Friday, December 31, 2004

A Lonely Night

New Year's Eve is a lonely night for some:
New Year's is not the only pressure-filled holiday. Saitta said Valentine's Day, Fourth of July, Memorial Day and other romantic or social holidays also cause anxiety. But she sees New Year's as the prime time for pressure to have fun, and the people who end up feeling depressed are usually singles.
The feeling tends to be worse for younger people with nothing to do, Saitta added.

Mississippi Malpractice

Kevin, MD recently linked to this article accusing the Mississippi malpractice industy of being racist.
The article is from the "San Francisco Bay View, National Black Newspaper." "The Jackson Advocate News Service contributed to this story. " This article is the product of 2 African-American newspapers (nothing wrong with that)- but not exactly mainstream media.
The article details the plight of Dr. Ronald Myers, a Black physician.
His medical malpractice insurance company, though obligated to cover all physicians in the state, is canceling his insurance despite his never having had a claim filed against him.
Mississippi’s controversial new tort reform legislation gave the company sole discretion as to which doctors it will insure.

These 2 sentences don't make sense. How can an insurance company both be "obligated to cover all physicians in the state" and have "sole discretion as to which doctors it will insure."
Contending he is a victim of “medical malpractice lynching,” he filed suit Dec. 8 against the company, but it may be too late to keep the clinics open.
This article is short on facts- the malpractice insurance company is not named even once. I wouldn't put too much faith in this article. I am hoping that the mainstream media will pick up the story and give an unbiased version.
In my opinion, the reason Dr. Myers had his insurance cancelled is because he lives in a judicial hell-hole. In some parts of Mississippi, you can sue for side effects of a drug without even taking the drug.
Opposing viewpoints are welcome.

Child Psychiatry

A typical encounter for a child psychiatrist is to see a child brought in by his mother for behavioral problems. In these cases, the most important question to ask is, "When was the divorce/separation/affair?" If the parents are divorced/separated, the child psychiatrist should next ask the mother if she has a boyfriend who might possibly be sexually/physically/emotionally abusing the child. Asking these simple questions provides key diagnostic information in many child psychiatry cases.
And if the father is the one bringing in the kid, then that kid really has problems.
Disclaimer: I am a general adult psychiatrist. I do not like children that much (except for my own). I am probably a little cynical from my experiences as a resident.
This post was inspired by the Dec 30 post on Mental Notes.
Comments are welcome

Thursday, December 30, 2004

Grand Rounds 15

It's time to submit your entries for Grand Rounds #15 to Dr. Rangel

The Dangers of Bracelets

From American Medical News:
The worlds of fashion, fund-raising and patient safety have collided, and the result is a rainbow of colored bracelets that can indicate either support for scientific research or the contents of a patient's living will.
At issue are bracelets that show support for a cause and are the same color as the bracelets hospitals use to identify patients with do-not-resuscitate orders or for other designations. There are concerns about patient safety because, even though the bracelets are made of different materials, the similar colors might cause confusion during an emergency.

"About a month ago, one of the nurses in our health system identified that the Lance Armstrong yellow bracelet could be confused with our DNR yellow bracelet," said Lisa Johnson, RN, Morton Plant Mease Health Care vice president, patient services.

"Seconds count in a decision whether to resuscitate someone or not," Johnson said. "In the highly charged environment of a cardiac pulmonary arrest, we don't want any confusion whatsoever."

Wednesday, December 29, 2004

The Effects of the Deceased on the Living

Kevin, MD discussed this article about the effects of tsunami victims on the living.
Check out this site for more information about the effects of the deceased on the living.

Tuesday, December 28, 2004

Generalized Anxiety Disorder

An online newspaper reports on a patient with probable generalized anxiety disorder (GAD):
GALESBURG, IL—Area mother of three Mary Kleibert, 54, was once again freaking out for no reason Tuesday, sources within the Kleibert family reported.
"All I did was mention that I had to go to the DMV because my license was going to expire the next day, and mom completely wigged," said Tim Kleibert, 18, the youngest son of the freaking-out woman. "She started totally spazzing, saying, 'What if they're closed? Then what?' and telling me that the police were going to impound my car if I drove it. I was like, 'Mom, relax.'"
Upon learning of her son's 11th-hour license-renewal plan, Kleibert reportedly went seriously buggo, excitedly listing off the various potential problems he obviously hadn't even taken the time to consider.
"What if you don't pass your vision test?" Mary Kleibert asked. "Or what if the DMV paperwork needs more than 24 hours to clear, and you're not eligible to drive until Thursday? Your father can't drive you to work tomorrow, you know: He'll be in Moline all day."
Her breathing rate audibly increasing, Kleibert reminded her son that if his driver's license is invalid, his car insurance policy would be, too. She described such a scenario as one she doesn't "even want to think about."
Over the next five minutes, Kleibert became more agitated, despite her son's repeated assertion that renewing one's license on the last day is not a federal offense or anything.
Tuesday's driver's-license incident is just one of 15 freak-outs to occur in the past month. On Dec. 26, Kleibert went nuts when she discovered that Tim had thrown away the packaging for his new laptop computer. "What if something goes wrong?" Kleibert, near tears, told her son. "You can't just call in the washing-machine repairman to fix it. Don't you care about your things at all?" She then noisily stomped down the basement steps carrying a laundry basket.
Kleibert went similarly hyper last Thursday, when Tim accidentally overslept, leaving him just 25 minutes to get to his job at a local grocery store. He was awakened by Kleibert, who yelled, "It's quarter after! Do you hear me? Quarter after!" Ten minutes later, as Tim pulled out of the driveway, Kleibert stood on the front steps, shouting, "You've got to eat breakfast! You can't just not eat!"
According to husband Gerald Kleibert, 56, no one in the family is safe from the freak-outs, which range in subject from the dangers of mechanical devices to the threat of food poisoning, with special attention given to heat exhaustion, blood clots, and hems. On Dec. 28, Gerald himself prompted his wife to flip out when he forgot to lock the empty house before running out for a newspaper, leaving the door wide open for anyone, in Kliebert's words, to "waltz off with whatever they could carry."
"Boy, oh, boy," Gerald said. "Mary really blew a gasket over that one."
Three days later, Kleibert went into another tizzy upon discovering that Gerald had failed to plan ahead for their nephew's wedding. Too late to request the day off from work, he called in sick with "the flu" in order to attend the event. As a result of her husband's failure to plan ahead, Kleibert nervously watched the door all night, fearful that someone from her husband's workplace would wander into the wedding reception by accident.
The most baffling of Kleibert's outbursts, family members said, are those involving her two eldest children, neither of whom still live at home. Without warning or provocation, Kleibert will fret loudly about Jason, 24, who "insists on flying everywhere" despite all the airplane accidents on the news, and 22-year-old Erin, who just wanders around from one job to another without getting enough protein.
Despite the preponderance of evidence suggesting otherwise, Tim said he maintains hope that when he leaves for college in August, his mother will acknowledge his adult status and not go batshit-loonball on him so much.
"She's a good mom, and I love her," Tim said. "But, man, she seriously needs to learn to chill."

This is Very Bad Idea

An article in USA Today reports Merck next month will make its second try for approval to sell cholesterol drug Mevacor without a prescription.
"I think it is a very bad idea," says Brian Strom, a medical doctor and professor at the University of Pennsylvania School of Medicine.
Over-the-counter drugs are meant for short-term conditions that patients can diagnose themselves, he says. "High cholesterol has none of those things."

Mevacor (lovastatin) is one of the "statins." These medications are effective in lowering cholesterol and the risk of coronary artery disease. However, these medications do have potentially serious side effects. They can cause liver damage; liver enzymes should be periodically monitored in patients taking them. The statins can also cause muscle pain and muscle breakdown. In severe cases (rhabdomyolysis), the muscle breakdown can lead to kidney failure. The statins should only be taken under a doctor's supervision.
If Merck suceeds in marketing Mevacor over-the-counter, they deserved to be sued into oblivion for any side effects that consumers suffer from taking this medication. You would think that Merck would be more cautious after the withdrawal of their medication Vioxx.
A bonus tip for any residents reading this: It is well known that combining statins with fibrates increases the risk of liver enzyme elevation and myopathy. Yet this combination is sometimes necessary in patients with combined increased LDL/increased triglycerides. Tricor (fenofibrate) is slightly safer in combination with statins than Lopid (gemfibrozil).

Resident Frustrations

Mad House Madman, in voicing his frustration with the malpractice situation, writes:
Personally, I’ve had enough. You patients suck. I know you believe this shit and, unfortunately, I don’t think you’re worth it any longer. From here on in my primary goal is to protect myself. Even, if it’s at a cost to your health, time and energy. Deal with it.
Most residents get frustrated with medicine at some point during their residency. Although residency conditions are improving, the hours are still long and the malpractice situation continues to worsen. The sickest and most complex patients are transferred to teaching hospitals; residents have a great deal of responsibility. As someone who finished residency/fellowship training 1.5 years ago, I can understand Mad House Madman's frustration. But a resident can't turn his anger at the system against his patients. A resident who continues to feel this way needs to get some counseling and/or reconsider his career options.

Grand Rounds 14

Check out Codeblog for the 14th edition of Grand Rounds.

An ethical dilemma

Dr. Chaplin posted an interesting case about a psychotic patient who is refusing food. Be sure to read the comments.

Monday, December 27, 2004

Reggie White Dies

The New York Times reports that Reggie White, the defensive end who was one of the greatest players in National Football League history, died yesterday at a hospital in Huntersville, N.C. White, who lived in Cornelius, N.C., was 43.
The cause was not immediately known, but White had a respiratory ailment for the past several years, Keith Johnson, a pastor serving as a family spokesman, told The Associated Press.
According to ESPN, Sara White confirmed her husband's death, saying that she believes White died of respiratory failure related to his sleep apnea. An autopsy is to be performed to determine the exact cause of death, which was not immediately known.

Did obstructive sleep apnea (OSA) kill Reggie White? OSA is sleep disorder in which a person has repetitive cessations of breathing during sleep due to obstruction of the upper airways. It can be caused by obesity and/or anatomical abnormalities of the throat. In severe cases, untreated OSA can cardiac arrhythmias, including ventricular tachycardia/fibrillation that can lead to sudden cardiac death (this is very rare). Untreated OSA also increases the risk of coronary artery disease, probably through its effects of increasing blood pressure and increasing infammatory factors. The cause of Reggie White's death is not yet known; maybe the autopsy will give further information. If his OSA was not adequately treated, it is possible that it killed him either directly by causing a ventricular arrhythmia or indirectly by increasing the risk of having a heart attack.

Screening for Cancer

This New York Times article discusses some of the pitfalls of cancer screening:
A new study found that people spent an extra $1,000 or so on health care in the year after a test raised suspicions that later proved unfounded. "The key here is to make sure that people are considering all the possible benefits and harms" when they go for a screening test, especially one not recommended by health officials, said Jennifer Elston Lafata, director of the Center for Health Services Research at the Henry Ford Health System in Detroit. Ms. Lafata led the study, which was published in this month's issue of Cancer Epidemiology Biomarkers and Prevention, a journal of the American Association for Cancer Research.
In addition to the financial costs of working up false positive results, there can also be health risks- for example bleeding or infection as the result of a biopsy. Go ahead and get the recommended screening tests (for example, colonoscopy for those over fifty) but avoid the "full body scans".

Thursday, December 23, 2004

The Lawyers Strike Again

WMed Weblog reports on a hospital being sued because no neurosurgeon was available to treat a stroke patient. Here is the original article in the Palm Beach Post.
Florida lawyers have succeeded in eliminating emergency neurosurgery in certain Florida counties. I guess they won't be happy until they have sued hospitals and emergency rooms out of existence.

Wednesday, December 22, 2004

The Holidays

The holiday season is fast approaching and my posting will be lighter for the next few days.
Whether you celebrate Christmas, Hanukkah, or Festivus, I wish you happy holidays!

Another Endorsement for Aspirin

Yesterday I blogged that aspirin may become more popular now that the NSAIDs have been linked with heart disease and stroke. Today, an article in USA Today also endorses aspirin:
"We will look back and say we spent the 1980s and 1990s abandoning aspirin in droves," Avorn says. "And now we find out that, well, aspirin is well-established to prevent heart attacks."
Physicians will need to reaquaint themselves on the use of aspirin for pain. I have personally not advised/prescribed aspirin above the cardioprotective dose of 325 mg/day for several years. I do not know the usual therapeutic or the maximum dose of aspirin for pain. I have some learning to do.
I do believe that physicians need to be cautious with the prescription of aspirin. Its adverse GI side effects- including gastrointestinal bleeding- are well known. On the plus side, Aspirin is well know to reduce cardiovascular mortality at doses of 81-325 mg/day. It has been studied for the prevention of strokes at doses up to 650 mg twice a day. But what about aspirin at higher doses?? Is it possible that aspirin at higher doses could increase cardiovascular mortality?
In addition, Aspirin has some nasty side effects in overdose situations (including accidental overdose in the elderly) including acidosis and tinnitus (ringing in the ears).

Tuesday, December 21, 2004

Post-Melodramatic Stress Disorder

America's Finest News Source discusses Post-Melodramatic Stress Disorder (PMSD).
According to this article, "PMSD sufferers walk through their days with the specter of an unnecessary musical number hanging over them like a mask. The prelude is constantly playing in their unconscious minds, threatening to crescendo into exaggerated, choreographed action at any moment. Anything can set them off: a chandelier, a strain of saccharine music, a gaudy outfit."
A psychiatrist quoted in the article urged loved ones to watch possible PMSD sufferers closely and seek professional help if necessary. While PMSD isn't a new phenomenon, the magnitude of the current outbreak is unprecedented.

Postpartum Psychosis

Mental Notes (Dec 20) discusses Texas law concerning the mentally ill who commit crimes and cites this article. In the article, Dr. Jones makes a good point about postpartum psychosis: Most of the time, women who develop postpartum psychosis turn out to be bipolar.
If there are any medical students or psychiatry residents reading this blog, you need to remember this. Bipolar disorder is the most common etiology of postpartum psychosis. Expect to see a question about this on board exams.

NSAID's and Heart Disease

In the last several months, all of the COX-2 inhibitors have been linked with heart disease. Vioxx is off the market; the FDA is evaluating Bextra and Celebrex. Now naproxen, a non-selective nonsteroidal anti-inflammatory drug, has been linked with heart disease. There is concern that the other NSAIDs, including ibuprofen (advil) may also increase the risk of heart disease.
I believe these medications are relatively safe for short-term use. Those at low risk for heart disease can continue to use these medications long-term under the supervision of a physician.
For those who are at high risk for heart disease and need long-term pain management, the choices now include aspirin, tylenol, and opioids. Aspirin is just as effective as the NSAIDs for pain management, and has the same risk of GI bleeding. Aspirin is well known to reduce the risk of heart attacks. I expect the use of aspirin to increase significantly in the upcoming year. Many patients find tylenol ineffective. Unfortunately, the Feds have cracked down on the prescription of opioids.

Health Care Flexible Spending Accounts

If you have a health care flexible spending account for 2004, the deadline is fast approaching to use up the money. An article in USA Today gives some tips for using up the money in these accounts by December 31st:
• You can use the funds for over-the-counter drugs. In 2003, the IRS ruled that a flex account can be used to buy non-prescription drugs. Not all over-the-counter drugs are eligible. For example, you can't use flex-account funds to buy vitamins unless they're prescribed by your doctor. But the list of eligible over-the-counter products is long, ranging from allergy medications to contact lens solution.

Medical Grand Rounds # 13

Be sure and check out THE SEX OF MEDICAL BLOGS: GRAND ROUNDS #13

Monday, December 20, 2004


The Agency for Healthcare Research and Quality (AHRQ) recently released an evaluation of melatonin. Here is a summary:

Evidence suggests that melatonin is not effective in treating most primary sleep disorders with short-term use, although there is some evidence to suggest that melatonin is effective in treating delayed sleep phase syndrome with short-term use.
Evidence suggests that melatonin is not effective in treating most secondary sleep disorders with short-term use.
No evidence suggests that melatonin is effective in alleviating the sleep disturbance aspect of jet lag and shiftwork disorder.
Evidence suggests that melatonin is safe with short-term use.
Evidence suggests that exogenous melatonin has a short half-life and it penetrates the blood-brain-barrier.
Evidence suggests a link between endogenous melatonin and the sleep cycle.
Evidence suggests a link between endogenous melatonin and the temperature rhythm.

I agree with the AHRQ report that melatonin is not an effective hypnotic (it will not help a typical insomniac fall asleep). I do think, however, that the report was too negative on melatonin's effectiveness in treating circadian rhythm disorders. For example, there are a few studies in which melatonin was effective in treating jet lag. Although melatonin does not directly induce sleep, if given at the proper time and dose, it can reset a person's (near) 24-hour biological clock.
There are 2 major difficulties in evaluating the effectiveness of melatonin for a particular condition: 1) There is no standard formulation of melatonin and its dose varies from study to study and 2) the timing of administration is critical and varies from study to study.
A good example of the difficulties of using melatonin is delayed sleep phase syndrome. In this disorder, a person has a biological tendency to fall asleep late and wake up late; a typical patient may sleep from 3 am to 11 am. If he is allowed to keep this sleep schedule, he will do fine. He will have a great deal of difficulty if he tries to fall asleep earlier. If he is forced to get up earlier (to go to school or work) he will probably be sleepy during the day and have trouble functioning. One way of treating this disorder is resetting the biological clock so that the patient can sleep at normal times. The biological clock can be advance by either exposing the patient to bright light (either sun light or a light box) in the morning or by giving melatonin in the evening. However, if you miss the critical window of light/melatonin administation by as little as 60 minutes it will have little effectiveness. If you miss it by more than that, it may have the opposite effect (causing the person to fall asleep later).
More research is needed in the use of melatonin in treating circadian rhythm disorders (disorders of the biological clock). Melatonin is unlikely to be effective if a patient buys a random dose at a vitamin store and takes it when they feel like taking it. It may be helpful for certain circadian rhythm disorders if taken under the supervision of a knowledgable sleep specialist.

COX-2 Inhibitors

The golden age of COX-2 inhibitors is over. Vioxx (produced by Merck) was recently pulled from the market due to its increased cardiovascular risk. Bextra and Celebrex (produced by Pfizer) have also been found to increase cardiac events. The COX-2 inhibitors were no more efficacious than the non-selective nonsteroidal antiinflammatory drugs (ibuprofen, naprosyn, etc) but did have a lower risk of GI bleeding.
It would be interesting to see an analysis of the mortality rate expected from taking a nonselective NSAID (such as ibuprofen-advil) for a year versus taking Celebrex for a year. In other words, would more people be expected to die from ibuprofen-induced GI bleeds than Celebrex-induced GI bleeds and heart attacks?
Of course, ibuprofen vs. Celebrex is not the only option. Ibuprofen can be combined with one of the proton pump inhibitors (Prilosec, Nexium, Prevacid) to significantly lower the incidence of GI bleeding. I expect to see the stock price of AstraZeneca (Nexium) and Procter + Gamble (Prilosec) rise in the next few weeks.

Thursday, December 16, 2004

How Low is Your Cholesterol?

Cardiovascular mortality decreases linearly as total cholesterol and LDL cholesterol (the bad cholesterol) decreases. The guidelines for cholesterol management are constantly changing, with lower and lower goals for LDL and total cholesterol. Many physicians are now trying to lower the LDL's of all of their patients with diabetes or coronary artery disease (CAD) to below 70. However, according to the guidelines, 70 is the goal only for those with CAD + multiple risk factors, or those with an acute coronary syndrome.
The following article on Fox News suggests that the President's physicians are aggressively lowering his cholesterol:,2933,141528,00.html.
Going beyond the established guidelines will further decrease a person's risk of CAD and cardiovascular mortality, but by only a small amount:
“Let’s say a person’s 10-year risk of heart attack is 5 percent, the statins would reduce that risk to just under 4 percent. So a person would have a maybe one in 100 chance of having a benefit from taking that statin,” says Sacks. “A lot of people would say forget it. Some people would say, ‘Well what do I have to lose?’”
Sacks says the fact is that many doctors will take a statin themselves even if they are very healthy because they believe the drugs are safe and have a low risk of side effects.
Personally, if my LDL was above 100 I would take a Statin, even though with my minimal risk factors a Statin would not be officially indicated until my LDL reached 160.

Tuesday, December 14, 2004

Doctors Taking Antidepressants

Shrinkette ( in her December 12 post comments about doctors taking antidepressants:
I think the boards have weighed the risk of supporting sick doctors in getting treatment and possibly having problems with the treatment, vs. creating a situation in which sick doctors won't even consider treatment because of risks to their licensure. If you're a doctor in treatment, there is another doctor looking after you, and (one expects) watching you like a hawk for side effects (including behavioral side effects). The illness is more likely to impair judgment than the treatment.
Being treated for mental illness or taking psyciatric medications is no longer career ending, but it will haunt a physician for the rest of his career. He will be asked about any history of psychiatric treatment on every residency/fellowship application, application for hospital staff privileges, and application for medical licensure. He will also be asked about it when applying for malpractice insurance. A doctor with a history of mental illness will have to disclose it for the rest of his career.


Autism is a devastating psychiatric disorder:
It strikes children between the ages of 12 and 36 months-sometimes manifesting with a sudden and rapid disappearance of early language acquisition. It is a lifelong disorder in which cute-often beautiful-children grow into very impaired adults. A large segment of the autistic community never acquires (or loses) all functional language and, even for those that do develop language, it is often unusual and alienating.
Socials skills are significantly impaired even in the highest functioning individuals with autism. A rigidity or attachment to sameness creates compulsive behavior on a scale matched only by the severest cases of obses-sive-compulsive disorder. Stereotypic movements are common. Severe sensory integration problems are well described in books written by some of the highest functioning autistic individuals. Descriptions-such as "when it rains, the sound on the roof is deafening, it sounds like it's drumming on my head"-only begin to give us an idea of what the subjective life of an autistic individual must be like.
The most severe behavioral problems present routinely. Aggression towards others and self-abusive behaviors are common, as is compulsive "picking" to the point of bleeding. Almost all of the routine aspects of life, including eating, sleeping and fundamental social awareness, can never be taken for granted. Some families with autistic members become housebound because the affected family member's behaviors preclude going out together in public.

An article in the New York Times today discusses screening for autism:
If detected early, behavioral therapy can greatly increase functioning in some young autistic individuals. Unfortunately, the required behavioral therapy is often intense, requiring over 20 hours per week in some cases.
Experts say that for all the promise it might hold, a screening technique that can consistently detect children younger than 18 months, not to mention in infancy, is probably years away. To the extent that that is even possible, scientists say they would then have to grapple with a much larger problem: providing treatment to an explosion of small children when services are already stretched thin.
"We're going to have more and more children under 3 getting diagnosed," said Dr. Volkmar. "But sadly, it looks like we're going to have fewer and fewer services for them."

Sunday, December 12, 2004


A reader asks...
"Is it judicious or not to be wary of a drug (Prochieve 4%, vaginally inserted progesterone to accompany Estradiol) that had been removed from the market for a time, then returned to the market but under a different name?"
I am not familiar with Prochieve. A quick search on Up to Date Online indicates that it is used in in-vitro fertilization and also for abnormal uterine bleeding.
The long-term adverse effects of oral progesterone when used in hormone replacement therapy to treat menopausal symptoms are well known: (
I would not expect the short-term use of Prochieve to be as risky, but in the primary care clinic that I supervise, fertility and uterine bleeding problems are usually referred to the university's Women's Health clinic, so I have little experience in this area. Anyone with experience with Prochieve care to comment?

Friday, December 10, 2004

Surgery for Obstructive Sleep Apnea

A reader commented on my Dec 8 post on Obstructive Sleep Apnea (OSA):

"Oh man, those CPAPs are uncomfortable. After a few years of use I went for the surgery - they took out my tonsils and did something to my uvula. Didn't help, so I stayed on CPAP. Then I lost 70 pounds. As long as I sleep on my side, I don't need the machine.I don't think the surgey was wasted, though. My cousin was thin as a rail and also needed it."
Uvulopalatopharyngoplasty (UPPP) is the most common surgery for the treatment of OSA. This surgery involves the removal of the uvula, tonsils, and surrounding tissues. It is effective in about 50% of patients. UPPP is usually performed by an ENT physician and is available in most locations.
Other possible surgeries for OSA include genioglossus advancement (surgically moving the tongue forward) and maxillomandibular advancement (breaking the jaw in several places, twisting it, and pulling it forward). These 2 surgeries are only available in specialized centers (Stanford and Atlanta are the 2 locations that I am aware of) and are usually performed by maxillofacial surgeons ( Maxillomandibular advancement is effective in over 90% of patients.
If you are considering sugery for OSA, it is important to work with both a sleep specialist and an ENT surgeon. The ENT surgeon can perform imaging (CT scan or endoscopic examination) of your upper airways to define your anatomy and help predict which surgery you are most likely to benefit from. A sleep study is necessary several months after the surgery to evaluate if the OSA has been cured.
In Mississippi, only UPPP is available. At the University of Missippi Sleep Disorders Center
(, we refer about 1% of our OSA patients to ENT for an evaluation for UPPP. We strongly encourage CPAP as a first-line treatment for OSA.
There is one other surgery for obstructive sleep apnea: tracheostomy ( This surgery is rarely performed in severe cases of OSA refractory to other treatment. It is also perfomed in emergency conditions ( a patient with undiagnosed sleep apnea whose airway collapses after a surgery).

Wednesday, December 08, 2004

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a disease characterized by episodes of complete or partial collapse of the upper airways during sleep. It has been estimated that 2-4% of the adult population has it. Symptoms of OSA include loud snoring, daytime sleepiness, and apneas (breathing pauses) witnessed by a bed partner. Risk factors for OSA include obesity, an abnormal jaw structure, and having a crowded oropharynx (the area around the tonsils).
OSA has long-term health risks, including hypertension.

The usual treatment for OSA in adults is continuous positive airway pressure (CPAP):

OSA is becoming increasingly more common in children. It used to be that most cases of OSA in children were due to adenotonsillar enlargement; the OSA could usually easily be cured by surgically removing the adenoids and tonsils. Now obesity is causing many cases of pediatric OSA and there are a lot of children on CPAP. This article discusses OSA in obese children.

OSA, in both adults and children, is usally diagnosed by an overnight polysomnogram (sleep study). Airflow, depth of sleep, and blood oxygen levels are closely monitored during a polysomnogram. Polysomnograms are a little different in children as compared to adults (for example, different criteria for measuring breathing pauses). Unfortunately, many sleep labs lack experience in diagnosing and treating childhood OSA.

If you suspect that you or a family member has OSA, you should discuss referral to an accredited sleep center with your primary care doctor. This site can help you find an accredited sleep center:

Thursday, December 02, 2004


The New York Times discusses Intrinsa, a testosterone delivering patch:

Procter and Gamble is trying to get FDA approval for Intrinsa. Intrinsa is mildly effective at increasing female sexual desire:

"In clinical trials, women who used Intrinsa had an increase in the number of 'satisfying episodes' of sex to five a month, from three. But women who received the placebo also had an increase - to four a month, from three. The definition of satisfying sex was left to the women, who kept log books during the clinical trials."
"Procter & Gamble is initially seeking F.D.A. approval for Intrinsa as a treatment for women who have had their ovaries removed. It said that 17 to 30 percent of the 10 million women who have undergone such surgery have 'hypoactive sexual desire disorder,' meaning low sex drive that they find distressing."

If the FDA approves Intrinsa, doctors can prescribe it off-label for other populations and disorders. The market for Intrinsa could be as big as the market for Viagra:

"The shares of Procter & Gamble gained $1.18 yesterday, to close at $54.66"

Unfortunately, like any medication, Intrinsa does have side effects

"Possible risks include hirsutism, acne, liver dysfunction, lowering of the voice, adverse lipid changes, virilization of a female fetus, and, as androgens are aromatized to estrogens, potentially the risks of estrogen therapy."
So Intrinsa can give women mildly increased sex drive at the expense of increased body hair, increased facial hair, high cholesterol, and possible birth defects in female offspring. If Intrinsa is approved by the FDA, lawyers will have a field day. After it has been out for several months, we will see ads in newspapers trying to get women who took it to sue Procter and Gamble. Due to the cholesterol-raising effects, this medication probably will slightly increase the risk of heart attacks in women who take it.

Wednesday, December 01, 2004

An Interesting Statistic

Mississippi's major newspaper, the Clarion-Ledger, has an article about HIV today-

According to this article, "As of Dec. 1, 2003, Mississippi had 7,387 residents living with HIV. Of those, 1,072 are males and 2,314 are female. Another 4,001 are in those considered transgender. "

This must be a mistake. I can't believe that there are more transexuals with HIV than men and women with HIV combined.

Tuesday, November 30, 2004


As a sleep specialist, I am often asked about insomnia.
Here are some tips about dealing with insomnia:

Although it's tempting to use liquor as a cure for chronic sleeplessness, be warned: Liquor is quite expensive.

Getting more exercise can help combat insomnia. If you suffer from sleeplessness, try shuffling from the bed to the kitchen, opening and shutting the refrigerator door, and shuffling back to bed.

According to researchers at the National Sleep Foundation, there is an actual National Sleep Foundation. Yes, for real.

If you are going to take pills to help you sleep, be sure you take enough to knock yourself out. Watching Good Morning America while sleep-deprived and tranquilized is a hellish experience.

Use your bed for sleeping only. Conduct all reading, eating, phone calls, and sexual relations on the kitchen table.

Try counting sheep, rather than the number of times you've failed as a wife and mother.

If you got less than three hours of sleep the previous night, it's important to inform everyone you meet of that fact all day long.

Minimize noise, light, excessive temperature—all factors that could potentially disrupt rest—by sleeping indoors.

(adapted from

Please Note: This is not meant to be taken as actual medical advice.

Psychiatric Diagnosis

An article in the New York Times discusses psychiatric diagnosis:

Criteria for psychiatric disorders are determined by committee. Political considerations (for example, the removal of homosexuality as a psychiatric diagnosis) often play a role in determining the contents of DSM, Psychiatry's diagnostic manual. Currently we have DSM-IV. Soon all will be forced to submit to DSM-V.

Monday, November 29, 2004

Bariatric Surgery

Obesity is becoming increasingly prevalent. One-third of the population is obese (Body Mass Index of 30 or greater). An additional one-third of the population is overweight (Body Mass Index of 25-29.9). The prevalence of obesity is even higher among some minority populations; over 50% of African American females are obese. Obesity increases the risk of hypertension, diabetes, and coronary artery disease.

Surgery for obesity (bariatric surgery) is increasing. I am involved in the bariatric surgery program at the University of Mississippi Medical Center. I screen these patients for sleep apnea (breathing pauses during sleep) prior to their surgery. Usually the surgeries go ok, but there are occasional complications. Nationally, the mortality rate is estimated at 1/50 to 1/1000. As a psychiatric consultant, I have seen several of these patients for depression after they have been in the hospital for months with complications, including fistulas and wound problems. One lady was hospitalized a total of 8 months within a 9 month period.

Medicare now covers bariatric surgery for most of the elderly, though work is underway to standardize the elgibility criteria: We need outcome data in the elderly. Most of the surgical experience so far has been with younger patients. In younger patients, bariatric surgery improves survival in the long-term at the expense of increased mortality in the first several months post-operatively. The risk/benefit ratio in the elderly is uncertain. We also need more standardization of the pre-operative work-up for bariatric surgery in all age groups:

Monday, November 22, 2004


Kevin,MD ( recently discussed a newday article about medical interpreters:,0,7003540.story?coll=sns-ap-health-headlines

Many smaller hospitals do not have trained interpreters available. Often family members/friends are pressed into service. This can create problems:

"We had a case where a patient was being treated for a venereal disease and asked the doctor how she could have contracted it. The doctor explained it, but her husband, who was interpreting, told her that she got it from a public toilet," Sala said.

Sunday, November 21, 2004

Developmental Disabilities

A collumn in Psychiatric News (the newspaper of the American Psychiatric Association) comments on the lack of training that psychiatry residents receive in treating adults with autism and mental retardation:

Child Psychiatry fellows receive plenty of experience treating this population, but once they reach the age of approximately 18-21, the patients are transitioned to often ill-prepared general psychiatrists.

Once a week I see patients at Mississippi's institution for the mentally retarded/autistic. I also see more functional patients at group homes. The most frustrating part of this assignment is that I have to invent psychiatric diagnoses for many of the patients in order to treat them with medications. Some mentally retarded patients are impulsive, have mood swings, or are violent. They are like my 4-year old son, except that they are six feet tall, weight 200 pounds, and can do a lot of damage when they get out of control. However, due to a consent decree between the Justice Department and this state institution, I am not allowed to treat their mental retardation. Instead I must give them an axis 1 diagnosis such as "bipolar disorder". A mentally retarded person with "bipolar disorder" is very different from a person with a normal IQ who has bipolar disorder. I don't mean to imply that I arbitrarily give these patients a psychiatric diagnosis. The full-time psychologists at the state institution have ultimate control over the diagnosis given the patient, and make sure that DSM-IV criteria are strictly followed. Something just seems wrong about giving the same diagnosis of bipolar disorder to someone with an IQ of 40 who has increased energy most of the time and is constantly pacing and a person with IQ of 100 who has clearly alternating depressive and manic episodes.

On the other hand, my experience is that depression in the mentally retarded is very similary to depression in the normal-IQ population. Depression is common among institutionalized individuals with an IQ of 50-70; these individuals often express frustration about not being able to lead a "normal" life.

I don't want to give the impression that mentally retarded individuals at the state institution are all medicated to control their behavior. Medication is only tried after behavioral interventions fail. Less than half of the residents of this state facility are receiving psychotropics.

Gradually, through experience and reading, I feel that I have gained competence in treating the developmentally disabled. However, I wish that I would have received more training during residency.

More on Antidepressants and Pediatric Suicide

Another article from the New York Times about antidepressants and Pediatric suicide:

Antidepressants and Suicide

The New York Times Magazine has a good overview of the possible link between antidepressants and pediatric suicide:

In the first several weeks of treatment, antidepressants can cause activation and this can increase suicide risk. In general, antidepressants over the longterm decrease the risk of suicide:

"The pharmaceutical companies are clearly making a product that most psychiatrists consider critical to treating depressed adolescents. Not prescribing these drugs may very well pose a greater threat than prescribing them. Studies have shown that areas in which antidepressant use among young people is widespread have experienced a dip in teenage suicide rates; according to Dr. John Mann, a suicide expert at Columbia University, fewer than 20 percent of the 4,000 adolescents who commit suicide in America each year are taking or have ever taken antidepressants."

Each patient responds to an differently to an antidepressant, and he must be monitored closely for side effects. My adult patients often need to take benzodiazepines such as klonopin or ativan to treat the anxiety, jitteriness, and activation that can be experienced during the first 1-2 weeks of antidepressant treatment.

Child and Adolescent Psychiatry is a difficulty field (which is one of the reasons that they make about $50,000 more per year than us general psychiatrists). There is currently a shortage of Child and Adolescent Psychiatrists. The new FDA black box warning on antidepressants and suicide is going to make pediatricians and family practitioners less willing to treat behavioral problems in children:

"while many child psychiatrists are unlikely to change their attitude toward S.S.R.I.'s, most pediatricians and general practitioners, who until now have written the bulk of these prescriptions, no doubt will. This could mean a lot of untreated children. There are only 7,400 child and adolescent psychiatrists in America; even in areas with high per-capita concentrations, the average wait to see one is six weeks. There is also the matter of cost. Many child psychiatrists charge steep hourly rates that are only partly offset by health insurance providers."

Part of my job as the Consult Psychiatry director at the U of MS is performing consults on pediatric patients (we have a shortage of child psychiatrists and our few child psychiatrists are not available to perform inpatient consults). Due to the legal risk, I now limit myself to triage of pediatric patients who I am asked to see for depression- I basically determine if the child needs transfer to a psychiatric ward or if he needs outpatient treatment with a child psychiatrist (of course, just recommending outpatient child psychiatric follow up doesn't ensure that it happens- it's a broken system out there, and not every child receives the help that he needs). With the current legal climate, I would never myself initiate treatment with an SSRI on a pediatric patient.