It’s negative oxygen ions you were smelling. And will again. More on that below.

The depression of SAD is made worse by a number of factors. Lack of exercise — too cold to play outside — is an important factor. There is ample evidence for the diet being a contributing factor (more on that below); and the many holidays in the winter bring our children in contact with their extended families, and no one does a greater job of making a child feel inadequate than a relative bragging about their own child, and why can’t you be like that?

What we know about SAD comes from many sources. SAD is 7 times more common in New Hampshire than in Florida. It occurs in 10% of Scandinavians and 20% of people in Ireland. Oddly, it is rare in Iceland despite a longer, darker winter (which suggested one of the effective treatments for SAD). And we know what works.

Why are we “dreaming of a white Christmas?” It fights SAD in two ways. First, you see the snow. Lots of it, all over the place, reflects light into your eyes. It is exactly the kind of bright, diffuse light that works best against SAD. Then, you get to shovel that snow. That’s exercise, and it is also very effective. No snow? Any exercise will do, and other sources of bright white (or green) light such as light boxes or bright fluorescents work, too.

Why are the Icelanders spared the worst of SAD? The only difference between them and other Northern Europeans is in the amount of fish they consume — many times more than Swedes or Danes or people in the British Isles. Fish is the only common food that is rich in Vitamin D and omega-3 fatty acids. And fish oil and Vitamin D supplementation do appear to be effective against SAD.

And ionized air? No need to wait for spring (not that far off now, but still…): there are commercially available air ionizers that have been shown to benefit people with SAD.

And, finally, brighten up their day. Say something nice to them. Praise them for something they did right — show them that you understand how hard it was to accomplish it. Maybe even throw caution to the wind and take them to Florida, or skiing. I said before, ‘don’t let your school interfere with your child’s health’; if you think a vacation will benefit your child’s health, school schedule should not stop you. The school should be happy when your child returns in better shape to study. We hope they should be happy.

With all this, what can you “Doc” do for you?”

First of all, is is really SAD? Major depression needs to be taken much more seriously. In major depression, feelings of hopelessness and worthlessness predominate, and “rumination” — obsessive thinking about the negative — occurs much of the time. If this is a concern, see your doctor right away.

It is also possible for the SAD feeling to be due to a real medical condition. Thyroid disease, hypoglycemia, anemia and mono can commonly present with depression-like symptoms; your doctor should be able to check for them, and begin treatment if they are found.

And, finally, you and your child should leave your doctor with the knowledge that, in the cold and dark in the dead of winter, you are not alone.


Swine Flu 4.994: Guidelines

Latest Pediatric Mortality Curve

A few pieces of information are coming together now:

There was a rise in the number of severe swine flu cases during the holiday season, and

CDC recently broadened its recommendations for use of antiviral medications in suspected H1N1 influenza.

First of all, how does CDC come up with recommendations?

CDC collects data from local health departments who collect it from doctors and hospitals; it analyzes it and looks for factors that predict best outcomes. Which is excellent. But it takes a while.

Our office saw its 100th patient with H1N1 flu when the epidemic was less than a month old. We were quite aggressive with early diagnosis and early antiviral treatment from the beginning, and to us the flu appeared mild. Flu appeared more severe to physicians who followed more traditional approach — wait and treat only those who appear to be getting worse after a few days. In essence, we were reformulating our own guidelines with each piece of incoming data — with each patient we saw and with each update we read from CDC, NYC Health Department, and the media. And each update to our own, ongoing summary of experience confirmed the validity of our approach. Which is as it should be in the early stages of an epidemic that has not yet been properly analyzed by the appropriate agencies.

And, sadly, there is only one explanation for the uptick in flu severity without a corresponding uptick in its incidence during the holiday season: a significant reduction in patient access to medical care, whether patients are away from home, or because their physicians are on vacation. Which brings up to the one lamentable limitation in our services over the holidays: Yes, we were open on Christmas and New Year Day, as well as Saturdays and Sundays, in our main office; but, no, we could not follow our patients to their vacation destinations. Sigh. I am told Mexico was lovely this time of the year…