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.
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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).
RELATED ARTICLES
This Month in Archives of General PsychiatryArch Gen Psychiatry. 2006;63:124.

Psychotic Break

This picture is from the article that is causing such a controversy in Shrinkette (Feb 10) and other blogs. Unfortunately the online article does not give any information about the artist.
Schizophrenia frequently permanently transforms a person. You can usually get rid of the hallucinations and delusions with medications, but negative symptoms often persist and cognitive decline sometimes occurs.

It's diplomate, not diplomat

dip·lo·mate Pronunciation: 'dip-l&-"mAt Function: noun: one who holds a diploma; especially : a physician qualified to practice in a medical specialty by advanced training and experience in the specialty followed by passing an intensive examination by a national board of senior specialists
---
dip·lo·mat ( P ) Pronunciation Key (dpl-mt)n.
One, such as an ambassador, who has been appointed to represent a government in its relations with other governments.
One who uses skill and tact in dealing with others.
One of my pet peeves is when a physician mistakenly calls himself a "diplomat", as in diplomat of the American Board of Internal Medicine. It's "Diplomate." I see this mistake all the time on letterheads and cv's.

No Need to Thank Me

I saw an ad by the American Medical Association in Time magazine that said:
"...when was the last time you let your doctors know how much you appreciate all they do for you...we have created some thank you cards that you can download..."
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This makes me embarassed to be a member of the AMA, which I recently joined because it was required for a local insurance network. The AMA should not be asking patients to thank its members. A physician advocacy organization should not be going around begging patients to thank them.

Should you do Your Own Taxes

Medical Economics has an article this issue that discusses whether a doctor should do his own taxes:
The answer: It depends. Certain financial situations are sufficiently complicated that you really need an accountant's expertise. And, in many cases, the hours spent doing your own taxes could be more profitably spent seeing patients.
A doctor (post-residency) who would do his own taxes and not even have an accoutant look at the tax form before sending it in is, in my opinion, being very foolish.