A Soldier with Sleep Apnea

An interesting case of obstructive sleep apnea was reported in yesterday's newspapers. Unless this soldier's sleep disorder suddenly worsened for some reason (e.g., weight gain), it's hard to imagine how he functioned in the military:
Sleepy soldier may be problem at trial
By ESTES THOMPSON, Associated PressFebruary 1, 2005
FORT BRAGG, N.C. - If a soldier accused of killing two officers in a grenade attack in Kuwait doesn't get help for his sleep apnea, he may not be able to stay awake enough to participate in the defense at his trial, his attorney said Monday.
Sgt. Hasan Akbar of the 101st Airborne Division stayed awake during a 45-minute hearing Monday, responding to several questions with, "Yes, your honor." But his drowsiness at previous proceedings prompted the judge to order treatment for a breathing condition that impedes sleep.
Defense lawyer Maj. David Coombs said Akbar continues to be plagued by problems and if a visit to his original doctor doesn't help, more extensive studies will be requested to determine "why he may have sleep apnea. ... It has been a consistent problem."
With Akbar's court-martial set for April, Coombs also asked military judge Col. Stephen Henley to make coffee available at the defense table and to order a break after every witness.
Henley said he was willing to consider special measures to keep Akbar awake but denied the request for a break after each witness. He said he also would consider allowing someone to sit next to Akbar during the trial to try to keep him awake, if the defense makes such a request.
Henley also ordered that Akbar be given an additional medical evaluation at Fort Knox, Ky., where he is being held while awaiting trial.
The 101st is based at Fort Campbell, Ky., but Akbar's trial is being held at Fort Bragg, where the 101st's higher command, the 18th Airborne Corps, has its headquarters.
If the medical evaluation does not resolve Akbar's problems, extensive neurological studies may be needed, the defense said.
Defense lawyers have said they intend to present an insanity defense, and the April trial date was a delay, intended to give them time to gather evidence.
Henley already has ruled that Akbar's statement acknowledging that he rolled grenades into tents at Camp Pennsylvania, Kuwait, will be admissible at his court-martial. The judge excluded statements Akbar made to two sergeants who guarded him after the attack, saying Akbar had not yet been informed of his legal rights.
Akbar, 33, is accused of stealing the grenades from a Humvee and initiating the attack on fellow members of the 101st just days into the March 2003 invasion of Iraq. Killed were Army Capt. Christopher Seifert, 27, and Air Force Maj. Gregory Stone, 40. Another 14 soldiers were injured.
If convicted of two counts of premeditated murder and three counts of attempted premeditated murder, the 33-year-old Akbar could get the death penalty.
The case marks the first time since the Vietnam War that an Army soldier has been prosecuted for the murder or attempted murder of another soldier during wartime.

Like Chocolate and Peanut Butter...

Some things just seem to go together: popcorn and the movies, a hot dog at the ball park, loud music while cruising down the interstate at 2am...
It seems that some feel that alcohol and caffeine go together:
BE Addicted?
Caffeine addicts are toasting Anheuser-Busch's latest invention — a beer infused with caffeine, guarana and ginseng. The new beer, BE (pronounced B to the E) has 59mg. of caffeine for each 10 oz. can. To put that in perspective, a can of Red Bull has 80 mg and an 8 oz. coffee has averages about 110 mg. Is adding caffeine to beer or other alcoholic beverages a good thing? We contacted several sleep experts and no one could state any benefit. Some expressed concern that adding caffeine might keep a person awake and drinking more instead of falling asleep or passing out. An added concern is that the caffeine might give a person a false sense of confidence and encourage drunk driving
From the National Sleep Foundation

Hopefully we don't act like this

DOCTOR UNABLE TO HIDE HIS EXCITEMENT FROM PATIENT WITH ULTRA-RARE DISEASE
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ROCHESTER, MN—Dr. Erich Stellbrach, a general practitioner at the Mayo Clinic, could barely contain his exhilaration Monday upon discovering that patient Oliver Patterson, 54, has the extremely rare degenerative nerve disease Gertsmann-Straussler-Scheinker syndrome. "Mr. Patterson, I'm so sorry to tell you this, but you have—you're not going to believe it—spinocerebellar ataxia!" Stellbrach said, waving an x-ray of Patterson's spinal cord. "It afflicts only one in 2.9 million people!" Stellbrach recommended Patterson begin aggressive treatment to mitigate his impending brain dysfunction and onset of dementia, and made the patient promise to remain in his care.
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from The Onion

Sleepy Drivers

From the National Sleep Foundation:
Massachusetts Senator Richard Moore, D-Uxbridge, sponsored a bill that would make it illegal to fall asleep while driving. The charge would carry the same penalties as drunken driving. If the bill is passed, Massachusetts would join the ranks of Maggie's Law in New Jersey, the only state to currently enforce a law against drowsy driving.

Grand Rounds Eighteen

Grand Rounds Eighteen is now up at Cut to Cure.

Pediatric sleep apnea

Treatment of pediatric obstructive sleep apnea with adenotonsillectomy improves behavior and quality of life:
NEW YORK (Reuters Health) Jan 17 - Children with obstructive sleep apnea (OSA) are at increased risk for behavioral and emotional difficulties, but tonsillectomy/adenoidectomy can improve both these problems as well as quality of life, new research shows.
The findings are based on a study of 42 children with OSA who underwent tonsillectomy and adenoidectomy and 41 control children with no snoring who underwent unrelated elective surgery. Behavioral and quality of life measures were assessed before and 3 months after surgery.
Dr. Nira A. Goldstein and colleagues, from SUNY Downstate Medical Center in New York, report their findings in the Archives of Otolaryngology-Head and Neck Surgery.
As noted, baseline behavioral scores were worse for children in the OSA group than for controls. However, following surgery, the former group experienced a significant improvement in scores (p = 0.009) compared with the latter group, whose scores tended to deteriorate.
Moreover, quality of life scores, both overall and in individual domains, improved significantly in OSA patients compared with controls.
"This study provides further evidence that behavioral and emotional problems are present in children with OSA and improve after treatment," Dr. Goldstein's team notes. "Additional work is needed to define the precise spectrum of behavioral abnormalities, to elucidate their pathophysiologic mechanism, and to provide diagnostic clues to facilitate their early recognition."
Arch Otolaryngol Head Neck Surg 2005;131:52-57.

I want this job

From Fox News:
ALBANY, N.Y. — Pat Freund has a job most people would envy. She spends her days at work reading the newspaper and finishing crossword puzzles, and earns about $100,000 a year for her troubles, including benefits.
But Freund isn't content to put up her feet and watch the paychecks roll in. Rather, she is suing her employer, the state of New York, for not giving her any real work to do.
"It could have been a lot easier for Pat had she continued to sit in her office and do nothing, and continue to basically be the most avid reader that the state has employed," says Sue Adler, the attorney representing Freund in her federal civil rights lawsuit. "But she decided that was not how she wanted to live out her years working for the state."
Freund, who has been a New York State Liquor Authority (search) employee for 25 years, says it all started in 2000. She believes her superiors were angered after she questioned the practice of colleagues attending Gov. George Pataki's (search) annual prayer breakfast. But instead of firing her, Freund says, her responsibilities were taken away.
Now Freund does nothing at work, on the taxpayers' dime.
Mike Causey (search) of Federal News Radio has examined government employment issues for more than 20 years, and says the same protections that make it difficult to fire government workers sometimes backfire.
"People say that they're [employers] either trying to drive them out one way or the other, and one of the ways to do it is to give them nothing to do," Causey says.
When asked about the lawsuit, the Liquor Authority said it was policy not to comment on pending litigation. So until a trial, Freund will most likely continue to do nothing at work.

Johnny Carson Dead

WASHINGTON (Reuters) - Legendary television entertainer Johnny Carson has died of emphysema at age 79, the NBC television network reported on its Web site on Sunday.
Carson hosted NBC's popular "The Tonight Show" for nearly 30 years, long dominating late-night television with an estimated 12 million viewers each night. He did his final show on Friday, May 22, 1992, seen by 55 million, and was replaced the next Monday by the current host, Jay Leno.
Sidekick Ed McMahon introduced him nightly with the rallying cry of "Heeeeeeere's Johnny!" Carson's blend of humor, music and conversation was the last thing millions of Americans heard before drifting off to sleep.
"I am one of the lucky people in the world. I have found something I liked to do, and I have enjoyed every single minute of it," a teary-eyed Carson said as he closed the show for the last time. "I bid you a very heartfelt goodnight."
In later years, Carson became something of a recluse in his Malibu, California, home, rarely venturing into the public eye.
After a 1999 quadruple bypass heart operation, Carson cut back on his tennis and discontinued his annual treks to Africa, the French Riviera and the Wimbledon tennis tournament. He had battled emphysema for years.

Health care workers needed

A rather poorly written article in the New York Times discusses the shortage of medical clerical workers in the New York region:
the New York region is confronting an acute shortage of physician assistants and clerical workers at the entry level in medicine, according to government labor statistics and industry executives.
Although many see the demand as positive, they also see a downside. The situation may provide ample opportunity for jobs, some experts say, but medical assistant and record-keeping work may lead to few, if any, chances for advancement because of rigorous training and licensing requirements.
Maritza Rodriguez of Manhattan, a 42-year-old divorced mother of two, had worked at clerical jobs in offices and in retail customer service before completing a 10-week course in medical billing and record keeping in October. She said she immediately found jobs with two doctors, splitting her workweek between Brooklyn and Manhattan. "There is so much demand," said Ms. Rodriguez, who said she rarely logged more than 40 hours a week total and expected to make more than $50,000 this year, also receiving health care benefits.
This isn't the greatest of articles; it combines discussion of 2 distantly related fields- physician assistants and medical clerical workers. And I fail to see how a career in which someone can earn $50,000 a year after a 10-week course offers "..few, if any, chances for advancement.." I think the New York Times dropped the ball with this article; I don't think the reporter fully understood what she was writing about.

Reminyl and Safety Concerns

The New York Times reports on new safety concerns regarding Reminyl, a medication for Alzheimer's disease:
In the trials, which lasted two years, 15 patients taking Reminyl died compared with 5 taking the placebo. There were various causes of death but many were from heart attacks and strokes, a company spokeswoman, Carol Goodrich, said.
The announcement comes at a time of heightened concern over the safety of widely used drugs after the withdrawal from the market of Merck's pain reliever, Vioxx, which studies indicated posed an increased risk of heart attacks and strokes.
Johnson & Johnson said that overall number of deaths in the trials was low for the elderly population in the trial and that the incidence of serious side effects was the same for patients getting the drug and the placebo. Also, it said, the investigators in the trials had not thought the drug caused any of the deaths.

Isn't it ironic?

ROME (Reuters) - An Italian pensioner committed suicide after his wife fell into a coma, but just hours after he killed himself the woman woke up, Italian media has reported.
Recalling the end of "Romeo and Juliet", the 70-year-old man, Ettore, who had sat by his wife's bedside for four months after she slipped into a coma following a heart attack, finally gave up hope and gassed himself in the garage of his family home.
Less than a day later, his wife, Rossana, woke up in her hospital bed in Padua and immediately asked for him.
The northern town of Padua lies just 60 km (40 miles) from Verona, where star-crossed lover Romeo killed himself believing Juliet to have died. But minutes later Juliet woke up and seeing Romeo dead, stabbed herself.

Nurses

Shrinkette posts today on the world of nurses.
Nurses do a very important job- they are the ones on the front lines, actually caring for the patients. When a psychiatrist writes an order for a haldol injection for an out-of-control patient, its a nurse who actually gives the shot while the psychiatrist is safe behind locked doors. Unfortunately, nurses have increasing amounts of administrative work to do. Nurses today spend too much of their time (like doctors) writing in charts instead of providing direct patient care. If it's not written in the chart it didn't happen. Nurses often have too many patients to care for and patients suffer because of it. I have seen many instances of patients having prolonged waits for prn (as needed) meds such as pain meds because their overworked nurse was busy charting.

New Psychiatric Diagnosis

From Psychiatric News:
Paul Chodoff, M.D.
Washington, D.C.
I would like to suggest a new diagnostic entity for DSM-V. The diagnosis is "the human condition." Diagnostic criteria would be any combination of the following:
For children: (1) distractability, (2) being fidgety, (3) disobedience, (4) disliking school. For adults: (1) unhappiness, (2) nervousness, (3) shyness, (4) dissatisfaction with one's looks, (5) dissatisfaction with one's sexual performance, (6) getting angry, (7) playing the horses, (8) getting upset when things go wrong, (9) preferring one's own company, (10) showing off, and (11) orderliness.
The advantages of this diagnosis are that it would facilitate insurance reimbursement, dispose of the bothersome problem of comorbidity, and encourage the quest for a drug to cure the disorder of being human.

Psychologist Prescribing

I was looking through some old journals and found this letter in the October 2004 Clinical Psychiatry News:
I continue to be amazed that psychiatrists are so up in arms about having psychologists prescribe medications after added training in psychopharmacology (“Prescribing Law in Louisiana Rankles Psychiatrists,” July 2004, p. 1 ).
We have no one to blame but ourselves. For years we have been content to give away our reflex hammers and stethoscopes for a prescription pad, and now we wonder why we are not heard when we invoke that we are medical doctors. We now even claim that monitoring blood work on atypical antipsychotics puts us in the domain of primary care. I teach residents who all too soon forget the basics of medicine and then feel uncomfortable about treating even simple medical problems.
Before we become more defensive, maybe we need to look at our own houses first. Why not reintroduce the 1-year medicine requirement into our residencies and continue to make our residents and attendings handle medical problems in their patients? If we do this, then we can state that we are qualified to prescribe where psychologists are not. Until then, we will continue to lose one state after another and we will have only one another to blame.
John Norton, M.D.Jackson, Miss.-->
The letter was written by one of my colleagues, a neurologist/psychiatrist at the U of MS Medical Center. I agree with him that psychiatry residents need more internal medicine training. I think that an ideal internship for neurology and psychiatry interns would consist of 8 months of internal medicine, 2 months of neurology, and 2 months of psychiatry. Currently most psychiatry interns only receive 4 months of internal medicine experience during their internship.

Plavix vs. Aspirin

The New York Times reports on a study comparing aspirin plus Nexium to Plavix:
Patients taking Plavix, a popular and expensive antistroke drug, experience more than 12 times as many ulcers as patients who take aspirin plus a heartburn pill, a study to be published today in The New England Journal of Medicine found.
This study was not a fair comparison of Plavix vs aspirin, since the Plavix group did not get a "heartburn pill":
Rob Hutchison, a spokesman for Bristol-Myers, said that the study did not directly compare aspirin and Plavix. Instead, the difference in ulcers could be entirely a result of the heartburn pill, which has long been known to prevent ulcers. He said the study should have included a group of patients who got Plavix plus a heartburn pill.
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Both Plavix and aspirin are antiplatelet agents that are use to prevent heart attacks and strokes. Plavix costs several dollars per pill, while aspirin costs pennies. They are approximately equally effective in preventing heart attacks and strokes, though each has advantages in certain situations. When an antiplatelet agent is necessary, I usually start off with aspirin at a dose of 81-325 mg per day. Sometimes I add Plavix to aspirin (for example, in patients with recent cardiac stents). I rarely use Plavix instead of aspirin- the only situation in which I would commonly do this is in patients with a history of a serious allergic reaction to aspirin.
I haven't had too many difficulties with patients developing ulcers or GI bleeding on aspirin (unless they are also taking an NSAID such as ibuprofen/aleve). I question the main premise of this study- that many doctors are prescribing Plavix because they feel it is safer from a GI standpoint. I have never prescribed Plavix soley for this reason. I'm interested in hearing from anyone with experience in this area: have you prescribed Plavix instead of aspirin due to the past perceived GI safety of Plavix??

Med Blog Spam

The following was e-mailed to many of the med blogs. Since I have nothing else I wish to post about today, I am posting the e-mail. Feel free to debunk it in the comments section.

DOD'S ANTHRAX VACCINE IS CAUSAL FACTOR OF GULF WAR SYNDROME OR GULF WAR ILLNESS"Vaccine-A" by Gary MatsumotoDear Elite Minds of the Blogosphere:We could greatly use your assistance in a matter of utmost urgency. And no thisis not another Nigerian 419 scam. Trust Me! :--). In my day job (paid) I'm acop (actually detective).The Homeland Security Polity Institute Group (HSPIG - www.hsig.org) isinterested in all things WMD including bioterrorism its agents and defenses. "Vaccine-A" a new book by Gary Matsumoto, a well-respected investigativejournalist, caught our attention. Matsumoto is reporting that the DOD's anthraxvaccine is the causal agent for Gulf War Syndrome or Illness (Autoimmuneresponse and disorder). This is a complex medical mystery thriller thatunfortunately is not fiction. Matsumoto is reporting direct forensic evidence(smoking gun)exists to conclude the vaccine is the causal agent.The vaccine adjuvant, squalene, was found in lots of this vaccine known to causeGWS. Squalene is a known immulogoically active agent. The key evidence issqualene antibodies has been identified in GWS victims' blood and not in controlgroups. Evidence suggests that squalene was used as emulsion "carrier" agent innew recombinant vaccine. However DOD may have knowingly used squalene secretlyfor its immune "boost" to make their recombinant anthrax more active. Withoutthis "boost" the new recombinant vaccine takes 5 or 6 doses to give anyimmunity. Mucho bucks spent to develop this "pure" vaccine only to ?fizzle.? It appearssmall factions within DOD's USAMRIID "Lil Shoppe of Horrors", the NIH, andFerengi pharma capitalists have run amuck pursuing "utilitarian" ethics in questfor personal fame and wealth.Problem is body's immune system "tolerance" factor - too little squalene noimmune boost - too much generates squalene antibodies that indiscriminatelyattack both "foreign" and the body's own "sequestered" squalene in cellularwalls. When this happens, cells are gutted causing a whole cluster ofautoimmune related disorders as seen in GWS. See groundbreaking work by Dr.Robert Parry and Dr. Pamela Asa. (Attached zipped file with two research papersas PDFs)My wife who is a Dr. of PH, MPH and OTR, teaches medical ethics and has taughtbioterrorism preparedness for healthcare professionals. She has spoken withMatsumoto and Dr. Asa for many hours and finds them to be very credible,ethical, methodical, meticulous researches. Dr. Asa was involved in the siliconbreast implant litigation and mad the cross connection with GWS. Dr. Asa isalso "off the grid." She is not on Uncle Sam's payroll and her research is notfederally funded. HSPIG over the last several weeks has attempted to break this story into theBlogos to fact check and report this story to the American people who then candecide what is the truth and/or fiction.Please exam the info below and consider this a research question to bechallenged. This is your quadrant area of the collective human consciousness ofthe Blogos. Please share this info with your colleagues Please visit ourforums section for updates and further information under "vaccine area":http://www.hspig.org/ipw-web/bulletin/bb/index.phpAlso you can visit Matsumoto's discussion board at:www.vaccine-a.comIf you decide what Matsumoto and Dr. Asa and others are saying is the truth thenyou need to hold your governmental, public health researchers, and industrycolleagues accountable for their total disregard of medical ethics.HSPIG is also tracking information that this vaccine technology has been used ina clinical vaccine trial in young children that resulted in injuries and deaths. A similar trial may soon begin in Japan. In short this could compromise confidence in critical vaccines necessary tocontrol the real scourges of mankind e.g., smallpox.Please see the attached email I just sent to John Hinderacer of Powerline (TimeMagazines Blog of the Year) that assisted in breaking Rathergate.Ron Wright, ModeratorHSPIG Forums Sitewww.hspig.org*****From: Ron Wright <nar9350@mac.com>TO: Informed Source <editor@informedsource.info>Date: Wed Jan 19, 2005 09:26:22 AM PSTSubject: HSPIG LTR TO POWERLINE RE DOD ANTHRAX VAC ANTHRAX VACCINE STORY RE MATSUMOTO'S BOOK -DOD's anthrax vaccine causal factor of Gulf War SyndromeFYI - see the email I sent to John Hinderaker at Powerline yesterday. Pleasefeel free to share or forward in any manner you wish. The MSM is avoiding thisstory like the Plague. The MSM has failed the American people in itsjournalistic responsibility to report objectively the news of the day. The MSMwas given the right of the free press to serve as a watchdog by WE THE PEOPLE tohold accountable those who WE THE PEOPLE chose to govern.This is a story the American people need to hear in an objective manner so theycan decide what is the truth and/or fiction and hold our government accountableif necessary.REPORT THE STORY - and yes I'll will wear my "tin foil hat" if that's necessary.Ron Wrightwww.hspig.org*****From: Ron Wright <nar9350@mac.com> TO: Power Line <feedback@powerlineblog.com> Date: Tue Jan 18, 2005 04:10:25 PM PST Subject: ATTN JOHN - ANTHRAX VACCINE STORY RE MATSUMOTO BOOKMr. Hinderaker, Thx for taking the time to listen to this story on the phone today. Here's athumbnail sketch. Sorry in advance for the amount of info I'm downloading here. My bloodhound nose has definitely detected several "big rats" in the works - asRoss Perot says, follow the money honey. HSPIG believes there is reasonable cause to believe that what Matsumoto's hasreported is true. Since the MSM is avoiding this story like the Plague, we aretrying to stir the Blogos to fact check this story and report it to the Americanpeople. With the MSM abdicating its journalistic responsibility that WE THE PEOPLE gaveit under the First Amendment to be our watchdog, WE THE PEOPLE cannot holdaccountable those who WE THE PEOPLE choose to govern accountable. We are attempting to fire off the Blogos on this story with its unimaginablepower/resources for distributive parallel processing like SETI. Here are some links on our site that will give a quick summary: CHALLENGE TO THE MSM TO REPORT "VACCINE-A" STORY http://www.hspig.org/ipw-web/bulletin/bb/viewtopic.php?t=2056 [...]Read more in "power3" file attachedAttached files:Read more in power3 (MS Word .doc file)Letter to AIM (MS Word .doc file)Letter to Hewitt (MS Word .doc file)Research Papers (zipped file containing two PDF files)

Grand Rounds Seventeen

Grand Rounds #17 is now up at Waking Up Costs.

I'm Going for It

I saw a new poster at the local McDonald's which said:
"I'm going for it
dqp (double quarter pounder with cheese)"
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According to the McDonald's website, it has 730 calories and 40 g of fat.

What are we supposed to be going for, an angioplasty??

The Cardiologist Shortage

Kevin, MD recently posted about this article from American Medical News. The article reports on the efforts of the American College of Cardiology to increase the number of cardiologists by creating a 5-year cardiology residency that combines the traditionational 3-year internal medicine residency and 3-year cardiology fellowship. Graduates of this shorter program would not do invasive procedures such as angioplasty:
"The ACC would like to add an alternative five-year program that eliminates the third year of internal medicine and cuts out training in the high-tech cardiology procedures."
The article goes on to say:
"The money saved by cutting out that year could be used to train more cardiology residents or fellows, according to the ACC. More cardiologists would be turned out over time, and such a program would attract medical graduates who might be turned off by either the length of the six-year program or the high-intensity lifestyle of a proceduralist."
I think that a 5-year cardiology residency is a pretty lame suggestion on the part of the ACC. Cutting training by one-year wouldn't save that much money. And the last I heard, there's no shortage of internal medicine residents trying to get into cardiology fellowships. Cardiology is a very popular specialty. There's no reason to try to attract "...graduates who might be turned off by either the length of the six-year program or the high-intensity lifestyle of a proceduralist."
If more cardiologists are needed, then the solution is to simply increase the number of slots in cardiology fellowships. This will require more Medicare funding.
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The proposal for a 5-year cardiology program is a power grab by the cardiologists, who want more autonomy from the American Board of Internal Medicine.

Why Clinton had a Heart Attack

This article from e Clinical Psychiatry News explains why former-President Clinton may have had a heart attack:
In a laboratory test intended to induce extreme stress, healthy subjects who reported engaging in penile-vaginal intercourse during the previous 2 weeks experienced significantly smaller increases in blood pressure than those who reported masturbating or engaging in noncoital sexual activity, Stuart Brody, Ph.D., said at the annual meeting of the Society for Psychophysiological Research.
The peak systolic blood pressure for the intercourse-only group averaged 130 mm Hg, while the other groups' averages ranged from 143 mm Hg to 165 mm Hg, which Dr. Brody described as “an enormous difference.” The effects on diastolic blood pressure were not as dramatic.
The magnitude of this effect was much greater than that reported in other studies. The beneficial effect of penile-vaginal intercourse on systolic blood pressure in the Trier Social Stress Test is apparently more pronounced than any other intervention, including whether the subjects smoke or have a family history of hypertension; whether they're using ACE inhibitors, -blockers, or oral contraceptives; or whether they exercise, are depressed, or are in marital distress, he said.
The beneficial effect of penile-vaginal intercourse on blood pressure seemed to disappear in people who also engaged in masturbation or noncoital intercourse during the 14-day period.
Dr. Brody described his results as politically incorrect: “The politically correct thing is to parrot the ideology first espoused by Kinsey and also by Herbert Marcuse, which is that all forms of sex are equivalent, except that intercourse is worse because it's part of the patriarchal power structure.”

A New Antidepressant

Amarin Corporation plc (NASDAQSC: AMRN) today announced positive data analysis from two exploratory phase IIa clinical studies using Miraxion (formerly referred to as LAX-101c) to treat depression. An analysis of the data from the two studies identifies a significant clinical benefit with Miraxion for a sub-group of patients with specific symptomology.
In a recent exploratory phase IIa study, Miraxion was used as monotherapy in 77 patients with a new episode of depression in a six-week trial. In this study it was prespecified, that the presence of specific depression symptomology (patients with melancholic vegetative symptoms) at the time of entry to the study (baseline), would predict response. In an exploratory analysis the Bech-Depression Scale, a subscale of the Hamilton Depression Rating Scale, which defines the affective core symptoms of depression, was used as the outcome variable. Miraxion achieved statistical significance over placebo in the sub-group of patients meeting these criteria.
Miraxion (formerly LAX-101) is a semi-synthetic, highly purified derivative of the n-3 fatty acid eicosapentaenoate (EPA). The mechanism of action is believed to involve stabilization of mitochondrial integrity of suffering neurons, thereby preventing or slowing progression from neuronal dysfunction to apoptosis.
Two Phase II clinical trials have been conducted with Miraxion in treatment-unresponsive depression that concluded with statistical significance that a 1-gram per day dose of Miraxion was effective in treating depression in patients who remained depressed despite receiving standard therapy. The results of these trials were published in the Archives of General Psychiatry in October 2002 and the American Journal of Psychiatry in March 2002.
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It's exciting to hear about a new antidepressant under development. I expect few new developments with antidepressants that target the traditional neurotransmitters (serotonin, norepinephrine, dopamine). It will be interesting to see if Omega-3 fatty acids (like Miraxion) and glucocorticoid receptor antagonists turn out to be effective antidepressants.

Grand Rounds at the Mad House

Check out Grand Rounds # 16 at the Medical Mad House.

Psychiatry Board Exams

I am taking my psychiatry oral board exams on Saturday the 15th. This is my 3rd attempt.
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Unlike most specialties, psychiatry has both written and oral board examinations. The written examination is a multiple choice test; most psychiatrists pass it. After passing the written boards, a psychiatrist can sign up for the oral boards. During the oral boards, the psychiatrist interviews a patient, presents him to examiners, and also answers the examiners' questions. Another part of the orals is the video exam, in which the psychiatrist watches a patient being interviewed on a videotape, presents the patient to examiners, and also answers the examiners' questions. To pass the orals, a psychiatrist must pass both the live patient interview and the video exam.
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The pass rate for the orals is only 55%. The pass rate is even lower for repeat candidates.
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Each exam (written or oral) costs about $1600. So far I have spent about $6400 on exam fees alone. Adding in travel costs brings the figure up to about $9500. Adding in the cost of board review courses brings up the cost to about $14000. Adding in the money I spent passing my sleep and internal medicine boards brings my total board exam expenditures to over $25,000.
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This is my last attempt at passing the psychiatry oral boards. After flunking for the 3rd time, the whole process starts all over again. You have to turn in another application and take the written boards ($1600) before taking the orals (another $1600) again. It's just too much money.
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I am pessimistic about my chances of passing the orals; the pass rate for repeat candidates is less than 50%. I am taking another board review course this week with mock examinations, but I am not sure how much it will help. Both times I took the orals in the past, I passed the live patient interview but flunked the video exam. Most residency programs prepare you for the live patient interview, but it's hard to prepare for the video exam. Hopefully this board review course will help.
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If I flunk this time, I am giving up on psychiatry. I will need to look for a new job, probably one that is mainly sleep medicine. This blog will no longer be "The commentary of an academic internist/sleep specialist/psychiatrist" but just the commentary of an internist and sleep specialist.
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tomorrow I am heading back to my home state of California for the board review course and the oral exams. Wish me luck. Posting will be light for the next week.

Lobotomy

I received this e-mail today:
Dear Dr. Rack, I thought you and the readers of your blog would be interested in my book The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness, a biography of the infamous psychosurgery pioneer Walter Freeman. Freeman was the neurologist who operated on Rosemary Kennedy, who died on January 7. My publisher, John Wiley & Sons, released the book last week. I began my research on Freeman in 1996 after meeting the family of a lobotomy patient. Over the years, I’ve focused my efforts on answering the questions of why Freeman, an undeniably brilliant and respected physician, felt drawn to lobotomy, and why he continued to stake his career on the procedure when better therapies became available in the 1950s. I found the answers in the grim psychiatric climate of his time and the complex mix of the strengths and weaknesses of his character. I’m the author of several previous books, as well as articles in The Atlantic Monthly, American Heritage, The Washington Post Magazine, The History Channel Magazine, and many other publications. In 2002 I received the June Roth Memorial Award for Medical Journalism. If you’d like to learn more about The Lobotomist, please get in touch with me at el-hai@lobotomist.com or check the book's website at http://lobotomist.com. Thanks, and I look forward to telling you more. Jack El-Hai ______________________ Jack El-Hai el-hai@lobotomist.com Author of The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness Just published by John Wiley & Sons http://lobotomist.com
Looks interesting

Everybody's in it for the Money

The latest issue of Medical Economics has a rather cynical article about hospice care:
When Medicare began to reimburse for hospice care in the '80s, it caused a sea change in the business structure of hospices. They went from the largely charity funded, volunteer-staffed organizations of the '60s to nonprofits and a few large for-profit companies.
Medicare reimburses the hospice roughly $122 for every day the patient is in hospice care. In return, the hospice provides meds, medical equipment, regular nurses' visits, pastoral care, and visits by home health workers and social workers. A nurse and doctor must be on-call 24/7.
If a hospice averages 30 Medi-care patients a day—and most larger companies average more than 30—it will generate more than $100,000 in Medicare re-imbursement each month. It doesn't take an accountant to see there's a profit to be made here. Three of the largest companies are showing impressive earnings or growth.
The article goes on to give several examples of hospice company reps trying to inappropriately get patients for their hospices. The author concludes:
I've had negative experiences with various hospices, but I'm still a strong proponent of hospice care. They're not all alike, and there are several things a physician should consider when ordering hospice care for a patient.
Most important, does the patient want hospice services? Some patients and families don't want strangers dropping in during this difficult time. It's very easy nowadays for a physician to have hospital beds, pain meds, and other medical goods delivered to a home without a hospice being involved.
If the decision is made to order hospice care, consider several things when choosing a company. What is its structure? How aggressive is the company? If it's spending a lot of money soliciting your business, do they have their priorities straight? Are they focusing on care or profits? Ask your patients who have lost loved ones to terminal illness if they used a hospice. What did they think of it? Were the nurses caring and responsive? Did they fulfill their obligations?
Lastly, keep your focus on the dying patient. Find out what's important to him, and decide whether a hospice can or is willing to provide for his needs.
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We all need to make a living. But our highest priority should be to do what is best for the patient.

Interns 1

This is the first of a series of posts about interns (not the type of intern of who works in the White House and ends up with white stains on her dress, but the type of intern who works in a hospital after completing medical school and ends up with all kinds of stains on his/her lab coat)
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Intueri writes (1/2/05):

Tomorrow is my last call night as an internal medicine intern.

She goes on to say that she will be starting the psychiatry part of her internship:

It’s like starting internship all over again! I don’t remember anything about psychiatry—it feels that way, anyway. I don’t remember how to conduct a psychiatric interview. I can hardly recollect the medications used, the psychodynamic methods employed, or how to successfully manage feelings of transference and countertransference (don’t ask me what those words mean, because I don’t remember).

As far as psych medications, the most important thing for a psychiatry intern to know is how to quickly calm down an agitated patient. Pych interns need to be especially familar with intramuscular haldol, thorazine, ativan, cogentin, geodon, and zyprexa. Psych interns should also be familar with the risperidone M-tab, and how to load a manic patient with oral depakote. Psychiatry interns do not need to know too much about psychodynamics, transference, or countertransference. The main things to know are that you should never have sex with a patient, and a little bit about the defense mechanisms used in borderline personality disorder (e.g., splitting). How to perform a detailed suicide risk assessment is necessary.

I’ve spent the past six months repleting electrolytes. I’m great at dosing potassium for patients, oh yes. And writing for antibiotics. And giving fluids. And blood. And running around as middle(wo)man for the nurses, social workers, and discharge planning.

Psychiatry interns usually won't have to transfuse a patient with blood. Many psych patients do need IV fluids, though not all psych wards allow the administration of IV fluids. Running around as a middle(wo)man for nurses and social workers is a big part of being a psychiatry inter.

I’ve worn a white coat for the past six months. And now—in two days!—I’m supposed to molt and shed that thing to become the beautiful butterfly of psychiatry (or something).
Nearly one and one-half years have passed since I’ve done any formal psychiatry. What if I’ve made the wrong choice? What if internal medicine is my true calling? What if I miss using my stethoscope? What if I miss reading x-rays? What if I miss repleting electrolytes (unlikely)?
I seriously don’t even know what I am going to wear on Wednesday.

I suggest wearing your lab coat and bringing your stethescope. You'll have plenty of x-rays to read (though in psychiatry it's usually not mandatory to read the x-ray yourself- but I recommend trying to read x-rays yourself instead of just passively reading the radiologist's report)- in my experience, psych patients frequently need chest x-rays and occasionally abdominal films. There will be many brain CT's and MRI's to look at.

Managing the medical problems of psych patients is a big part of being a psych intern on the inpatient psych wards.

Klonopin

Shrinkette recently posted about Klonopin being prescribed at excessively high doses:

When you see a patient taking Klonopin, it's helpful to recall the approximate dose equivalents:Klonopin 0.25 mg is approximately equivalent to Xanax 0.5 mg, or Ativan 1 mg, or Valium 5 mg, or Librium 10 mg. Of course, the kinetics are different, and there is tolerance and so on. But high potency meds can be...highly potent.
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I agree with her completely. Patients are often started out on a dose of Klonopin of .5 mg twice a day, which is probably too high of a starting dose. I think that the primary reason this is done is because .5 mg is the smallest dose that the Klonopin tab comes in (though the orally disintegrating wafers also come in .125 mg and .25 mg strengths).
When I start a patient on Klonopin, I typically have them take 1/2 of a .5 mg tab, twice a day. The manufacturers of clonazepam (Klonopin) really need to come out with a .25 mg tab.

Grand Rounds 15 at RangelMD.com

Grand Rounds 15 has been posted at RangelMD.com
Dr. Rangel did a great job of organizing and presenting the posts.
Check it out.

Last Chance for Grand Rounds

Dr. Rangel is hosting Grand Rounds this week:

Accepting submissions for the next Grand Rounds - Deadline is 9 pm mountain standard time (GMT-7) on 1-3-2005. Send submissions to drrangel - at - swbell.netEven though the deadline is 9 pm I will still be checking my email into Tuesday morning and will try and add on late entries however you have the best chance of being read if you get in your submission early. Submit early. Submit often!

Would you like a side of fries with your CABG?

Hospitals are struggling with the problem of whether to allow fast food:
"It becomes a philosophical question that has to be answered in every hospital. Do we serve healthy foods because we're in a health care facility, or do we serve what the customers are interested in having?" said Joyce Hagen-Flint, president of the AAHCSA. "There are hospitals all over the country that have fast food outlets."
It's not uncommon for hospitals to earn money by leasing space to food court companies or restaurants.
I personally have no problem with a hospital serving "fast food" as long as healthy options are available. This can be a problem in the South, where everything is "chicken-fried."
I must admit that I have come to develop a particular hatred for McDonald's. In their advertisements, McDonald's likes to pretend that they have all these healthy alternatives available. Then when you get to the actual McDonald's, it's not available. There is a McDonald's at the rehab hospital directly adjoining the University of Mississippi Medical Center. When I arrive for work (anytime between 6:30 and 8 am) and try to buy a fruit-and-yogurt parfait, I am usually told that they are not ready yet or that they are out of them. I have never seen them run out of, or not have available, sausage patties.
(edited slightly since time of initial posting)

Who Does a Doctor Treat?

This comment was posted on DB's Medical Rants:

As one from the “payer” side, I’d recommend we take the argument on health care costs a step further. Like it or not, employers pay a significant portion of health care costs, both directly (premiums) and indirectly (cost-shifting for uninsured, FICA taxes, income taxes, etc.)
The real issue employers have with health care costs is they have NO sense for their return on the investment. And that is the fault of the medical and managed care communities. Employers carefully assess each investment into plant and equipment, personnel and training, investment options and new products. They calculate RoIs carefully, assess performance constantly, and get as comfortable as possible with an expenditure BEFORE they make the investment.
Think about health care - what do employers get? Happy employees? Rarely - health insurance is a terrible “good” - people only use it when they are ill or injured, it is convoluted and difficult to understand, and they have topay for part of it too!
Actually, what employers SHOULD be thinking about is the demonstrated ability of a health care provider to “deliver” healthy, fully functional employees and families, thereby enhancing productivity and, therefore RoI. Health insurance is an investment in productivity.
If we can evolve to this way of thinking, much of the present bickering about health care costs will end. Sure, there will be arguments about impact rates, who delivers what benefit, and what evaluation methodology makes the most sense, but that will signal we are talking about the right things.
So, the next time someone complains about charges, costs, or premiums, ask them how that “good” will help them function. They won’t know the answer, but perhaps they’ll start thinking about it.

I see patients one person at a time. My duty is to the patient, not their company. The individual patient is the one who signs a form agreeing to accept the responsibilty for my bill. There are occasional exceptions (I recently did a Workers Comp Eval in which I received payment directly from Workers comp; before the eval I informed the patient that I was providing services to Workers Comp and not him and obtained informed consent before proceeding with the evaluation). In most cases, doctors have relationships with individual patients, not companies or businesses. Although businesses do pay for much of healthcare in this country through health insurance premiums, this is at the expense of higher wages. So ultimately, it is the worker who is paying.

Schizophrenia and obstructive sleep apnea

Schizophrenics have a higher risk of obstructive sleep apnea than the general population. This increased risk has generally been attributed to obesity and the weight gain caused by antipsychotics.
In addition to obesity, nasal obstruction is also a risk factor for obstructive sleep apnea.
This recent study found reduced nasal cavity size in schizophrenic men:
To investigate, Dr. Moberg's group used acoustic rhinometry to measure nasal volume in 40 men with and 40 without schizophrenia.
They discovered that the schizophrenic patients had smaller posterior nasal volumes in both the left and the right nostrils (p <>
Could reduced nasal cavity size be part of the reason that schizophrenics have higher rates of obstructive sleep apnea??

A Simple Cure for Obesity

I found this on Medscape:
How can we stop the obese from becoming more obese? Pretty simple. Stop feeding them. Think about the other common self-destructive human behaviors. On a commercial airplane, in a saloon, or at a professional sports event, if the customer is deemed to be drunk, the keepers of the booze key will lock the cabinet. If a person drives a car at a dangerous speed, the driver is subject to substantial penalties. For young persons known to be at high risk for early chemical addictions, society tries to prevent exposure to the addicting drugs. Overeating with underexercising is now killing more Americans than anything else except tobacco addiction. Yet, an obese person enters an eating joint, or a supermarket, and buys and eats any and everything he or she wants, and nobody seems to care. Does that make any sense to you? Meanwhile, Big Science strives to understand why people get fat; Big Genetics searches for the obesity gene so that stem cells could correct the flaw; Big Surgery lines up the morbidly obese to shunt their stomachs; Big Pharma seeks the next weight-loss pill that will help more people than it kills; Big Nutrition hawks the newest sure-thing, weight-loss diet; Big Fast Food pushes "healthy food" lines right next to their billion dollar unhealthy food lines; Big Soda and Big School Boards share the profit from drowning kids with calories from vending machines; and Big Exercise pushes group rates for aerobics class. Money made by so many special interests. All this while the simple answer is to stop eating; stop feeding the obese until they are no longer obese. Of course, that may be hard to do, and who makes any money that way? Fat chance for this crazy idea to go anywhere. That's my opinion. I'm Dr. George Lundberg, Editor of MedGenMed. Happy Holidays!
Readers are encouraged to respond for the editor's eye only or for consideration for publication via email: glundberg@webmd.net.

George D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine
Disclosure: George D. Lundberg, MD, is an employee of WebMD.
Medscape General Medicine 6(4), 2004. © 2004 Medscape
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This is a pretty simplistic solution- an alcoholic can avoid alcohol but an obese person can not avoid food- some food is necessary for survival.
On the other hand, we have several 600+ pound patients at our sleep lab who are unable to leave their houses except with the assistance of an ambulance. Yet they manage to obtain and consume buckets of fried chicken and bottles of cola. Someone (usually a relative) is bringing the extremely obese person unhealthy food in these cases.
There aren't any easy solutions to the obesity epidemic, though I have seen good results with bariatric ("stomach stapling") surgery. I have also seen bariatric patients develop wound problems requiring prolonged hospital stays (6+ months) and sometimes leading to death.

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.
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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."
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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.
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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.
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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.
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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.
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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.
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This post was inspired by the Dec 30 post on Mental Notes.
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Comments are welcome

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."

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.

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.

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".

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.

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).

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

Melatonin

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.

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: http://www.foxnews.com/story/0,2933,141528,00.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.

Doctors Taking Antidepressants

Shrinkette (http://shrinkette.blogspot.com/) 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

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.
(fromhttp://www.psychiatrictimes.com/p971155.html)
An article in the New York Times today discusses screening for autism:
http://www.nytimes.com/2004/12/14/health/14auti.html?pagewanted=1.
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."

Prochieve

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: (http://www.currentpsychiatry.com/2003_12/1203_letters.asp).
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?

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 (http://www.aaoms.org/). 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

(http://psych.umc.edu/sdc.shtml), 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 (http://www.tracheostomy.com/what.htm). 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).

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):
http://familydoctor.org/791.xml.

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 http://news.bbc.co.uk/2/hi/health/4059357.stm 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: http://www.aasmnet.org/listing.asp

Intrinsa

The New York Times discusses Intrinsa, a testosterone delivering patch: http://www.nytimes.com/2004/12/02/health/02patch.html.

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
(from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15065634):

"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.

An Interesting Statistic

Mississippi's major newspaper, the Clarion-Ledger, has an article about HIV today-
http://www.clarionledger.com/apps/pbcs.dll/article?AID=/20041201/NEWS01/412010363/1002.

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.