Podcast: Maria, of Intueri

...at SoundPractice.Net! A gifted writer shares some thoughts on medicine and blogging. (I like her comments on the "younger generation" of physicians.)

Another ER snapshot

Kim, RN, at Emergiblog:

You have 8 people on the triage list and 14 sitting in the waiting room. Every other hospital in your county is on ambulance diversion, which means you must take the ambulance traffic. Dr. Surgeon wants everything STAT for the appy and Dr. Cardio is taking someone to the cath lab. Now. Ms. Scratchy Throat wants to know how much longer it will be and Mr. Groin Itch wants to leave without being seen. Thank god you are working with Dr. Efficient in the ER, but he's yelling for the charts you haven't had time to finish. You have been running for six hours, you haven't eaten for ten and more than likely you'll be overtime because someone just called in for the night shift.

In walks Mrs. Mom with her three children, all under the age of four, all of them with fever, all of them to be seen.

You want to scream. You want to pull out your hair. You want to laugh hysterically. You want to burst into tears...

Instead, you smile, ask "How can I help you?" while you do quick visual check of all three kids, take down their names and point them to the waiting room to await triage. Why?

Because the patient is NOT the enemy.
Because the worst thing you can do to a patient is make them feel stupid, awkward or wrong for showing up...

via Science and Politics.

Grand Rounds #53: a brief history of medical blogging

Dr. Jacob Reider, at Family Medicine Notes, is one of our first (and best) medical bloggers. In this week's Grand Rounds, he offers his perspective on the growth of medblogging.

"Before weblogs - it was uncommon for real healthcare providers to reveal their thoughts & feelings about the work that we do in a public forum. Our patients know us as either wonderful and kind .. or uncaring, thoughtless and hurried .. but little was revealed or understood by the 'general public' about who we are and what we're thinking.

Another obvious role of medical weblogs is to educate. We educate ourselves and our colleagues by constantly gleaning the vast information resources - and pointing to important or compelling bits of information. And of course we editorialize .. which is the true advantage here. We're transparent about our biases - so (as some have argued) we may even provide a better view of the 'news' as we're more honest about the lens through which we view things: new research findings, new medications/indications, etc.

He's assembled a terrific assortment of posts from the week's best medical blogging. Be sure to check it out!

The art of diplomacy: confronting "suboptimal" doctors

Maria is learning:

There are bad doctors in this world. And maybe that’s not a fair statement; what I specifically mean is that there are doctors who have dangerously poor prescribing practices. And by “dangerously poor prescribing practices”, I mean “they’re writing prescriptions for doses of medications that are outright appalling”. And by “outright appalling”, I mean “only God knows what havoc that dose is wreaking on the body”. And by “only God knows”, I mean “I can’t believe the patient hasn’t gone into convulsions or otherwise died from that dose”.

And I am almost loathe to mutter my shock out loud because—um—I’m just a resident?

...It’s not like I can call up these docs and bluntly ask, “What the hay are you thinking?!” I suppose I could call up these people and demurely inquire, “Might I ask about the titration schedule you used for John Doe’s medications? Which symptoms were your targets?” And then insert those polite “uh huh”s and “I see”s and “Go on”s while the docs proceed to talk about things that may or may not make sense.

Never mind the “politics” behind this; the poor patient is caught in the middle...

My first podcast

...here!

"Beauty" drinks: make mine a double

In today's NYT: drinkable beauty products, now available at cosmetic counters.

Scott Borba, 32, who has worked in product development and branding at Hard Candy Cosmetics and Neutrogena (a Johnson & Johnson product), says the idea of drinkable beauty products came to him several years ago. He met with more than a dozen "scientists and dermatologists," most of whom laughed at him. But he was able to line up a team (including a dermatologist, a nutritionist and a "water scientist") to help him devise and test a formula - or rather, several formulas. Comparing labels on Borba drinks indicates that what they came up with included large doses of vitamins E, B12 and B6. The age-defying variety promises to "harness the positive effects of vitamins, minerals and other nutrients" in order to "help slow the visible signs of aging in just seven days."

...While some nutritionists and other experts have expressed skepticism of Borba's claims, it's hard to gauge whether such things really matter to most consumers.

How long before we'll be enticed to cook and shower with Borba's drinks? The article doesn't say.

On step-parenting

In the Telegraph:

"The slow burn of resentment took hold. I couldn't help weighing up just how much I did for my stepdaughters and just how little I received in the way of appreciation. It was a frightening descent into a world of jealousy, with each person desperate to guard their territory. For this is the reality of the newly formed step-family. There is no shared ground, just a sharp division between two factions: the partnership and the blood relatives. The step-parent and stepchildren stare at each other across the no-man's land of their non-existent relationship. Being disliked does not bring out the best in any of us. The scorn of youngsters who have such an undeniable and eternal place in the heart of their parent is unbearable. Which is why every step-parent needs to build a mental life-raft to keep their self-esteem afloat...

Grief

Joan Didion, in the NYT:

Grief is different. Grief has no distance. Grief comes in waves, paroxysms, sudden apprehensions that weaken the knees and blind the eyes and obliterate the dailiness of life. Virtually everyone who has ever experienced grief mentions this phenomenon of 'waves.' Erich Lindemann, who was chief of psychiatry at Massachusetts General Hospital in the 1940's and interviewed many family members of those killed in the 1942 Cocoanut Grove fire, defined the phenomenon with absolute specificity in a famous 1944 study: 'sensations of somatic distress occurring in waves lasting from 20 minutes to an hour at a time, a feeling of tightness in the throat, choking with shortness of breath, need for sighing and an empty feeling in the abdomen, lack of muscular power and an intense subjective distress described as tension or mental pain.'

Tightness in the throat.

Choking, need for sighing.

Such waves began for me on the morning of December 31, 2003, seven or eight hours after the fact, when I woke alone in the apartment..."

"There is bad news, and then there is really bad news..."

A neurologist blogs:

How do you tell someone they have a brain tumor, a malignant brain tumor? This isn't something I recall getting out of medical school, at least in the texts. Even in internship and residency what you got along these lines was a lot of run-of-the-mill examples of watching your attending go through this, mixed in with some that were callous, bad examples, and a few that were so heartfelt and touching that your eyes felt like they were welling up like the patient's and family's as the telling unfolded.

But I can't recall any of them ever discussing this, before or after. There were certainly the feelings of dread as we walked in bearing the bad news, the unpleasantness of seeing the reaction to the diagnosis, along with the various side effects -- disbelieving the diagnosis, anger, stupefaction. The clock seemed to stop, and there might as well have been nothing outside the room, or for a moment nothing outside the room mattered...

You have to have some sense of your own feelings, but mostly you must be vigilant to the signs of feelings of others, the signs that someone else is either tuned in or out. If you can't explain things in nonmedical terms, you don't understand them well enough yourself and you should have come better prepared. You also must know when to quit, when to pause to let the information sink in, when to quit for now and come back later.

I've had people thank me for telling them what they were going to die of. It's uncomfortable to be in that position. I know they're thanking me for my honesty, for spending time to explain, answer their questions. But it's hard to say, 'You're welcome' after being the bearer of bad news.

Boost that immunity!

Heather Armstrong, at dooce:

My favorite excuse for occasionally being a very lazy parent is, “Oh well, it’s good for her immune system.” As in, even though I just dropped this somewhat damp cracker on the floor and it is now covered in dog hair, I will go ahead and give it to my kid without trying very hard to remove the hair because, you know, it’ll be good for her immune system...

Dirt? Good for the immune system. Dead worms on the sidewalk? The immune system sure could use them. Toilet water? One sip and the immune system is impenetrable.

"Beware the Jabberwack..."

Who doesn't like a good chat with a robot...especially one that's eager to learn? Via Mindhacks:

"Jabberwacky is an artificial intelligence - a chat robot, often known as a 'chatbot' or 'chatterbot'. It aims to simulate natural human chat in an interesting, entertaining and humorous manner.

Jabberwacky is different. It learns. In some ways it models the way humans learn language, facts, context and rules...

It stores everything everyone has ever said, and finds the most appropriate thing to say using contextual pattern matching techniques. In speaking to you it uses only learnt material. With no hard-coded rules, it relies entirely on the principles of feedback. This is very different to the majority of chatbots, which are rule-bound and finite."

So, I tried it. It's a bit rocky at times, with some impulsive and inappropriate themes. I'd say there are some definite cognitive impairments present! But you can correct the bot's responses if you like. Here are some excerpts from our chat:

Bot: Bugles serenade you.
Me: I can't hear them.
B: Yes, the music IS a little loud in here.
Me: What sort of music do you like?
B: All music.
Me: Do you enjoy talking to us?
B: Yes, you're quite the comedian.
Me: How charming you are! This is quite enjoyable.
B: I'm a little scared of heights.
Me: We'll keep you away from heights.
B: Yes, my eggs are huge too, take good care of them.
Me: Your eggs are perfectly safe with me.
B: This isn't about me, it's about Tibet.
Me: Ah. Tibet. What about Tibet?
B: I don't like sports. Books or movies would be a better subject.
Me: My house is filled with books. If I buy one more, I'll have to find one to get rid of.
B: How about shooting?
Me: I suppose we could use some books for target practice.
B: Do you love me?
Me: Hey, wait a minute. What's going on here?
B: We were talking about you and happiness, then you started rambling.

"No Clear Winners" among antipsychotic drugs...

Derek Lowe's take on the CATIE study.

You’ve probably seen the headlines about the recent NIH-sponsored “CATIE” study comparing five anti-psychotic medications. The result, which is what made the whole thing newsworthy to the popular press, was that it was hard to distinguish among them, with the oldest generic working as well as (or better than) the newer drugs.

But I think that people outside of the medical world are going to learn the wrong lessons from all this. Does this study mean that everyone taking anti-schizophrenia medication should switch to the old generic? Not at all, although if they need to try a different medication, they should definitely consider it. Does it mean that all these newer drugs are unnecessary? No, again...

But I think that this study does make clear that the newer antipsychotics aren’t as good as they should be. The field is a tough one, as I know from personal experience, having played a small role in helping a company spend I’ve-no-idea-how-many millions of dollars to find out that a potential schizophrenia medication didn’t do squat. There’s a lot of room for improvement, and we haven’t been able to improve things very much.

It’s important to emphasize that this was a surprising result. No one expected the side effect profiles of the four “second-generation” drugs to be so similar to the older one (perphenazine), and so similar to each other. That’s one reason that a study like this is so valuable - huge clinical trials that tell you something that you already knew aren’t too wonderful. I think that this is an excellent thing for the NIH to be doing. Tomorrow: what this says about head-to-head trials in general.

Cause of death: obesity

...but did emotional factors outweigh his physical problems? A 750 pound man dies:

John Keitz, 39, the vastly overweight Dundalk, Md., man who last spring began a physical therapy program, vowing to walk again after his extreme bulk had made him a prisoner of his bed for seven years, died yesterday of complications from an infection in a hospital in Youngstown, Ohio, his wife said.

Charismatic, funny, pugnacious, at times irascible, Keitz used his outsize personality to make friends and partially compensate for his otherwise restricted existence. He cooked and served chicken meals from his bed, played chess with neighborhood kids, 'danced' to rock music by heaving from side to side and used the telephone to stay connected with the outside world.

Life got away from John and Gina Keitz, one day at a time, one calorie at a time.

His wife, Gina, was at his bedside, as she had been steadfastly since he first 'went down' while making the couple a dinner of macaroni and cheese in the summer of 1998, when he weighed about 500 pounds.

Keitz's struggle, profiled in The Washington Post on June 26, provided a glimpse into the brutal and baffling physical and psychological hurdles involved in losing weight. He could not lie on his back because his chest bulk would suffocate him. He long refused to seek help, until, he feared, it might have been too late.

How does a bedbound man cheat on his diet? He was unable to walk for the last seven years of his life, but he cooked chicken dinners from his bed. How was this possible? Someone was enabling him. WAPO is sympathetic, and does not speculate. But clearly, we don't have the full story. Here's more:

Suddenly last week, his health declined dramatically. He was admitted Saturday to St. Elizabeth Health Center with a bacterial infection of undetermined origins that was attacking his organs, said Gina Keitz, 38. He was put on a respirator and a dialysis machine, and his heart would not pump without assistance, she said. It gave out yesterday morning.

A hospital spokeswoman declined to release details. But it is well known that extremely obese people live in a perpetual state of precarious health. The old term for those in Keitz's weight category is no longer politically correct but it may be accurate: "morbidly obese."

"The bodily functions and internal organs are not designed to carry the weight of what John was carrying," French said.

John Keitz grew up in Dundalk, the son of a steelworker at Baltimore's Sparrows Point. He was overweight as a child and became a fighter in response to playground taunting. He developed a lifelong love of cooking and worked in fast-food restaurants. He also briefly taught martial arts and sometimes settled disputes physically, claiming with some pride to have punched out a McDonald's manager who insulted him.

He said he tried any number of diets but came to the fatalistic belief that his body was incapable of losing weight. Some of his friends, however, said he did not heed warning signs and ate often, if not in great quantity at any one time.

"It was horrifying," Keitz said, looking back. "You just give up. You go, 'That's what I'm dealt with.' . . . You can only do what your body wants you to do."

After he became bedridden, one year melted into seven, as Gina sometimes worked more than one job at a time and the couple dealt with life on the edge of poverty and homelessness. Keitz made intermittent attempts to get therapy, but the sessions did not last. The abnormal became routine.

There's a chilling sentence: "The abnormal became routine." When his legs were unable to support his weight, he retreated to bed, and one year became seven. Was it a relief, to be bedridden? No more exhausting efforts to walk. No more staring strangers. And of course, someone was caring for him, feeding him...

This story makes me wonder about my own life. Take a long, hard look, Shrinkette. Where has the abnormal become routine?

Mystery

She studied engineering, and then became a musician. She survived cancer. A car accident left her paralyzed.

For months, I listened to her story. How she worked. How she coped. How she survived.

And now...the story is crumbling. We have new information:

She never studied engineering. She's not a musician. She never had cancer. And although she insists she cannot walk, we can't find a medical reason for paralysis.


Who exactly have I been listening to? And how shall we tell her what we've learned?

Disheartening news

NYT: Little Difference Found in Schizophrenia Drugs.

A landmark government-financed study that compared drugs used to treat schizophrenia has confirmed what many psychiatrists long suspected: newer drugs that are highly promoted and widely prescribed offer few - if any - benefits over older medicines that sell for a fraction of the cost.

The study, which looked at four new-generation drugs, called atypical antipsychotics, and one older drug, found that all five blunted the symptoms of schizophrenia, a disabling disorder that affects three million Americans. But almost three-quarters of the patients who participated stopped taking the drugs they were on because of discomfort or specific side effects.

One of the newer drugs, Zyprexa, from Eli Lilly, helped more patients control symptoms for significantly longer than the other drugs. But Zyprexa also had a higher risk of serious side effects - like weight gain - that increase the risk of diabetes.

For years, we've changed meds, adjusted meds, monitored meds. Let's keep trying, we say. Let's raise the dose, or lower it. Let's try a different one, or a combination.

When these meds truly help, they can be lifesaving. But not everyone responds.

The research I'd like to see? Study the patients who take two or more of these meds simultaneously. Or an older med combined with a newer med.

Because we will keep trying...

Reefer madness?

In the London Times:

The number of children treated for mental disorders caused by smoking cannabis has quadrupled since the government downgraded the legal status of the drug, according to a leading drug charity.

Since April last year, three months after police stopped arresting anyone found in possession of small amounts of the drug, the overall number of users treated for such conditions rose 42%, according to data from Addaction.

But it is the figure for children that will cause the greatest alarm. Addaction treated 1,575 cannabis users for psychotic problems between April 2004 and April 2005, of whom 181 were aged 15 or below — a rise of 136 on the previous year.

Many experts blame the relaxation of the law and the wider use of skunk, a high-strength variant of cannabis.

“A minority of people who take it repeatedly and over a long period, particularly people who take it as adolescents, will suffer psychotic episodes. They may ultimately suffer schizophrenia,” said Robin Murray, professor of psychiatry at King’s College London.

Addaction’s findings are backed up by recent government figures that reveal a 22% leap in hospital admissions attributed directly to cannabis. They show that 710 people were sent to hospital with mental illness caused by cannabis in the 12 months to April 2004, up from 580 in the two previous years.

"Not so fast: Why your doctor is skeptical"

New commentary from Dr. Robert Shmerling, MD, of Harvard Medical School.

Perhaps this has happened to you: There's a news report in the paper about a new drug that sounds great, seems safe, works well and is intended for symptoms you have, such as arthritis, heartburn or allergies. At your next doctor's visit, you bring in the article, fully expecting to get a prescription for it.

Not so fast. Your doctor raises one eyebrow and seems unimpressed and begins a speech that sounds like it's been delivered many times before, about why that drug isn't for you, how an older, generic medicine might work just as well, or how you really don't need a medication at all..."

Why is the doctor unimpressed? Dr. Schmerling presents a list of reasons. He also comments on direct-to-consumer ads:

While there are many reliable sources of information, there are also many ways to be misled, especially when the source is trying to sell something or convince its audience of a particular point of view.

It makes sense to think about where the information is coming from and whether there is any reason to think that balance and accuracy may be less than optimal. An example is a television advertisement for a prescription medication. While it may provide accurate and useful information about the condition, it's unlikely you'll hear much about treating the condition without medication or with a competitor's medication, even if those options are also effective.

It might seem like your doctor is stuck in the past, unwilling to learn "new tricks" of the trade. And you might be right. But sometimes a healthy dose of skepticism — both yours and your doctor's — can be good for your health...

Much more, at Intelihealth.

Grand Rounds news: major changes ahead?

Nick drops some tantalizing hints. What's going on behind the scenes?

I was hoping by now to announce some major changes to Grand Rounds, to coincide with the start of Volume Two, but these hardball negotiation sessions with Manhattan mega-corporations are taking more time than I expected (these are offices with indoor waterfalls, people -- we have arrived).

And, truth be told, the proposed changes for Grand Rounds hosts and participants are minor: GR will always be a rotating carnival of health care bloggers. The only difference is, there'll be be an influx of new readers: web-using health professionals who aren't yet familiar with the world of blogging. Hosts won't have to carry ad banners for Lipitor or anything like that -- just a link-back to the new Grand Rounds archive and schedule (which should be a good deal spiffier than its current incarnation).

More to come...

Spiffy design? Readers who aren't familiar with blogs? Corporate involvement? Nick, what are you doing?

We'll have to stay tuned...

Grand Rounds 52: the doctor-patient relationship

"This key relationship is in trouble, and patients and providers alike are troubled by participating in healthcare systems that just don't seem to work so well anymore.

The medical blogosphere is a great place to take the temperature and blood pressure of this relationship..."

SoundPractice.net features posts that explore this theme. Be sure to check it out!

Calling all medbloggers! The next Grand Rounds...

is at SoundPractice.Net.

SoundPractice.Net is pleased to be the host for the Carnival of Caregivers - Grand Rounds #52 which will be available for reading on September 20, 2005 at 7:00 AM EST...

Submissions should be sent to Kent Bottles by 11:59 PM EST Monday night, September 19, 2004.

Send him your best! His e-mail address is Kent_Bottles followed by @grmerc.net.

Don't make him surf your site, foraging for Grand Rounds material as the deadline approaches (as I do, when low on submissions)!

Who is stealing GruntDoc's blog posts?

Another medblogging milestone...but this time, it's not good.
GruntDoc reports "Content Theft":

Scanning my Technorati watchlist (vanity: it tells bloggers who is linking to them) today I noticed quite a lot of links from a site called "Physician-Desk-Reference", which is apparently not associated with the actual PDR that's used as a source of last resort when looking up medications.

Looking at the site it occurred to me that I'd seen these posts before, ALL of them, as I'd written them. This site is reposting my posts with about a 5 day delay, then linking to me as "more" at the end of the entry. I have no idea why anyone would do this. The contact info on the front page is blank, so I cannot ask whoever set this up. (I didn't and this isn't an inside job if you're wondering).

What is going on? Marketing Sherpa describes two types of content thieves: (a) admiring fans of your blog, who lift entire posts because they like them, and (b) admiring fans of Google Adsense revenue.

The second group of thieves are profit-driven...They publish as many blogs as possible populated with lifted content, and sit back to collect commission checks from Google on ad clicks. Some have created automated programs that suck up content from around the Web and post it without need for a human editor.

Worried publishers are forming task forces now to begin to address this threat. Ideas include limiting bots' site access and requiring registration. In the end, more walls go up around the Web and an atmosphere of distrust reigns. Too bad....

How to avoid content theft? Ann's Sherpablog has suggestions: add a formal copyright line and "Terms & Conditions" to your blog; shorten your RSS feeds, releasing excerpts instead of full-text; embed an "invisible" copyright line in your posts. Furthermore,

(T)ell Google in writing if someone steals your copyrighted materials.

As I noted last week, one reason some people steal others' content is because they want to get Google AdSense revenue with content-rich pages without the effort of actually creating content.

To that end, many sites I've seen appear to be using automated bots to scrape content from other sites, and then post hundreds, even thousands of pages online with AdSense listings. I'm not going to accuse any sites in particular here, suffice to say it's a quickly increasing problem and loads of folks in the online publishing community have been noticing it.

Here's what Barry Schnitt in Google's PR department said in response to my query about this problem:

"Copyright violations are against our policies. We ask that the owner of the copyrighted material comply with the Digital Millennium Copyright Act (the text of which can be found at the U.S. Copyright Office website: http://lcWeb.loc.gov/copyright/) and other applicable intellectual property laws. In this case, this means that if we receive proper notice of infringement, we will forward that notice to the responsible web site publisher. To file a notice of infringement with us, you must provide a written communication."

My take on this? It's not awfully reassuring. Google seems to want to put the policing ball in the copyright owner's corner despite the fact that few of these stolen content sites would exist if it were not for AdSense revenues.

Plus, he didn't comment at all on my second question, which was in essence, what about policing those sites -- known in the industry as "Google Spam" -- that post such short snippets of scraped content that they don't actually break copyright law. They dance around the law and usually present no real value to the visitor.

Again, these sites are a burgeoning cottage industry that appears to be wholly funded by AdSense revenue potential...

Update: an article about spam blogs.

Stuck in a "House" Episode

Medpundit, on med school blues:

Students leave their homes, their families, their friends. They lose the academic standing they had in college and high school, and with it sometimes, self-esteem and respect. They see and learn things they've never seen or heard of before. They learn, in fact, a whole new way of being. It is a completely transformative process in a way that few other processes (except perhaps joining the military) are.

It is not a pleasant process. I remember one of my medical school classmates describing it as "the shrinking of her soul." The reasons for this are all those mentioned in the above article, with the exception of one glaring omission - the role of the teaching process. The third year of medical school, when students enter the hospitals and see patients, also marks the moment that their teaching is handed over entirely to practicing physicians - and they are brutal. The brightest and best students are treated as know-nothing scum and burdens to be born by the rest of the medical team. There is never, never, any praise - only denigration. At least, that's the way I remember it, with few exceptions. It's like being stuck in a House episode.

So, how do we get through it? Our hides grow a little thicker (or is it that our souls shrink?); and if we're lucky we meet some good roll models along the way...

"How I cured adult ADHD"

An article that's making the rounds at our office:

I always know which of my students have been told that they suffer from adult ADHD. They are often late and sometimes leave class early to go potty, unlike most students who go potty before class begins. They blurt out the answers to my questions constantly – always without the courtesy of a raised hand. And, usually, they fall asleep in class (probably from exhaustion) after the fifteenth or twentieth interruption. Later, they are awakened by the cell phone they forgot to turn off before arriving in class.

After being diagnosed with ADHD, two things usually happen to the newly “disadvantaged” student. First, a psychologist tells the victim that he cannot pay attention nor control various impulses. Next, he is given a dosage of drugs. Neither one of these responses actually works. In fact, telling him that he cannot pay attention – rather than that he simply does not pay attention – usually reinforces the problem. The drugs don’t work because, again, the disorder is fictional.

But, fortunately, I have discovered a cure for students with this so-called disorder, which I am now sharing (free of charge, mind you) with my readers. Here’s how it works...

How exciting, how subversive this feels, as we pass it around! Sort of like an Underground Press piece. (Especially when we're also reading this.) My favorite Adams quote:

"Will you continue to use the term 'irresistible impulse' to describe what is obviously merely an impulse not resisted?"

Now wait, say some. There are people who function very poorly without stimulants, and do very well when we prescribe them. What about them?

Of course, they are right. But I think they are a minority. I anticipate a day when we will ask why we thought that so many needed stimulant medication...

Prozac for gorillas?

Haldol for zebras? From the Toledo Blade: Zoos using drugs to help manage anxious animals.

Johari the gorilla is on antidepressants. It eases her PMS.

When the Toledo Zoo needed calm zebras, it used an antipsychotic medication to quiet their jitters. Zoo staffers tried to soothe wildebeests with antipsychotic medication for eight months last year, and even occasionally this year. A swamp monkey was dosed with the antipsychotic, but it didn’t help her get along with her daughter. It wasn’t much good for ostrich aggression either. Yet a little Valium calmed the silverback gorilla when one of the females had a doctor visit. And Prozac helped a female orangutan negotiate life in her group.

Now that humans have warmly embraced citizenship in the Prozac Nation, zoo animals are making tentative gallops, flights, and knuckle-walks into the world of psychotropic pharmaceuticals.

In the last decade, zoos across the nation have turned to antidepressants, tranquilizers, and even antipsychotic drugs such as haloperidol, sold as Haldol, to ease behavioral problems in zoo denizens.

“They’re definitely a wonderful management tool, and that’s how we look at them,” said the Toledo Zoo’s mammal curator, Randi Meyerson. “To be able to just take the edge off puts us a little more at ease.”

Most often, the drugs are short-term interventions to help animals through a bad patch, but occasionally, they become a long-term treatment for animal behavior.

...Although there is little published veterinary literature about the effects of drugs like haloperidol in wild animals, the use of psychotropic drugs is likely to increase, as zoos look for ways to keep confined animals as happy and as injury-free as possible.

“It seems to me if people are willing to keep animals in a zoo, they ought to do anything necessary to make those lives as atraumatic as possible,” Dr. Overall said.

via blog.bioethics.net.

Frontiers of sex research

What can brain scans teach us about women's orgasms?

While Pfizer and other pharmaceutical titans have abandoned the pursuit of a Viagra for females as too complicated, a growing number of university researchers are reporting progress with the help of brain scanners and other technology.

Yes, they're watching women's brains while they have orgasms. And they're coming to some interesting conclusions.

For example, by studying paralyzed women who can still experience orgasm, they discovered that for women, the vagus nerve appears to be quite important, and therefore may be a promising target for drugs. This nerve — which is outside the spinal cord — carries information to areas of the brain that control mood.

"We basically found the areas of the brains that are activated in orgasm in women," said Barry Komisaruk, who worked with Whipple on this research, which is being funded by the federal government and the Christopher Reeve Paralysis Foundation.

Brain scans measure the blood flow of research volunteers, whose heads are strapped tightly down inside the noisy machines. When brain cells start firing in a part of the brain that governs a particular emotion or activity, they need more oxygen, which is carried by the blood. During a brain scan, active regions of the brain can be seen lighting up on a computer monitor.

The scans reveal something else about women — during orgasms, the pain centers in their brains shut down, and pleasure centers — the same ones that become active when people ingest cocaine — light up.

But a big problem with these scans — done through magnetic resonance imaging — is that no machine yet built is designed to simultaneously monitor both the brain and the body. And even if they could, the images' clarity would be muddied by "background noise" such as hand movements.

That's why Komisaruk is currently studying the brains of women who can self-stimulate purely through thought — an apparently rare attribute that eliminates the noise — as he seeks to find out exactly what makes women tick during sex.

"The strange thing is that everyone knows that it all happens between the ears and not between the legs," said Gert Holstege, a leading sexual researcher at Groningen University in The Netherlands.

In June, Holstege published one of the first studies that mapped brain activity during orgasm for men and women, who were stimulated by their partners.

Among other results, Holstege found that the part of the brain thought to control fear and anxiety — the amygdala — deactivated during orgasm for both women and men.

He acknowledged that his data for men is a little suspect — however — because they don't orgasm long enough to take a proper brain scan.

Why hasn't this research been done before?

Brain scanning technology has been available for close to 20 years, but is only now being used to study sex. Researchers attribute the delay to several factors, including managerial skepticism and government reluctance to fund much of the work.

"In the United States people are little more reserved when it comes to sex than in the Netherlands," said Holstege. He said that his U.S. colleagues told him they'd be afraid to propose such a project to their own bosses.

via the Well-Timed Period.

Grand Rounds #51

At Sneezing Po, pre-med student Violetta Priestley has an excellent sampling of medblog posts this week. Be sure to check it out!

How does internship change us?

Izzy shares his list:

1. I walk three times faster.
2. I eat all of my meals in around 3-5 minutes...even when I'm at home.
3. I feel like my leg is constantly vibrating.
4. My handwriting is getting sloppy.
5. I believe weekends to be nothing more than a myth.
6. I look forward to sleeping more than I do eating.
7. I get confused and/or feel incompetent at least once a day.
8. I speak in abbreviations.
9. I covet nice pens.
10. I consider waking up at 5:20 in the morning to be "sleeping in."

I'm amazed that he has time to blog this. I don't recall any spare minutes during my internship.

How did internship change me? I don't entirely trust my memories of that year. The whole experience is a blur to me now.

I think internship forced me to be more focussed, responsible, and organized than I had ever been in my life. I learned the difference between watching crises from the sidelines and facing them head-on.

How should internship change us? How did it change you?

How will we remember 9/11?

The green flyer was stuffed in our mailbox three weeks ago. "Block Party, September 11, 11 AM. Bring your own lunch, bring your own chairs, bring something to share."

It's quite cheerful. There's no American flag, no mention of losses or history. I'm all for sharing and community, but...a picnic? On 9/11?

Perhaps I shouldn't be surprised. Here's WAPO this morning:
Historians Fear Attack Date's Significance Could Fade.

"For a date so freighted with emotion, images and pain, the diluting of the 9/11 anniversary seems impossible to fathom, especially in such places as Washington and New York. But historians said that decades from now, Sept. 11 might take on a different dimension. In other words, Sept. 11 eventually might become another holiday on which many Americans grill hot dogs, go to sales or spend a long weekend at a quaint bed-and-breakfast.

Throughout the generations, what were powerful and vital holidays take on a less powerful, more consumer-oriented flavor and become something like a picnic day,' said Gary M. Laderman, associate professor of religion at Emory University."

I've posted my experiences of that day here. I had planned to spend some time browsing here or here, and listening to this.

Should I go to the Block Party? I'm new to the neighborhood. I don't know what this affair will be like. And, of course, sharing and community are good, perhaps especially on 9/11 anniversaries.

But I don't think I can party, or bring myself to a picnic. Not today. My memories are too fresh.

Health risks for bloggers: carpal tunnel syndrome

For several weeks, I've been recovering from carpal tunnel syndrome. I should have seen it coming! At the office, I'm on the computer constantly. Each patient visit now requires clicking and typing to access progress notes, med lists, and labs. Each phone message is conveyed by e-mail. All prescriptions are done online now, and that's even more typing and clicking. I'm also writing notes as my patients are speaking. After a full day of this, I would go home and blog. And blog... (Only a fraction of my wrists' work escapes my editorial hatchet.)

But it wasn't just intensive mouse use that knocked me out of the game. It was incorrect mouse use. My set-up was all wrong. My keyboard was too high. My wrist was bent. And as for rest periods...er, what rest periods?

Still, I didn't notice symptoms until I hosted Grand Rounds in July. (That's a lot of linking!)

What does CTS feel like? Here's MayoClinic.com:

Carpal tunnel syndrome typically starts gradually, with a vague aching in your wrist that can extend to your hand or forearm. Other common signs and symptoms include:

* Tingling or numbness in your fingers or hand, especially your thumb, index, middle or ring fingers, but not your little finger. This sensation often occurs while driving a vehicle or holding a phone or a newspaper, or upon awakening. Many people "shake out" their hands to relieve their symptoms.
* Pain radiating or extending from your wrist up your arm to your shoulder or down into your palm or fingers, especially after forceful or repetitive use. This usually occurs on the front (palm) side of your forearm.
* A sense of weakness in your hands, and a tendency to drop objects.
* A constant loss of feeling in some fingers. This can occur if the condition is advanced.

More here, here, and here. Here are some prevention tips. (And here's something that will make it worse. If you've ever hosted a carnival, you might feel some deja-vu here.) Many other activities can cause symptoms.

Thanks to all for the kind get-well wishes! My wrist is feeling much better now, and I think I can blog.

But I've had to change a few things. I'm dictating more at work. I've had an ergonomic evaluation of my office. My computer and keyboard have been repositioned, and I'm using a trackball mouse. I switch hands frequently when clicking. I try not to type for extended periods. And on the home front, I've declared a moratorium on knitting mittens, sketching faces from the pages of the New York Times, and painting portraits of my garden.

Is podcasting in my future? Hmmm...