What not to put on a CV

I received an e-mail today from someone applying for a sleep fellowship at the local university (I briefly held the position of sleep fellowship program director before I left the university in 2005). The following was included in the applicant's cv:

HONORS AND AWARDS:

2006- Selected in Strathmore’s Who’s Who
Strathmore’s Who’s Who publishes annual registry of outstanding professionals based on one’s position and accomplishments. Inclusion is limited to individuals who have demonstrated leadership and achievement in their occupation, industry or profession.

2006- Selected in Marquis Who’s Who in the world
Marquis Who’s Who publishes annual directory of leading citizens from all over the world in different professions.
Lucky for him I am no longer program director, I would have just deleted his application. I forwarded his application to the current program director.

Some foreign medical graduates do not realize that these Who's Who books are just scams in which your brief biography is published in hopes that you will spend a lot of money on the book. Do not put it on your cv.

Welcome to Mississippi

This Marshall Ramsey cartoon was reprinted in today's Clarion Ledger.

Obesity is not good for the health status of Mississippi, but it does make it a good place to practice sleep medicine (which from a financial standpoint is the treatment of sleep apnea). The population of Mississippi is less than 3 million, yet there are over 40 sleep labs in the state.

Thanks to my Readers

Rebel Doctor and sleepdoctor blogs got click # 50,000 today. Still a while to go before I catch up to blogs with 1 million clicks. I am going to try to increase the frequency of posting over the upcoming year. It wouldn't hurt if Kevin MD linked to at least one of the blogs. And I need to get back into submitting to grand rounds on a regular basis.
Thanks to those who have read Rebel Doctor and sleepdoctor, and to those who have linked to the blogs. I especially want to thank those who patronize my advertisers, and allow me to earn 50 cents a day from Google adsense.

Michael Rack, MD

Not Everyone Benefits from Health Insurance

USA Today has a feature in their financial section in which they present a person's financial problems and then have an expert devise a financial plan for that person. I think USA Today got it wrong this time.
The financial problem:
Dana Dwyer, 24, had just quit her first job after college as a manager at a Ralph Lauren store in Miami and hadn't started her second yet when, wham!
She was in a car wreck. Her front teeth were knocked out, and her palate was broken. In between jobs, she had no health insurance.
Worse, though, was the $16,000 bill. Dwyer was forced to use her savings and work out a deal with the hospital to pay $200 a month.
"I paid $2,000 upfront to have my teeth fixed," she says. "You have to have teeth."
Their Solution:
Davis recommends that Dwyer buy an individual health insurance policy — she could get coverage for about $300 a month in Florida — before she focuses on paying down credit card debt. "She's one more bad drive down the street from being right back where she was" when she had a wreck, the planner says.
I think Dana Dwyer is currently getting a good deal. Instead of paying $300 per month for bare bones health insurance coverage, she is paying $200 per month to the hospital- a savings of $100 per month.
Even if she did have health insurance at the time of the accident, she would probably still owe the hospital- many health insurance plans exclude injuries that are the result of motor vehicle accidents. What she really needs is a good automobile insurance policy.
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I was recently in an auto accident with some minor injuries. Luckily I have good auto insurance.

The New York Times Slams Eli Lilly (again)

Earlier I posted about Eli Lilly withholding information from the public and physicians about some of the dangerous side effects of Zyprexa, an antipsychotic used for the treatment of schizophrenia and bipolar disorder. Today the New York Times reports that Eli Lilly has been promoting off label uses for Zyprexa:
Eli Lilly encouraged primary care physicians to use Zyprexa, a powerful drug for schizophrenia and bipolar disorder, in patients who did not have either condition, according to internal Lilly marketing materials.
The marketing documents, given to The New York Times by a lawyer representing mentally ill patients, detail a multiyear promotional campaign that Lilly began in Orlando, Fla., in late 2000. In the campaign, called Viva Zyprexa, Lilly told its sales representatives to suggest that doctors prescribe Zyprexa to older patients with symptoms of dementia.
Zyprexa is not approved to treat dementia or dementia-related psychosis, and in fact carries a prominent warning from the F.D.A. that it increases the risk of death in older patients with dementia-related psychosis. Federal laws bar drug makers from promoting prescription drugs for conditions for which they have not been approved — a practice known as off-label prescription — although doctors can prescribe drugs to any patient they wish.
Yet in 1999 and 2000 Lilly considered ways to convince primary care doctors that they should use Zyprexa on their patients. In one document, an unnamed Lilly marketing executive wrote that these doctors “do treat dementia” but “do not treat bipolar; schizophrenia is handled by psychiatrists.”
As a result, “dementia should be first message,” of a campaign to primary doctors, according to the document, which appears to be part of a larger marketing presentation but is not marked more specifically.
The issue of off-label marketing is controversial in the drug industry. Nearly every company is under either civil or criminal investigation for alleged efforts to expand the use of its drugs beyond the specific illness or condition for which they are approved.
At the 2001 meeting in Dallas with Zyprexa sales representatives, Mr. Bandick praised 16 representatives by name for the number of prescriptions they had convinced doctors to write, according to a script prepared in advance of the meeting. More than 100 other representatives had convinced doctors to write at least 16 extra prescriptions and thus “maxed out on a pretty sweet incentive,” he said.
“Olanzapine is the molecule that keeps on giving,” Mr. Bandick said.

Polycystic Ovarian Syndrome, an introduction for psychiatrists

Polycystic ovarian syndrome (PCOS), also known as Stein-Leventhal syndrome, affects 6-10 % of women of reproductive age. Characteristic features of PCOS include menstrual cycle abnormalities and hyperandrogenism. Menstrual cycle abnormalities range from a decreased frequency of menses to complete amenorrhea, though some patients have normal menstrual cycles. Abnormal uterine bleeding can occur. Fertility is decreased. Manifestations of hyperandrogenism include acne, alopecia, and hirsutism. Recently hyperinsulinemia and insulin resistance have been recognized as features of PCOS (hyperandrogenism can lead to insulin resistance, and vice versa), and women with PCOS are at increased risk of type II diabetes mellitus. Obesity is common. The pathophysiology of PCOS is incompletely understood and the components of PCOS interact with each other in a complex manner. For example, obesity can lead to insulin resistance which can lead to hyperandrogenism.

Diagnosis of PCOS requires the exclusion of other causes of hyperandrogenism and anovulation/oligo-ovulation. Since pituitary or thyroid disease can cause ovulatory dysfunction, a prolactin level and TSH should be checked. Although the luteinizing hormone (LH)/ follicle stimulating hormone (FSH) ratio is usually greater than 2.5 to 3, a normal ratio does not exclude the diagnosis. A pregnancy test should also be checked. Androgen-producing neoplasms can be excluded by checking total testosterone and dehydroepiandrosterone sulfate (DHEAS) levels. Total testosterone levels are often mildly elevated in PCOS, but a level greater than 200 ng/dl suggests a virilizing neoplasm. 17-hydroxyprogesterone should be checked to screen for late-onset congenital adrenal hyperplasia. Sometimes a dexamethasone suppression test is performed to rule out Cushing’s syndrome. Non-obese patients should be screened for anorexia nervosa.

A transvaginal ultrasound is sometimes obtained in patients with PCOS; this test can identify most virilizing tumors. However, patients with PCOS do not always have radiographically demonstrated polycystic ovaries. In addition, approximately 25% of women with normal ovulation have polycystic-appearing ovaries.

Patients with PCOS are at increased risk for cardiovascular disease due to hyperandrogenism. Therefore fasting lipids should be checked. The patient should be assessed for other cardiac risk factors, such as smoking and hypertension. Due to the association between PCOS and insulin resistance, a fasting glucose level should be checked. Some also recommend checking insulin levels or glucose tolerance testing.

One of the primary treatments for PCOS is oral contraceptives, which suppress androgens. Sometimes spironolactone, which suppresses enzymes in the androgen biosynthetic pathway, is combined with oral contraceptives. Fertility can be increased by clomiphene citrate. Metformin, an insulin-sensitizing agent, has been shown to restore menstrual regularity. Weight loss is also helpful.

Several studies suggest that PCOS is more common in women with bipolar disorder or epilepsy than in the general population. Valproate probably increases the risk of PCOS. However, since the disorders that valproate is used to treat are also associated with PCOS, valproate has not been conclusively proven to be a causative factor for PCOS.

Psychiatrists should take a detailed menstrual history in female patients with bipolar disorder. It is also important to ask about hirsutism. Patients with baseline abnormalities should be referred to a primary care doctor for further evaluation. The development of PCOS symptoms during treatment also warrants referral to a primary care doctor. Symptoms of PCOS often remit or improve after the discontinuation of valproate. Prolactin-elevating antipsychotics can also cause menstrual abnormalities, and occasionally hirsutism.
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the above is for a psychiatry newsletter article I am writing

Eli Lilly Minimizes Zyprexa Risk

The New York Times reports that Eli Lilly has been minimizing Zyprexa's risk for years:
Lilly’s own published data, which it told its sales representatives to play down in conversations with doctors, has shown that 30 percent of patients taking Zyprexa gain 22 pounds or more after a year on the drug, and some patients have reported gaining 100 pounds or more. But Lilly was concerned that Zyprexa’s sales would be hurt if the company was more forthright about the fact that the drug might cause unmanageable weight gain or diabetes, according to the documents, which cover the period 1995 to 2004.
Critics, including the American Diabetes Association, have argued that Zyprexa, introduced in 1996, is more likely to cause diabetes than other widely used schizophrenia drugs. Lilly has consistently denied such a link, and did so again on Friday in a written response to questions about the documents.
However, psychiatrists became well aware that Zyprexa was much more likely to cause weight gain, diabetes, and high cholesterol than other 2nd generation antipsychotics. So what did Eli Lilly do?
Lilly did expand its marketing to primary care physicians, who its internal studies showed were less aware of Zyprexa’s side effects. Lilly sales material encouraged representatives to promote Zyprexa as a “safe, gentle psychotropic” suitable for people with mild mental illness.
Eli Lilly repeatedly lied to or withheld information from doctors:
To reassure doctors, Lilly also publicly said that when it followed up with patients who had taken Zyprexa in a clinical trial for three years, it found that weight gain appeared to plateau after about nine months. But the company did not discuss a far less reassuring finding in early 1999, disclosed in the documents, that blood sugar levels in the patients increased steadily for three years.
In 2000 and 2001, more warning signs emerged, the documents show. In four surveys conducted by Lilly’s marketing department, the company found that 70 percent of psychiatrists polled had seen at least one of their patients develop high blood sugar or diabetes while taking Zyprexa, compared with about 20 percent for Risperdal or Seroquel. Lilly never disclosed those findings.
(Risperidone and Seroquel are antipsychotics that have a moderate risk of causing diabetes. The risk with these 2 drugs is less than that of Zyprexa, but greater than that of Abilify or Geodon)
I hope that Eli Lilly loses its lawsuits:
Last year, Lilly agreed to pay $750 million to settle suits by 8,000 people who claimed they developed diabetes or other medical problems after taking Zyprexa. Thousands more suits against the company are pending.
Because of the efforts of Eli Lilly, guidelines now force psychiatrists to monitor patients taking Geodon or Abilify for diabetes and other metabolic side effects. These drugs rarely cause metabolic side effects. All of the 2nd generation antipsychotics have been tarred with the FDA diabetes warning because Eli Lilly refused to own up to the problems with Zyprexa.

Malpractice Immunity for Academic Physicians

Kevin MD linked to this article regarding immunity for physicians working for the state (in this case Ohio):
The Ohio Supreme Court issued its opinion this week in Theobald .v University of Cincinnati, granting blanket immunity from liability to physicians for their negligent acts when the medical malpractice occurs while the physician is teaching medical students or residents of a state medical school. It makes no difference whether the doctor is being paid privately or whether the doctor is acting outside of his official teaching capacity when the malpractice is committed. The bottom line is that the doctor may now be immune from suit and from accountability whenever a student is present during a medical procedure.
The lawyer writing this article just doesn't get it. In most states, full-time physician state employees are working for the state all the time, whether they are with students/residents or not. The usual university contract forbids full-time employees from practicing medicine except as part of their state employment. Billing is often done through a group practice plan (the university usually can't bill insurance companies directly). The income from this group practice plan is often controlled/distributed by the department chairman and is not the same as "being paid privately."
Here is how it works in Mississippi.
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The actual court decision is interesting reading.

Paxil linked to cardiac birth defects

WEDNESDAY, Nov. 29 (HealthDay News) -- A group representing America's obstetricians is recommending that women avoid the antidepressant Paxil if they are pregnant or planning on becoming pregnant, due to a potential heightened risk for birth defects.
The American College of Obstetricians and Gynecologists (ACOG) also cautioned that treatment with other antidepressants should be considered on a case-by-case basis.
ACOG's Committee on Obstetric Practice "recommends that treatment with all SSRIs [selective serotonin reuptake inhibitors] or selective norepinephrine reuptake inhibitors or both during pregnancy be individualized and paroxetine [Paxil] use among pregnant women or women planning to become pregnant be avoided, if possible," read the statement, which is in the December issue of Obstetrics & Gynecology.
The guidelines come a full year after the U.S. Food and Drug Administration (FDA) issued a warning about possible birth defects associated with Paxil when the drug is taken during the first trimester of pregnancy.
This warning was based on two studies. The first found about a 2 percent risk of heart defects in babies born to mothers who took Paxil early in their pregnancy, compared with a 1 percent risk in the general population.
The second study found that the risk of heart defects was 1.5 percent in babies whose mothers took Paxil in the first three months of pregnancy, compared with 1 percent in babies whose mothers took other antidepressants in the first trimester. The most common defects were cardiovascular.
"Since the FDA warnings a year ago, most ob/gyns have been trying to avoid Paxil during pregnancy," noted Dr. Jennifer Wu, an obstetrician/gynecologist at Lenox Hill Hospital in New York City. "This is just a formal statement by ACOG."
The initial FDA warning came in September of 2005. In December of the same year, the FDA instructed Paxil's maker, GlaxoSmithKline, to reclassify the drug from a Category C to D (a stronger warning) for pregnant women. Category D means studies in pregnant women have demonstrated a risk to the fetus.
Other reports had indicated that SSRIs, the category of antidepressants which includes Paxil as well as Celexa, Prozac and Zoloft, may cause newborns to have withdrawal symptoms.
ACOG acknowledged that these potential problems must be weighed against yet another study which found that pregnant women who discontinue their antidepressant medication are five times more likely to relapse into depression than women who continue with the medication.
"Untreated depression has its own risks, including low weight gain, alcohol and substance abuse, and sexually transmitted diseases, all of which have negative maternal and fetal health implications," the statement said.
Women of reproductive age have the highest prevalence of major depressive disorders, with ACOG experts estimating that about 1 in 10 will experience a bout of major or minor depression sometime during pregnancy or the postpartum period.
Ideally, these issues should be considered before a woman becomes pregnant, the ACOG panel said. But, given that about half of all pregnancies are not planned, many decisions regarding treatment will inevitably happen after the woman has conceived. Fetal echocardiography, which looks for heart trouble, should be considered for women who were exposed to Paxil in early pregnancy, the statement recommended.
"Women who have certain health problem such as depression really should try to plan their pregnancies with their ob/gyn and psychiatrist," Wu confirmed. "The major danger will be to women who have an unplanned pregnancy and don't realize it until they're two months along. There's a lot of organ development during that time, and exposure to certain SSRIs may pose some dangers."

That Wacky Kramer

The Reverend Jesse Jackson feels that Michael Richards needs psychiatric help:
First he went on national television to apologize for his racial tirade against two black hecklers. Now Michael Richards is taking his contriteness to the next level: he's hired a public relations expert with deep contacts in the black community.
New York publicist Howard Rubenstein took on Richards as a client Wednesday after being contacted by the actor-comedian. He then arranged for Richards to call the Revs. Jesse Jackson and Al Sharpton.
"Clearly he needs some race sensibility training, and some psychiatric help. His anger is volatile and dangerous to himself and others," Jackson said.

The number of children on Psych meds is increasing

The New York Times reports on the increasing number of children on psychiatric meds. Many children are now taking combinations of 3 or more psychiatric medications:
There is little doubt that some psychiatric medicines, taken by themselves, work well in children. For example, dozens of studies have shown that stimulants improve attentiveness. A handful of other psychiatric drugs have proven effective against childhood obsessive compulsive disorder, among other problems.
But a growing number of children and teenagers in the United States are taking not just a single drug for discrete psychiatric difficulties but combinations of powerful and even life-threatening medications to treat a dizzying array of problems.
Last year in the United States, about 1.6 million children and teenagers — 280,000 of them under age 10 — were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.

Sleep deprivation and driving

Sleep Review reports:
A recent online article from ABC News reports that Stanford University researchers have found that staying awake for 24 hours has the same effect as being legally drunk. Clearly, sleep deprivation can be pretty strong stuff. We know it leads to mood swings, confusion, impaired motor coordination and more. But can going without sleep for 24-hours make you, say, slur your speech and wear a lampshade on your head? Steven Howard, associate professor of anesthesia and an expert on sleep deprivation and fatigue teamed up with colleagues to study 24 nurses and 25 doctors who worked the 12-hour graveyard shift at Stanford Hospital. Half were given a 40-minute nap break at 3am, in the middle of their shift, and the other half worked straight through. At the end of their shifts, study participants took a variety of tests including a simulated 40-minute drive. Those who had not napped—but were instead sleep-deprived—turned out to be dangerous drivers. According to the researchers, the non-nappers crashed “over and over again.” The nappers did much better when it came to memory, dexterity, and mood as well. They outranked the non-nappers on a written memory test and a simulated insertion of an intravenous tube. Both groups even took a test designed by NASA that measured different mood states like confusion, fatigue, anger, and vigor. On the test, the nappers showed fewer performance lapses, less fatigue, and more vigor.
Both sleep deprivation and alcohol intoxication make driving more dangerous. Combining the two is especially dangerous.

Pre-Traumatic Stress Disorder

NORFOLK, VA—Pre-traumatic stress disorder, a future-combat-related psychological condition previously thought to afflict only young soldiers drafted against their will, is now found in growing numbers among National Guard members, Army, Navy, Marine, and Air Force reservists, semi-retired officers, and the newly recruited, according to a government study released Monday.
"When soldiers are put in the extreme situation of facing the possibility of large-scale death and shocking violence, many experience sleeplessness and outbursts of anger," said Walter Reed Army Hospital psychologist Capt. Sidney Mullenthauer. "We're seeing more victims experience vivid, ultra-realistic flash-forwards of roadside bombings that tear through a group of innocent children, or rocket attacks on their convoys that leave fellow soldiers charred and smoldering."
The study, conducted by the Department Of Future Veterans Affairs, found that 80 percent of part-time soldiers reported no signs of Pre-TSD while carrying out their obligatory one weekend of duty a month, but quickly developed severe symptoms upon receiving orders for active combat.
In addition, a significant number of those who will enter a war zone say they are plagued by repeated visions of atrocities, torture, and the CNN logo.

Risperidone approved for autism

The Food and Drug Administration has approved risperidone for treatment of irritability associated with autism. This approval addresses aggression, deliberate self-injury, and temper tantrums in children aged 5 years and older, and in adolescents.
In an interview, Dr. Christopher J. McDougle characterized the FDA approval as a major development. “There is no drug currently approved for autism, so it's a tremendous breakthrough,” said Dr. McDougle, the Albert E. Stern Professor and chairman of the department of psychiatry at Indiana University, Indianapolis.
The new indication is based in part on a multicenter, randomized, double-blind study that showed significant behavioral improvements among 49 children treated with risperidone, compared with 52 given a placebo (N. Engl. J. Med. 2002;347:314–21). Researchers assessed response using the Irritability Subscale of the Aberrant Behavior Checklist and the rating on the Clinical Global Impressions-Improvement Scale. There were 33 responders in the risperidone group and 6 responders in the placebo group.
In an open-label, 8-week follow-up study, the 46 nonresponders to placebo were given risperidone, and 30 responded. Researchers then monitored all responders and demonstrated that the benefit of treatment persisted for these patients out to 6 months (Am. J. Psychyiatry 2005;162:1361–9). The authors added, however, that discontinuation after 6 months “was associated with a rapid return of disruptive and aggressive behavior in most subjects.”
These studies were sponsored by the National Institute of Mental Health. The benefit of treatment persisted out to 6 months in the 63 of the children who had a positive response at 8 weeks.
Dr. McDougle emphasized that the approval is not for treatment of autism across the board. “It's important for people to realize the drug is approved for associated symptoms—not the core social and communication symptoms,” he said.
The percentage of pediatric patients with autism who display aggression, deliberate self-injury, and/or temper tantrums is probably in the range of 20%–30%, Dr. Scahill said. He characterized that range as sizable.
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I have several adult patients with autism, and have found risperidone effective for treating their hyperactivity and self-injurious behavior.

Doctors are like Convicts

"They make you feel like a convict" is what doctors say about the people, commissions, agencies and departments we must answer to, every month, for the rest of our lives, or be stripped of the right to practice medicine (as well as the ability to earn a living). Every doctor lives under continuous scrutiny from federal, state, hospital, insurance company, specialty board, medico-legal, and professional conduct organizations. Hundreds of pages of forms must be filled out, hundreds of thousands of dollars spent, hundreds of hours of study and examination must be completed every year — just to stay in practice — and that's after Board Certification, a process at then end of ten years of intense training, study, work and examination.
Each of these burdens is placed on the doctor in the name of "protecting the public", but everyone in the medical business knows the plain truth: that not one of these actually helps us treat patients, not one makes us better doctors. You become a better doctor when you notice patterns, when you get out of your own way enough to hear real complaints and treat them. You might scrub in with a friend who does a new procedure, go to an interesting course (the good ones often don't give CME — mandated continuing medical education — credits) or you might become a better doctor in your room at night with your old books that you see in a new light because you've seen a certain case that day. Every doctor knows this: however it happens, professional growth does not take place via "administrative compliance." The public is not protected at all by these things. What they do protect is the livelihood of an entire class — the millions who make their livings in the public and private "administration" of American medicine. Do I want to feed my little girl to this beast? I don't think so.

Democrats hate Mississippi

A Mississippi congressman says Rep. Charles Rangel of New York owes the southern state an apology, and he asks if insults are what Mississippi should expect when Democrats take over leadership in Congress.
Rangel, a Democrat, was quoted in The New York Times on Thursday saying: "Mississippi gets more than their fair share back in federal money, but who the hell wants to live in Mississippi?"
Rangel said he didn't intend to insult the state, but Rep. Chip Pickering, R-Miss., issued a sharp statement criticizing the choice of words.
"I hope his remarks are not the kind of insults, slander and defamation that Mississippians will come to expect from the Democrat leadership in Washington, D.C.," Pickering said.
via Drudge
the image is from this website.

Gov gives with one hand and takes away with the other

On November 1, the Centers for Medicare and Medicaid Services (CMS) issued its final rule for the 2007 Physician Fee Schedule. The rule increases Medicare relative value units (RVUs) for office visits and other undervalued evaluation and management (E/M) services. The RVUs are one of the factors that Medicare and many other payers use in setting their pay rates. The RVU increases will result in Medicare paying approximately $4 billion more for E/M services than it has in the past. CMS’s decision to increase the RVUs was due in large part to the College’s efforts, supported by other physician organizations, to document that the typical complexity and work involved in these services has increased substantially.
Regrettably, though, the initial beneficial impact for patients that result from paying more for personalized, primary care services will be undermined because of Congress’ inexcusable failure to act to avert a 5 percent cut mandated by the flawed sustainable growth rate (SGR) formula. In fact, CMS now projects that the SGR cut will more than cancel out the 2007 dollar improvements internists would have received from the RVU increases.
The 5 percent payment cut results from the SGR formula, which was created in 1997 and ties physician payment to growth in the overall economy. When growth in physician expenditures exceeds growth in the economy, the difference is subtracted from physician payments. This results in an across-the-board cut in Medicare payments to physicians.
The College agrees with CMS that by paying physicians more for the time they spend talking with patients about their health care and by emphasizing personalized care, patients will benefit from better outcomes and more efficient use of resources. The College also believes that the improved RVUs, if not offset by the Medicare SGR cut , would begin to address long-standing inequities in how Medicare pays for services that are contributing to the imminent collapse of primary care medicine in the United States.
One result of the SGR cut is that many internists, who are already struggling to keep their practices open, will find that Medicare payments will continue to fall behind their costs. A new 2006 randomized survey of ACP’s membership found that if a 5 percent cut goes into effect, 27.6 percent of those surveyed will decrease the number of new Medicare patients accepted into their practices; almost 40 percent of those who are self-employed or in private practice reported that they would decrease the number of new Medicare patients they would accept . Other specialties will experience even larger reductions in Medicare payments, which will also lead to reduced beneficiary access.
It is not too late, however, for Congress to act to avert the SGR cut and assure that internists and your Medicare patients get the full benefit of the RVU increases for E/M services.
Congress will be returning in a matter of days for a post-election “lame duck” session to complete action on “must pass” legislation before adjourning for the year. We need your help to assure that legislation to halt the SGR cuts is among those “must pass” bills.
We ask you to help us prevail upon each and every member, including those in the congressional leadership and on Medicare authorizing committees, to enact legislation to:
Halt the 5 percent cut in Medicare payments that will result from a flawed SGR formula and replace it with a positive update, and
Support implementation, without delay, of CMS’s final rule to increase Medicare relative value units (RVUs) for office visits and other undervalued evaluation and management (E/M) services.
Each and every member of Congress is critical – we need your help today. Time is of the essence as Congress will reconvene this coming Monday, November 13 and may only remain in session for a few days. Please take a few minutes and use ACP’s Legislative Action Center (LAC) to contact your members of Congress, http://www.acponline.org/lac . [To logon, use your email address as the username and ACP as the password, unless you’ve personalized it.] A sample message is available for you to personalize and forward to your federal lawmakers. Different messages are posted for medical students, associate members, and internists. Even better, please take a few minutes to call your members of Congress in their Washington offices. Use AMA’s toll-free grassroots hotline at 1-800-833-6354 and press 1, then enter your zip code and ask for the member’s health legislative aide. If you have problems, please contact Tracy Novak at tnovak@acponline.org or by phone at 800-338-2746 ext. 4532.
Many thanks to those of you who contacted your legislators previously this year but I urge you to contact them again now. Many of you were told by your lawmakers that they would fix the SGR problem after the elections – we must hold them to that promise. Without immediate Congressional action, primary care will suffer and the intended improvements for patients that would result from emphasizing the value of personalized, primary care will not be realized. We work too hard to provide the best care possible to our patients – we can’t let Congressional inaction change the paradigm. Thank you in advance for your help.
Lynne Kirk, MD, FACPPresident, ACP

USA TODAY Raises Healthcare Costs

USA Today, after a week of articles promoting health care reform, published an article about missed heart attacks that will lead to more defensive medicine:
Over the past six years, studies in the New England Journal of Medicine and other journals have found a heart attack diagnosis is missed in 2% of heart attack patients seeking help in the USA's emergency rooms, 3% in Canada and 6% in the United Kingdom.
"It is the horns of the dilemma. On one hand, there are limitations to the diagnostic tools, and they are very real limitations," Ornato says. "The electrocardiogram is the first screening tool, and it's only going to pick up, on a good day, 70% to 75% of heart attacks."
He says new devices, including an experimental ECG that maps the heart and CT scanners that can look inside of clogged heart arteries, offer new hope for the future.
But he says patients and their advocates must sometimes push doctors who are not listening.
"If something doesn't feel right to them, they have the responsibility to express that," Ornato says. "It's the responsibility of the nurses and physicians to listen."
The rate of missed heart attack diagnoses is better in the US than in several countries with single-payer systems. The only way to improve the rate is admit practically everyone who comes to an ER with chest pain, thus raising costs dramatically. Some ER docs do this already, and I think more are going to do this as a result of the article. The article also promotes cardiac catheterization:
After Gustafson had the same battery of tests Pettry had taken and doctors found no evidence of a heart attack, they went a step further. They admitted him to the hospital and performed more tests, including a stress test, putting Gustafson on a treadmill and monitoring his heart as the 59-year-old social worker was pushed to his physical limits.
"They could find nothing obvious," Connie says. "The cardiologist on call was dismissive. She said there was nothing to support the diagnosis that he had any kind of heart event."
But Connie says her husband "could feel that something was not right."
As the staff prepared to discharge Gustafson, he saw Barry Crevey, a cardiologist he had met through his social work, in the hallway. Crevey listened to Gustafson's story and explained that 25% of heart attacks may be "silent."
Considering Gustafson's history and the fact that both his parents had cardiovascular disease, the doctor suggested his arteries should be checked by threading a heart catheter into them, injecting dye and measuring the openings.
"When he told me his story, I'm thinking, 'This person needs a heart catheterization,' " Crevey says. "This is Cardiology 101. I would not have even bothered to do a non-invasive stress test."
The arteries were cleared with stents and a drilling procedure, and Gustafson is now back at work with "a clean bill of health," Connie says.
Gradus-Pizlo (the patient's initial cardiologist during the hospitalization) says, "In a patient with known disease, there is no question there are blockages there," but none of the blockages were putting Gustafson's life at immediate risk.
His heart was working fine with the reduced blood flow, which was confirmed by the fact that he passed the stress test, she says. "Even with those blockages, he had adequate blood supply. I'm not saying he doesn't have disease. He has severe disease. I didn't recommend therapy. I recommended aggressive medical management based on guidelines."
Though she agrees the blockages should have been opened once they were seen, she does not believe she misdiagnosed Gustafson. "I believe it is a difference of approach," Gradus-Pizlo says. "This is a matter of clinical judgment."
For patients not having and acute coronary event, there is no evidence that angioplasty/stenting improves survival more than aggressive medical management (lowering cholesterol, aspirin, beta-blockers, etc). Cardiac catheterizations and angioplasty have serious risks. I think USA TODAY did a disservice to the cardiologist (Gradus-Pizlo) who was conservatively treating the patient.

1st vs 2nd Generation Antipsychotics

1st vs 2nd Generation Antipsychotics
Retired Doc recently compared 1st to 2nd Generation Antipsychotics.Here are my thoughts:My opinion on atypicals vs 1st generation antipsychotics is:
1. Clozaril has clearly superior efficacy, Zyprexa is moderately more effective, and the rest of the atypicals are marginally more effective than the 1st generation.
2. Although ALL antipsychotics(old and new) can cause weight gain and diabetes and hypercholesterolemia, the risk is clearly greater with zyprexa and clozaril.
3. Risperidone frequently causes hyperprolactinemia. This commonly causes sexual side effects, including breast enlargement in men. Whether this hyperprolactinemia causes osteoporosis in the long term is unknown.
4. Seroquel, Geodon, and Abilify are reasonable initial choices when an antipsychotic is indicated. Like all of the atypicals, the risk of tardive dyskinesia is lower than the 1st generation drugs. In my opinion, their side effect profile is better than zyprexa/risperidone.
5. Clozaril remains the drug of choice in treatment resistant patients, but because of the risk of agranulocytosis, should not be used initially.
(republished from several weeks ago with copyrighted cartoon deleted. Sorry, I didn't save the comments).

McCain Discusses Suicide

Arizona Sen. John McCain, a likely Republican presidential contender in 2008, joked on Wednesday he would "commit suicide" if Democrats win the Senate in November.
McCain, on a visit to Iowa to campaign for Republican congressional candidates, was asked his reaction to a potential Democratic takeover of the Senate in the November 7 elections.
"I think I'd just commit suicide," McCain told reporters, to accompanying laughter from Republicans standing with him. "I don't want to face that eventuality because I don't think it's going to happen."

boutique medicine

Marketwatch reports on Boutique Medicine:

Taylor was seeing as many as 35 patients a day but his business was struggling after a five-doctor practice he was part of disbanded. So he contracted with MDVIP, a company based in Boca Raton, Fla., that helps doctors transition to boutique practices.
"What convinced me to try it was I tried everything else," he said. Now he's winnowed his patient base to 425 from a high of nearly 4,000 and sees "anywhere from eight to 15 at the most on a very busy day."
Such a reduction often translates into longer and same-day appointments, extensive physicals, better coordination with specialists and more follow-up as well as a greater emphasis on preventive care. Taylor's staff of two, for example, is able to keep track of which patients taking cholesterol medications are due for blood work and call them.
"Patients are happier; I'm happier," he said. "I've got more time to devote to each problem a patient has. I feel much more comfortable and confident about what I do."
Physicians want to regain control of their schedules and are frustrated that they still have to spend so much time wrangling with insurance companies after years of pushing for systemic changes, he said.
Retainer practices also cater to some patients' desire to check out every health risk factor and has evolved as an alternative way to navigate the system, Caplan said.
"It's there because the current health-care system is broken and we actually have to pay people to talk to us," Caplan said. "You're buying back personalized medicine, a relationship with somebody, because the current business model has weeded that out."

"It's a tiny drop in a huge ocean," Plested said. "The economic reality and demographic reality is there aren't that many areas that will support this type of practice."
Still, retainer practices point to an uncomfortable truth, Caplan said. "It undermines one of our favorite myths, which is same quality of health care for all. That's never been true, but this rubs our nose in it as a society."
It's hard to practice high quality medicine in a primary setting. PCP's need to see too many patients in too short a time. Fortunately, in my specialty (sleep medicine), I am able to subsidize patient visits with income from sleep studies. The generous reimbursement for sleep studies allows me to spend more time with patients.

Pill Splitting

Should physicians encourage pill splitting as a way to help patients save money?

Splitting pills can help patients save money:
The first time that a patient asked me to write a prescription for a higher dosage of a medication was in the late 1990s. Viagra was a highly desired medication for some older male patients, but at $10 a pill, many couldn't afford that much of it. But these motivated patients soon learned that both the 50-mg and 100-mg tablets cost the same amount. Splitting the higher-dose pills effectively gave them a 50% discount.
Many of the world's best-selling drugs, including Lipitor, Zocor, and dozens of others, are priced similarly, with higher doses carrying the same price tag as lower doses. These medications are candidates for cost savings by splitting tablets.
However, pill splitting has its risks:
Splitting pills can be dangerous for certain types of patients and for certain medications. The difficulty is determining what medications can be safely split and for which patients.
Medications that have special enteric coatings, have extended-release formulations, or are capsules containing powder or gel are some examples of those that should never be split.
Another category of medicines that are dangerous for pill-splitting are those that have a narrow therapeutic index, where precise dosing is a critical element of the therapy. Even with pill- splitting devices, splitting the medicine can result in a plus or minus 20% variation in the effective dose.
Similarly, there are certain types of patients who are not good candidates for pill splitting, such as the elderly, patients suffering from dementia, and those with visual impairments or other conditions that would make it difficult for them to split a pill precisely.
So even if you had a medication that might appear to be safe to split, there are always going to be patients for whom the practice is going to be risky.
Another risk of pill splitting is confusion about the dose of medication. For example, a patient may have a bottle full of 40 mg blood pressure pills. If he goes to the ER with his bag of meds, the ER doc may think he is taking 40 mg daily of the medication rather than the 20 mg his primary care doc told him to take. I've seen this happen before in busy ER's and inpatient services.

Foley is not a pedophile

Any suggestion that Mark Foley is a pedophile is false," the former congressman's lawyer, David Roth, said Tuesday at a news conference in West Palm Beach, Fla. He was right, but not for the reasons he probably had in mind. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, pedophilia involves "intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger)." The disorder is one of a number of conditions known as paraphilias, which the APA defines as sexual obsessions or fixations "that generally involve non-human subjects, children, or other non-consenting adults, or the suffering or humiliation of oneself or one's partner." Examples of other well-known paraphilias include bestiality, necrophilia, exhibitionism, sadomasochism, and voyeurism. Some therapies that focus on changing cognitive and behavioral patterns are believed to help sufferers of paraphilias control themselves, if they are motivated to do so. But fully overcoming their predilections is a more difficult challenge.
Based on what has been revealed so far, former Rep. Foley seems to suffer from a different condition: ephebophilia, which is defined as a sexual attraction to post-pubescent adolescents and older teenagers. The DSM IV doesn't include ephebophilia as a diagnostic category. Sexual contact with children is explicitly illegal in all jurisdictions in the United States. But such contact between older teenagers and adults presents a murkier legal picture. The laws on age of consent vary from state to state, and prosecutors have wide latitude to determine whether to charge an individual with a sexual offense.
From Slate

Sell Stocks Now

The Dow Jones Industrial Average reached its highest level in six years on Thursday afternoon but edged off the peak to finish just short of its all-time closing high. The S&P 500 hit a fresh a five-year high.
“The Dow is nothing but a flirt,” said Ken Tower, chief market strategist at Cybertrader. “It’s enjoying the attention and prolonging the mystery.”
The Dow will not reach another all-time closing high until at least 2009. We are currently in a long-term bear market. This rally will not last. Sell your index funds now. There is a 50% chance of a major ( greater than 15% drop in the Dow and S+P 500 indexes ) market crash in the next 45 days. If you are adventurous, buy Diamond and Spyder Put options.

Tort Reform Works

Medical Assurance Company of Mississippi
404 West Parkway Place
Ridgeland, Mississippi 39157
www.macm.net

FOR IMMEDIATE RELEASE
September 13, 2006

MACM Announces Premium Reduction for 2007

Medical Assurance Company of Mississippi (MACM) announced today that it will reduce its medical liability insurance rates across the board by 10 percent for 2007. This action was approved by MACM’s Board of Directors on September 6, 2006.

“We are very pleased to announce a rate reduction for our insureds for the second straight year,” Michael D. Houpt, President and Chief Executive Officer of MACM, said. “The favorable trends relative to losses and loss adjustment expenses that were evident in 2005 have continued through 2006; therefore our Board felt comfortable in making this decision.”

Numerous claims that were filed in late 2002 to avoid provisions in the tort reform packages passed by the Mississippi Legislature have been favorably resolved during this year. “We are finally disposing of large numbers of non-meritorious claims with little or no expense,” Houpt said. “Combined with the other positive effects of tort and judicial reform, our financial results to date indicate that another rate reduction is justified, and I trust that our insureds will be pleased.”

In September 2005, the Board of Directors reduced renewal rates for 2006 by 5 percent and in December 2005, granted a retroactive refund of up to 15 percent on 2005 premiums.

Mississippi leadership responded favorably to the news.

“This across the board reduction in medical liability rates by the largest insurer of doctors in Mississippi is a significant and welcome decision that will have an immediate positive impact,” Governor Haley Barbour said. “It is another concrete example of how tort reform is working to protect the quality and availability of health care by ending lawsuit abuse and leading to reduced medical liability rates in Mississippi. This is great news.”

Commissioner of Insurance George Dale said, “Mississippi continues to show insurance companies that recent reforms are working and do aid in providing and maintaining a fair and equitable marketplace. I commend MACM for establishing a financial position that allows for this second consecutive rate reduction. Reforms were needed and now benefits such as this reduction are the result.”

Founded in 1976, Medical Assurance Company of Mississippi is an organization of physicians and non-physician staff members dedicated to providing sound, stable insurance products and quality related services to physicians and other health care providers practicing in the state of Mississippi

Stanford Bans Drug Company Gifts to Doctors

Kevin MD links to an article about a new policy at Stanford:
Stanford University Medical Center will prohibit its physicians from accepting even small gifts like pens and mugs from pharmaceutical sales representatives under a new policy intended to limit industry influence on patient care and doctor education.
The policy would also apply to sales representatives from makers of medical devices and other companies, not just pharmaceutical companies. Company representatives would be barred from areas where patient treatment and doctor education occur, with some exceptions.
“We want to secure the public trust to value what happens in academic medicine,” Dr. Philip A. Pizzo, dean of the Stanford School of Medicine, said in an interview.
Stanford academic physicians will continue to be able to accept speaking fees (which can be up to $5000) for drug company dinners and CME seminars, but the residents won't get $1 pens. This really restores my trust in the Stanford University Medical Center Physicians.

Nurses and Secretaries Demand Free Food

An article in the New York Times describes the common practice of drug reps providing free lunches for doctors' offices:
Free lunches occur regularly at doctors’ offices nationwide, where delivery people arrive with lunch for the whole office, ordered and paid for by drug makers to the tune of hundreds of millions of dollars a year.
Like the “free” vacation that comes with a time-share pitch attached, the lunches go down along with a pitch from pharmaceutical representatives hoping to bolster prescription sales. The cost of the lunches is ultimately factored in to drug company marketing expenses, working its way into the price of prescription drugs.
“We found that some offices get breakfast and lunch every day,” said Dr. Scott, who calls lunch the “currency” that buys access to doctors’ offices for drug representatives. He also noted that some doctors were hard pressed to meet payrolls and that the lunches provided an added benefit for their employees.
The deliveries often start even before lunchtime, with representatives bringing in pastries and large containers of coffee from Starbucks or Dunkin’ Donuts.
Ms. Slattery-Moschkau, the former pharmaceutical representative, said that nurses and staff members in some offices were quite demanding about lunch.
“It was almost a game, and it was unbelievable the animosity they would show if you did not bring the right kind of food, or if it was the third time they had pizza that week,”
I don't like to do drug company sponsored office lunches more than once a week, though not for any ethical reasons. I just prefer to go off by myself for a while and grab a sandwhich at Subway or McAlister's. The office lunches mainly benefit the office staff.

Superman Movie made by anti-Americans

Ever since artist Joe Shuster and writer Jerry Siegel created the granddaddy of all comic book icons in 1932, Superman has fought valiantly to preserve "truth, justice and the American way." Whether kicking Nazi ass on the radio in the '40s or wrapping himself in the Stars and Stripes on TV during the Cold War or even rescuing the White House's flag as his final feat in "Superman II," the Krypton-born, Smallville-raised Ubermensch always has been steeped in unmistakable U.S. symbolism.
But in the latest film incarnation, scribes Michael Dougherty and Dan Harris sought to downplay Superman's long-standing patriot act. With one brief line uttered by actor Frank Langella, the caped superhero's mission transformed from "truth, justice and the American way" to "truth, justice and all that stuff.""The world has changed. The world is a different place," Pennsylvania native Harris says. "The truth is he's an alien. He was sent from another planet. He has landed on the planet Earth, and he is here for everybody. He's an international superhero."
We were always hesitant to include the term 'American way'
Seems like a bad weekend to open the movie if the film-makers are ashamed of patriotism.

I'm Not One Of Those Fancy College-Educated Doctors

You want to know where I got my doctor's degree? At the Medical School of Hard Knocks, that's where. No matter what they say, advanced graduate studies won't teach you when somebody needs a shot of whiskey. Yale and Harvard don't tell you when to throw a bucket of water on a patient. And they can never teach you how to tell when someone just needs a good solid punch in the nose to bring them around.
I got my M.D. on the street. These people think they're suddenly a "doctor" because they memorized a lot of big words and took a bunch of formal tests. But there's plenty of things about being a doctor they'll never learn in their ivory-tower medical school.
For example, did you know that human intestines, if they spill out of the abdomen during surgery, can spool out all over the floor if you're not careful? You won't find that in a book, my friend.

A Dangerous Obsession

An article in the Sunday New York Times Magazine describes the growing poker addiction problem among college students:
Online, Hogan would play 60 to 100 hands an hour — three times the number of his live games. There was no more shuffling between hands, no more 30-second gaps to chat with his friends or consider quitting. Each hand interlocked with the next. The effect was paralyzing, narcotic. "Internet poker induces a trancelike state," says Derevensky, the McGill professor, who once treated a 17-year-old Canadian boy who lost $30,000, much of it at PokerStars. "The player loses all track of time, where they are, what they're doing." When I spoke with an online hold-'em player from Florida who had lost a whopping $250,000 online, he told me: "It fried my brain. I would roll out of bed, go to my computer and stay there for 20 hours. One night after I went to sleep, my dad called. I woke up instantly, picked up the phone and said, 'I raise.' "
On-line poker is a dangerous and seductive mistress. I fight her allure (usually unsuccessfully) every night.

A Case of Plagiarism?

I took my son to see the movie "Cars" today. I was going to write a long post comparing the movie to "Doc Hollywood," but someone at Canada.com has already done so:
The makers of Doc Hollywood called. They want their movie back.
Cars rolls along like an animated, automotive version of that 1991 Michael J. Fox gem, from its basic plot points to its feel-good conclusion.
Stop us if you think you've heard this one before: A young hotshot on his way to Los Angeles causes a crash and gets stuck in a small town. Before he can leave, he must spend several days doing community service, only to find out that he likes the simple life there and that he's learned more about family and friendship than he'd ever imagined.
The main difference in Cars is that the characters are . . . well, they're cars, hence the title.
I was unable to find any attributation to the movie/book "Doc Hollywood" on the "Cars" website, or when I was watching the credits in the theatre. If Neil Shulman, MD didn't get a cut of the movie "Cars," he should sue.

Slate Comes Out in Favor of Tanning

From www.slate.com:
You can't stop tanning; the best you can do is help people control it. Toward that end, the industrialization of ultraviolet light is a blessing. It gives us the power to clarify, modulate, and customize dosage. Salons need oversight to make sure they help clients understand and manage this power. But if you shut them down or lock out teenagers, be prepared to enforce a dawn-to-dusk curfew or face an epidemic of skin cancer. If you liked back-alley abortions, you'll love backyard tanning.
For those of my readers in their teens and twenties, my advice to you is not to tan. If you do, you'll be sorry 5-10 years from now when you develop wrinkles. And there is always the risk of skin cancer.

Dogs and Ducks for Depression

I think that we're all aware of service animals for the physically disabled, especially the blind. But now patients with psychiatric disorders are claiming that their dogs are "emotional service dogs," often with dubious rationales:
"If you have backing of a medical professional and you can show a connection between a disabling condition and the keeping of an animal, I have 99.9 percent success," said Karen Copeland, a tenants' lawyer.
One of her current clients maintains that she needs an animal in her apartment because she is a recovering alcoholic and, apart from her pet, all her other friends are drinkers.
Even ducks are getting in on the act:
These days people rely on a veritable Noah's Ark of support animals. Tami McLallen, a spokeswoman for American Airlines, said that although dogs are the most common service animals taken onto planes, the airline has had to accommodate monkeys, miniature horses, cats and even an emotional support duck. "Its owner dressed it up in clothes," she recalled.
My opinion on the matter:
This isn't cute and is a total insult to the disabled community. They are ruining it for people who need it."

Surgical Teamwork

The New York Times reports on a study of operating room communications:
"nurses often describe good collaboration as having their input respected, and physicians often describe good collaboration as having nurses who anticipate their needs and follow instructions."
There is a bit of a culture clash; nurses want respect, and surgeons want submissive, helpful nurses.

Dunlop Disease

A new epidemic is spreading across America:

A model's flesh squeezes out between her blue jeans and tank top in what is known as "Dunlop disease," as in her flab "dun lap" over her pants

Hepatitis C

Hepatitis C is an increasingly common disease. Up to 90% of patients who have injected illicit drugs and between 7% and 10% of individuals who received blood or blood products prior to 1992 test positive for hepatitis C. Other risk factors include: 1) history of multiple sexual partners (though hepatitis C is much less readily transmittable sexually than the hepatitis B virus); 2) chronic hemodialysis treatment; 3) being the child of a hepatitis C positive woman; 4) tattoos or body piercings; and 5) needle stick accidents. Hepatitis C should also be suspected in anyone with unexplained elevated serum alanine aminotransferase (ALT) levels or signs of liver disease, such as jaundice or hepatomegaly.
Acute hepatitis C infection often does not come to clinical attention. Patients may experience nonspecific symptoms such as malaise, abdominal pain, and nausea. A few have jaundice. Acute hepatitis C infection progresses to chronic hepatitis C in approximately 75% of patients. It is chronic hepatitis C that is of chief concern to psychiatrists, especially those who work with chemically dependent populations.
The screening test for hepatitis C is the ELISA test for antibody to the hepatitis C virus (anti-HVC), which can sometimes give false-positive results. The confirmatory test is HCV RNA, which can distinguish between past and active infection. The recombinant immunoblot assay is no longer commonly used as a confirmatory test.
Patients with hepatitis C should be referred to an internist or GI specialist for further assessment, which in selected cases may include liver biopsy. Liver biopsy can be helpful in determining if the patient is likely to progress to cirrhosis, which occurs in about 20% of individuals with chronic hepatitis C, typically over a period of 20-40 years.

Treatment of hepatitis C is an evolving field. All patients with hepatitis C should be advised to abstain from alcohol, which accelerates the progression to cirrhosis and reduces the response to HCV treatments. Prime candidates for drug therapy include patients with persistently elevated ALT readings, detectable HCV RNA levels, and appropriate liver biopsy results [“liver biopsy results (if available) that show portal or bridging fibrosis or at least moderate inflammation or necrosis”]2. For those patients who are candidates for drug therapy, the current standard regime is weekly subcutaneous pegylated interferon alpha plus oral ribavarin for six to twelve months, depending on HCV genotype. The response rate is approximately 50% but varies depending on HCV genotype. Common side effects of ribavarin include hemolytic anemia, fatigue, irritability, and rash. Side effects of interferon include fatigue, flu-like syndrome, nausea, headaches, and depression. Suicidal ideation and suicide attempts have also been reported. Selective serotonin reuptake inhibitors have been used to treat interferon associated depression. If psychiatric side effects are severe, antiviral treatment may need to be discontinued.

REFERENCES
1. American College of Physicians. PIER (Physician’s Information and Education Resource) module for Hepatitis C. Available online at http://pier.acponline.org/physicians/diseases/d163/d163-pdf.html
2. Park JS, Dieterich DT. Chronic Hepatitis C: Latest Diagnosis and Treatment Guidelines. ConsultantLive.com 2006. Available online at http://consultantlive.com/article/showArticle.jhtml?articleID=184429289

Calculus

This newspaper article reminds me of my days of high school calculus:
The Onion
Calculus Problem Hits Too Close To Home
April 26, 2006 Issue 42•17
PULLMAN, WA–The analysis of formulae derived from the fundamental theorem of calculus had a profound and seemingly personal impact on Washington State University freshman Barry Feldman on Monday, teaching assistants in Feldman's differential calculus section reported. "There was something about having to consider multiple rates of change and their effect on one another that really struck a nerve with Barry. I've never seen a student flinch so violently at terms like 'increasingly negative curves' or 'derivatives,'" TA Melanie Peppers said. "As uneasy as the unresolved equation seemed to make Barry feel, the prospect of eventually arriving at a solution for it actually appeared to upset him more." Feldman was recently the subject of gossip among the faculty after he interrupted a lecture on increasing-tensor calculus by screaming that "enough is enough" and asking if the professor would "please just change the subject."

Medical Porn

From Medscape:
NEW YORK (Reuters Health) Apr 17 - A study suggests that dermatology images available online are sometimes being used pruriently. Moreover, pornography and fetish websites seem to be a major source of referral, researchers report in the April issue of the Journal of the American Academy of Dermatology.
The thought that DermAtlas, a searchable archive of clinical photography, was being misused first occurred to the curators when they noticed a marked jump in queries for images containing genital sites.
The bulk of searches -- 62% -- involved queries for a specific diagnosis. Of these, 12% involved a genital site. Of the 11% of requests for an anatomic site, 37% involved a genital site. Twelve percent of the 10,000 free text queries were for images containing a genital site.
In searches that specified both an age group and an anatomic site, images involving children were 48% more likely to be requested than those involving an adult.
An analysis of the top 43 referring sites to DermAtlas revealed that 9 (21%) were pornographic/fetish sites. However, these sites only accounted for 14.3% of all 141,285 referrals.
The authors conclude that "Developers of online clinical image libraries containing potentially sensitive health information on topics such as sexuality and anatomy must be aware of issues beyond technical and domain knowledge."
No, I will not provide a link to the DermAtlas.

Resident Work Hours

Several bloggers, including Kevin,MD link to the Time Cover Story, "What Doctors Hate About Hospitals".
Part of the cover story discussest the relatively new 80-hour work week regulations for residents:
Studies showed that long work hours increased stress, depression, pregnancy-related complications, car wrecks and damage to residents' morale and personal life. So now residents' hours are limited to 80-hr. workweeks averaged over a month, in shifts that are limited to 24 hours of patient care, with at least 1 day off in 7. Remaining on call in the hospital is limited to every third night.
The reforms made intuitive sense; but the unintended result, older doctors warn, is a 9-to-5 mentality that detaches the doctor from the patient. They fear that young doctors don't get the experience they need or build the instincts and muscle memory from performing procedures so many times that they can do them in their sleep. Even the residents may agree: in a 2006 study in the American Journal of Medicine, both residents and attending physicians reported that they thought the risk of bad things happening because of fragmentation of care was greater than the risk from fatigue due to excess work hours. Other residents say that while they may feel more rested, they sense that they are not learning as much or as fast as they need to.
So, residents are now more rested, but care is more fragmented. I don't think anyone can conclusively state whether the new system currently improves or worsens care in teaching hospitals.
What will happen 20 years from now, when the majority of practicing physicians have trained under the new system??
"I know that I will not like it 20 years from now when I'm 68 and having to be taken care of by these guys," says Dr. Paul Shekelle, a professor of medicine at UCLA. "It's all shift work now. When 5 o'clock comes, whatever it is they're doing, they just sign it all out to the 5 o'clock person. It's eroding the sense of duty, or commitment to being the person responsible for a patient's care."

New Clozaril Monitoring Requirements

A requirement for absolute neutrophil count (ANC) has been added to the baseline requirements for clozapine therapy; patients must have both WBC and ANC in the normal range (3500/mm3 and 2000/mm3 or greater, respectively). ANC must be determined and reported along with each WBC.
A monthly monitoring schedule may only be initiated after 1 year (6 months weekly, 6 months every 2 weeks) of WBCs and ANCs in the normal range.
Because of the increased risk for agranulocytosis in patients rechallenged with clozapine after recovery from an initial episode of moderate leukopenia (WBC range, <3000/mm3 and 2000/mm3 or higher, and/or ANC range, <1500/mm3 and 1000/mm3 or higher), these patients now require weekly monitoring of WBC and ANC for a period of 12 months.
Complete information regarding changes in monitoring frequency after interruption of therapy is available at: http://www.fda.gov/medwatch/safety/2006/Clozaril_2005-19.pdf.
For patients whose WBC is currently being monitored on a weekly or biweekly basis according to the previous schedule, ANC reporting is required from this point on. Patients may continue on their monitoring schedule and 6-month transition to biweekly or monthly monitoring if WBC and ANC remain in the normal range.
Healthcare providers are required to submit all WBC and ANC values to the Clozaril National Registry during treatment and until values reach the normal range after discontinuation of clozapine in nonrechallengeable patients (WBC, <2000/mm3 and/or ANC, <1000/mm3).
The FDA also warned of the increased risk for death associated with off-label use of clozapine in elderly patients with dementia-related psychosis.
The warning was based on an analysis of data from 17 placebo-controlled, 10-week trials showing that use of olanzapine, aripiprazole, risperidone, and quetiapine in 5106 elderly patients with dementia-related behavioral disorders was associated with an increased risk for mortality compared with placebo (4.5% vs 2.6%).
Because the 1.6- to 1.7-fold increase in death risk was linked to medications from all 3 classes of atypical antipsychotic medications, it is considered by the FDA to be a class effect.
In addition, the FDA advised that use of clozapine is now contraindicated in patients with paralytic ileus, a condition previously listed as a potential adverse event in the labeling. The change was based on a review and evaluation of data from global postmarketing safety and clinical trial databases.
The postmarketing safety database also included reports of hypercholesterolemia and/or hypertriglyceridemia in patients receiving clozapine. Moreover, database and literature data indicate that concomitant use of citalopram results in significantly increased clozapine blood concentrations, potentially resulting in adverse effects.
Clozapine is indicated for the treatment of severely ill patients with schizophrenic who fail to respond adequately to standard therapy and for reducing the risk for recurrent suicidal behavior in at-risk patients with schizophrenia or schizoaffective disorder.
The above is taken from Medscape.com.
I hadn't heard of the citalopram (Celexa)-clozapine drug interaction before.
A quick Pub Med search reveals these 2 relevant articles:
1.
Int Clin Psychopharmacol. 1998 Jan;13(1):19-21.
Co-administration of citalopram and clozapine: effect on plasma clozapine levels.Taylor D, Ellison Z, Ementon Shaw L, Wickham H, Murray R.Bethlem & Maudsley NHS Trust, London, UK.Antidepressants are frequently used in the treatment of depressive symptoms associated with schizophrenia. In patients taking clozapine, choice of antidepressant is complicated by additive pharmacodynamic effects and by pharmacokinetic interactions. We predicted that citalopram would not elevate plasma clozapine levels when the two drugs were co-administered because it does not inhibit the relevant enzyme systems. In this preliminary study of five patients given citalopram and clozapine there was no overall change in mean clozapine levels. Based on this limited evidence, citalopram might be the antidepressant of choice in patients taking clozapine.
2.
J Clin Psychiatry. 2000 Apr;61(4):301-2.
Citalopram and clozapine: potential drug interaction.Borba CP, Henderson DC.Publication Types:
Case Reports
Letter No abstract available.
-----
Does anyone have anymore info about the Celexa/Clozaril drug interaction???

Alternative Medicine has its Limits

March 29, 2006 Issue 42•13
PORTLAND, OR—Alternative-medicine practitioner Annabeth Severin, a Portland-area acupuncturist and holistic healer, announced Tuesday that she is refusing to accept anything but conventional monetary compensation from her patients. "I'm sorry, but there just isn't any sound economic theory to support the idea that bartering or visualization of payment has the same effect as traditional cash or check up front," Severin said. Her customers are protesting her billing methods, saying that removing money from their accounts would be financially invasive and spiritually upsetting to their karmic and bank balances.
From The Onion

A message from the MPA

HAPPY DOCTORS' DAY !

FROM THE

MISSISSIPPI PSYCHIATRIC

ASSOCIATION

Yet another lawsuit

Got this link in my email today:
http://www.orthoevra-legal-center.com/

OTC Allergy Meds

I saw this article about over-the-counter allergy meds via Kevin, MD:
Over-the-counter hay fever medication works just as well as much more expensive prescription medication for seasonal allergies, according to a new study.
The research, published in the Archives of Otolaryngology -- Head & Neck Surgery, is based on a small sample and focuses exclusively on two specific drugs: a 240-milligram dose of pseudoephedrine hydrochloride (sold over the counter under the brand name Sudafed 24 Hour) and a 10-mg dose of montelukast sodium (prescription brand name Singulair). "When we compared them head-to-head, we found that for treatment of allergic rhinitis, these drugs at these doses were virtually identical," said Dr. Fuad Baroody, associate professor of surgery at the University of Chicago and the study's director. "This came as a genuine surprise."
OTC allergy drugs work great and are often more effective than perscription meds. For example, Benadryl is more effective than some perscription antihistamines. Sudafed is also very effective. The problem is that many of the OTC allergy meds have a lot of side effects. Benadryl can cause constipation, urinary retention, and confusion. Sudafed can cause hypertension and heart arrhythmias. Many of the OTC's would be considered too dangerous even for perscription status if they were being submitted to the FDA today.

NASCAR is not a sport

RangelMD states:
Then Gumbel goes after ice-skating and I began to realize that he sounds just like any American jock who can't comprehend, let alone appreciate, any sport that doesn't begin with "foot" or "basket". Apparently Bryant thinks that the triple axel is no big deal and that sport isn't really sport without the brute force of a dunk or tackle. I'd love to hear what Bryant thinks of NASCAR; "Those guys get to sit down through the entire event!"
NASCAR is not a real sport. I am sure it helps to be in good physical shape to win a NASCAR race, but it also helps to be in good shape to be an orthopedic surgeon, and I don't see anyone calling them athletes. Poker is just as much a sport as NASCAR; they even show poker on ESPN now. I hope to be in the World Series of Poker one day.
I am not originally from the South, which explains why I am not into NASCAR.

AMA Advertising Campaign

Last week I criticized some of the American Medical Association's ads. Today Medical Economics offers an explanation of the ads:
The general behind it is Gary C. Epstein, the AMA's chief marketing officer. Before joining the AMA in 2004, Epstein worked to develop "brand-building solutions" for clients like Proctor & Gamble, Kraft Foods, and Pepsi. In his new role, he hopes to do much the same for the AMA.
One of his strategies is to reach out to doctors indirectly, through their patients. In a series of consumer ads that began running last summer, the AMA pays homage to the profession's "everyday heroes"—doctors across a variety of specialties who've touched peoples' lives in ways both large and small. Both the print and broadcast versions are powerful, tug-at-your-heart messages calculated to enhance public goodwill.
Gary C. Epstein should be fired. If the AMA wants to reach out to doctors, it should lower its membership fees. It's a waste of money and insulting for the AMA to try to reach out to doctors through our patients.

Drug Voucher Programs

Kevin, MD recently wrote about drug voucher programs. In these programs, drug addicts get vouchers that are exchangeable for consumer goods in return for clean urine samples. This study, from the Archives of General Psychiatry, found that Bupropion (Wellbutrin) combined with vouchers (contingency management) reduced cocaine use in opioid addicts maintained on methadone:
Six-Month Trial of Bupropion With Contingency Management for Cocaine Dependence in a Methadone-Maintained Population
James Poling, PhD; Alison Oliveto, PhD; Nancy Petry, PhD; Mehmet Sofuoglu, MD, PhD; Kishorchandra Gonsai, MD; Gerardo Gonzalez, MD; Bridget Martell, MD; Thomas R. Kosten, MD
Arch Gen Psychiatry. 2006;63:219-228.
Context No effective pharmacotherapies exist for cocaine dependence, although contingency management (CM) has demonstrated efficacy.
Objective To compare the efficacy of bupropion hydrochloride and CM for reducing cocaine use in methadone hydrochloride–maintained individuals.
Design This 25-week, placebo-controlled, double-blind trial randomly assigned participants to 1 of 4 treatment conditions: CM and placebo (CMP), CM and 300 mg/d of bupropion hydrochloride (CMB), voucher control and placebo (VCP), or voucher control and bupropion (VCB).
Setting Outpatient clinic at the Veterans Affairs Connecticut Healthcare System.
Participants A total of 106 opiate-dependent, cocaine-abusing individuals.
Interventions All study participants received methadone hydrochloride (range, 60-120 mg). Participants receiving bupropion hydrochloride were given 300 mg/d beginning at week 3. In the CM conditions, each urine sample negative for both opioids and cocaine resulted in a monetary-based voucher that increased for consecutively drug-free urine samples during weeks 1 to 13. Completion of abstinence-related activities also resulted in a voucher. During weeks 14 to 25, only completion of activities was reinforced in the CM group, regardless of sample results. The voucher control groups received vouchers for submitting urine samples, regardless of results, throughout the study.
Main Outcome Measure Thrice-weekly urine toxicologic test results for cocaine and heroin.
Results Groups did not differ in baseline characteristics or retention rates. Opiate use decreased significantly, with all treatment groups attaining equivalent amounts of opiate use at the end of the study. In the CMB group, the proportion of cocaine-positive samples significantly decreased during weeks 3 to 13 (P<.001) relative to week 3 and remained low during weeks 14 to 25. In the CMP group, cocaine use significantly increased during weeks 3 to 13 (P<.001) relative to week 3, but then cocaine use significantly decreased relative to the initial slope during weeks 14 to 25 (P<.001). In contrast, by treatment end, the VCB and VCP groups showed no significant improvement in cocaine use.
Conclusion These findings suggest that combining CM with bupropion for the treatment of cocaine addiction may significantly improve outcomes relative to bupropion alone.
Author Affiliations: Yale University School of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven (Drs Poling, Sofuoglu, Gonsai, Gonzalez, Martell, and Kosten); University of Arkansas for Medical Sciences, Little Rock (Dr Oliveto); and University of Connecticut School of Medicine, Farmington (Dr Petry).
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This Month in Archives of General PsychiatryArch Gen Psychiatry. 2006;63:124.