Friday, March 5, 2010

The Voices of Fibromyalgia - Well Blog -

People who suffer from fibromyalgia experience problems beyond the pain caused by their illness. Their condition is little understood and hard to explain, and often they are disbelieved by doctors. Even friends and loved ones may express skepticism toward the fibromyalgia sufferer, who, burdened with inexplicable pain, may cancel social plans, miss work and recoil from physical affection because it hurts too much.

For a glimpse into the frustrating world of fibromalgia sufferers, listen to the latest installment in the Patient Voices series by producer Karen Barrow in which six men and women speak about living with the condition.

You'll meet Christine Wysocki, 33, of St. Augustine, Fla. who waited three years before a close friend and co-worker believed she had a health problem.

"Frankly I still don't know if I understand exactly what it is," says Ms. Wysocki. "Everything seems so vague about what fibromyalgia is, and it feels like no one wants to commit to what an actual answer is."

And there's Leon Collins, 59, of Clayton, N.J., who was relieved when he heard he had fibromyalgia because he at least had a diagnosis after many other doctors had dismissed his symptoms.

"We even experienced one doctor who wanted to send me to a psychiatrist because he felt my pain was imagined," he said.

To hear all the voices of fibromyalgia and see the accompanying slideshow, click on this Patient Voices link. And be sure to check out the Times Topics page on fibromyalgia to read "The Long Search for Fibromyalgia Support", an expert Q&A with a rheumatologist and five things you need to know about the condition.

Concerns Over ‘Metal on Metal’ Hip Implants -

Some of the nation's leading orthopedic surgeons have reduced or stopped use of a popular category of artificial hips amid concerns that the devices are causing severe tissue and bone damage in some patients, often requiring replacement surgery within a year or two.

In recent years, such devices, known as "metal on metal" implants, have been used in about one-third of the approximately 250,000 hip replacements performed annually in this country. They are used in conventional hip replacements and in a popular alternative procedure known as resurfacing.

The devices, whose ball-and-socket joints are made from metals like cobalt and chromium, became widely used in the belief that they would be more durable than previous types of implants.

The cause and the scope of the problem are not clear. But studies in recent years indicate that in some cases the devices can quickly begin to wear, generating high volumes of metallic debris that is absorbed into a patient's body. That situation can touch off inflammatory reactions that cause pain in the groin, death of tissue in the hip joint and loss of surrounding bone.

Doctors at leading orthopedic centers like Rush University Medical Center in Chicago and the Mayo Clinic in Rochester, Minn., say they have treated a number of patients over the last year with problems related to the metal debris.

Artificial hips, intended to last 15 years or more, need early replacement far more frequently for reasons like dislocation than because of problems caused by metallic debris. But surgeons say that when metal particles are the culprit, the procedures to replace the devices can be far more complex and can leave some patients with lasting complications.

"What we see is soft-tissue destruction and destruction of bone," said Dr. Young-Min Kwon, an orthopedic surgeon at Massachusetts General Hospital in Boston.

A recent editorial in a medical journal for orthopedic surgeons, The Journal of Arthroplasty, urged doctors to use the metal-on-metal devices only with "great caution, if at all."

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NEJM -- Medicine's Ethical Responsibility for Health Care Reform -- The Top Five List - Howard Brody, M.D., Ph.D.

Early in 2009, members of major health care–related industries such as insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration's health care reform efforts. Skeptics have questioned the value of these promises, regarding at least some of them as more cosmetic than substantive. Nonetheless, these industries made a gesture and scored some public-relations points.

The medical profession's reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians' income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Physicians might insist that they should be immune from income loss if the causes of excessive health care costs are beyond their control. The American Medical Association (AMA), for example, addresses cost containment almost solely by calling for malpractice reform, suggesting that high costs are the fault of the legal and not the medical system.1

Unfortunately, the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained. What we now know about regional variation in costs within the United States suggests that nearly one third of health care costs could be saved without depriving any patient of beneficial care, if physicians in higher-cost regions ordered tests and treatments in a pattern similar to that followed by physicians in lower-cost regions.2 We also have good reason to believe that physicians in lower-cost regions order and provide evidence-based tests and treatments just as often as their higher-cost colleagues do, but they tend to avoid providing care whose usefulness is not well supported by existing evidence.3 In short, U.S. physicians could do a great deal to control costs if they were willing to practice more in accordance with evidence-based guidelines and to study more seriously the data on regional practice variations.

Physicians should recognize that the high cost of future medical care is one of the main stumbling blocks to the passage of health care reform legislation that would extend insurance coverage to most Americans who now lack it. Physicians know from experience how people's health is placed at risk when they lack insurance and access to basic, timely care. A profession that has sworn to put the patient's interest first — to conduct itself as a profession and not merely as a business — cannot justifiably stand idly by and allow legislation that would extend basic access to care to go down to defeat while refusing to contemplate any meaningful measures it might take to reduce health care costs.

In my view, organized medicine must reverse its current approach to the political negotiations over health care reform. I would propose that each specialty society commit itself immediately to appointing a blue-ribbon study panel to report, as soon as possible, that specialty's "Top Five" list. The panels should include members with special expertise in clinical epidemiology, biostatistics, health policy, and evidence-based appraisal. The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit. Examples of items that could easily end up on such lists include arthroscopic surgery for knee osteoarthritis and many common uses of computed tomographic scans, which not only add to costs but also expose patients to the risks of radiation.4,5

Having once agreed on the Top Five list, each specialty society should come up with an implementation plan for educating its members as quickly as possible to discourage the use of the listed tests or treatments for specified categories of patients. Umbrella organizations such as the AMA might push hard on specialty societies and pressure the laggards to step up.

Some societies will be tempted to bluff their way through the Top Five exercise, deliberately omitting cost-cutting measures that would particularly affect members' revenue streams. Societies could display their professional seriousness by submitting their lists for review and comment to several societies in other specialties.

Some would object that considerably more comparative-effectiveness research is needed before such lists can be compiled and implementation strategies developed. And indeed, today we have no idea how to implement a practical plan that would recapture the roughly 30% of health care expenditures estimated to be wasted on nonbeneficial measures.2 I would guess, however, that if we were trying to save that entire sum of money, we would be proposing "Top Twenty" or "Top Fifty" lists for many specialties, not just the Top Five. I suggest that no matter how desirable more research is, we know enough today to make at least a down payment on medicine's cost-cutting effort. As good citizens and patients' advocates, we should begin where we can.

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Thursday, March 4, 2010

All-Nighters - Opinionator Blog -

What do you do when the world's asleep and you're awake? All-Nighters is an exploration of an ancient malady and modern fixation — insomnia. With contributions from writers, scientists, artists and others, it will document the many ways we approach sleeplessness — as a nuisance, a disease, a curse, an opportunity or even a gift.

Wednesday, March 3, 2010

New biomedical search engine – Novoseek

What is novoseek

Search engine for biomedical literaturein MedlineFull Text publications and US Grants that will help you to:

  • Retrieve meaningful documents related to your search.
  • Narrow your search to find results in the relevant scientific journals.
  • Identify the most relevant biomedical concepts to your query.

Tuesday, March 2, 2010

Health Crises Loom in Lionel Shriver’s ‘So Much for That’ - Review -

A novel about the health care crisis in America? Well, Lionel Shriver's new book, "So Much for That," doesn't tackle health care head-on, but in recounting the intertwined stories of several characters suffering from medical conditions — ranging from the most grievous and deadly to the more cosmetic and absurd — it creates a harrowing picture of the fallout that the current health care and insurance system can have upon regular, middle-class families struggling to care for their loved ones.

This description might suggest that Ms. Shriver has constructed a didactic or lugubrious novel, willfully topical and laboriously relevant. She hasn't. In fact, she's managed to take an idea for a kind of thesis novel and instead create a deeply affecting portrait of two marriages, two families, as cancer in one case and a rare, debilitating childhood condition in the other threaten to push their daily lives past their tipping points.

Though there is one farcical plot development that is poorly woven into the emotional fabric of the story, and though some of the asides about health care feel shoehorned into the narrative, the author's understanding of her people is so intimate, so unsentimental that it lofts the novel over such bumpy passages, insinuating these characters permanently into the reader's imagination.

When we first meet him, Shep Knacker is contemplating the Big Escape. For years, he's fantasized about what he calls "The Afterlife," about using the money he made selling his handyman-home repair business — some $700,000 — and taking his family off to a faraway, third world country, where his savings will last them forever, and they can lead the good life.

His wife, Glynis, has made him postpone these plans for years, and now he's decided that if she tries to delay their departure again, he will proceed without her. He hates working for the man he sold his business to; he hates the daily commute from the suburbs; and he likes the image of himself as a guy willing to press the Eject button — someone with the guts to get off the New York City treadmill and chase after his long-held dream.

Shep's pipe dream is blown to smithereens when it turns out that Glynis has an announcement of her own: she's been diagnosed with mesothelioma, a type of cancer associated with exposure to asbestos, and in her case, a deadly form with terrible survival odds. Glynis's cancer turns everything in their life into a Before and After, and it indelibly alters their relationship.

More ...

Sunday, February 28, 2010

Why Psychiatry Needs Therapy -

To flip through the latest draft of the American Psychiatric Association's Diagnostic and Statistical Manual, in the works for seven years now, is to see the discipline's floundering writ large. Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

Psychopharmacology, or the treatment of the mind and brain with drugs, has come to dominate the field. The positive side is that many illnesses respond readily to medication. The negative side is that the pharmaceutical industry seeks the largest possible market for a given drug, and advertises huge diseases, such as major depression and schizophrenia, the scientific status of which makes insiders uneasy.

In the 1950s and '60s, when psychiatry was still under the influence of the European scientific tradition, reasonably accurate diagnoses still sat at center stage. If you felt blue, uneasy and generally jumpy, "nerves" was a common diagnosis. For the psychotherapeutically oriented psychiatrists of the day, "psychoneurosis" was the equivalent of nerves. There was no point in breaking these terms down: clinicians and patients alike understood "a case of nerves," or a "nervous breakdown."

Our psychopathological lingo today offers little improvement on these sturdy terms. A patient with the same symptoms today might be told he has "social anxiety disorder" or "seasonal affective disorder." The increased specificity is spurious. There is little risk of misdiagnosis, because the new disorders all respond to the same drugs, so in terms of treatment, the differentiation is meaningless and of benefit mainly to pharmaceutical companies that market drugs for these niches.

For those more seriously ill, contemplating suicide or pacing restlessly and saying "It's all my fault," melancholia was the diagnosis of choice. The term has been around for donkey's years.

All the serious disorders of mood were once lumped together technically as "manic-depressive illness"—and again, there was little point in differentiating, because medications such as lithium that worked for mania were also sometimes effective in forestalling renewed episodes of serious depression.

Psychopharmacology—the treatment of disorders of the mind and brain with drugs—was experiencing its first big push, and a host of effective new agents was marketed. The first blockbuster drug in psychiatry appeared in 1955 as Wallace Lab's Miltown, a "tranquilizer" of the dicarbamate class. The first of the "tricyclic antidepressants" (because of their chemical structure) was launched in the U.S. in 1959, called imipramine generically and Tofranil by brand name. It remains today the single most effective antidepressant on the market for the immediate treatment of serious depression.

In the 1960s an entirely different class of drugs appeared, the benzodiazepines, indicated for anxiety rather than depression. (But one keeps in mind that these indications are more marketing devices than scientific categories, because most depression entails anxiety and vice versa.) In the benzodiazepine class, Librium was launched for anxiety in 1960, Valium in 1963. Despite an undeserved reputation for addictiveness, the benzos remain today one of the most useful drug classes in the history of psychiatry. They are effective across the entire range of nervous illnesses. In one World Health Organization study in the early 1990s, a sample of family physicians world-wide prescribed benzos for 28% of their depressed patients, 31% of their anxious patients; the figures are virtually identical. In the 1950s and '60s physicians had available drugs that truly worked for diseases that actually existed.

And then the golden era came to an end. The 1978 article of British psychiatrist Malcolm Lader on the benzos as "the opium of the masses" would be a good landmark. The patents expired for the drugs of the 1950s and '60s, and the solid diagnoses were all erased from the classification in 1980 with the appearance of the third edition of the DSM series, called "DSM-III." It was largely the brainchild of Columbia University psychiatrist Robert Spitzer, an energetic and charismatic individual who had been schooled in psychometrics. But his energy and charisma nearly led psychiatry off a cliff.

Mr. Spitzer was discouraged with psychoanalysis, and wanted to come up with a new illness classification that would ditch all the old Freudian concepts such as "depressive neurosis" with their implication of "unconscious psychic conflicts." Mr. Spitzer and company wanted diagnoses based on observable symptoms rather than on speculation about the unconscious mind. So he, and members of the Task Force that the American Psychiatric Association designated, set out to devise a new list of diagnoses that correspond to natural disease entities.

Yet Mr. Spitzer ran smack against the politics of the American Psychiatric Association, still heavily influenced by the psychoanalysts. Mr. Spitzer proposed such diagnoses as "major depression" and "dysthymia," diagnoses that were themselves highly heterogeneous, lumping together a number of different kinds of depression. But the terms turned out to be politically acceptable.

So in DSM-III there was a lot of horse-trading. The biologically oriented young Turks got a depression diagnosis—major depression—that was divorced from what they considered the psychoanalytic mumbo-jumbo. And the waning but still substantial number of analysts got a diagnosis—dysthymia—that sounded like their beloved "neurotic depression," that had been the mainstay of psychoanalytic practice. Psychiatry ended up with two brand-new depression diagnoses with criteria so broad that huge numbers of people could qualify for them.

There was one more bow to psychoanalysis: DSM-III continued to make depression separate from anxiety (because the analysts thought anxiety the motor that drove everything). And in homage to several influential figures in European psychiatry, DSM-III brought in "bipolar disorder," a condition alternating between depression and mania thought separate from "major depression."

A word of explanation: The evidence is very strong that the depression of "major depression" and the depression of "bipolar disorder" are the same disease. Experienced clinicians know that in chronic depressive illness many patients will have an episode of mania or hypomania; it is implausible that such an event would change the patient's diagnosis completely from "major depression" to "bipolar disorder," given that they are classified as quite different illnesses.

These rather technical issues in the classification of disease had enormous ramifications in the real world. Bipolar disorder became divorced from unipolar disorder. And anxiety—the original indication for the benzos—became soft-pedaled because the benzos were thought, incorrectly, to be highly addictive, and anxiety became associated with addiction.

Major depression became the big new diagnosis in the 1980s and after, replacing "neurotic depression" and "melancholia," even though it combined melancholic illness and non-melancholic illness. This would be like incorporating tuberculosis and mumps into the same diagnosis, simply because they are both infectious diseases. As well, "bipolar disorder" began its relentless on-march, supposedly separate from plain old depression.

New drugs appeared to match the new diseases. In the late 1980s, the Prozac-type agents began to hit the market, the "SSRIs," or selective serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa and Lexapro. They were supposedly effective by increasing the amount of serotonin available to the brain.

The SSRIs are effective for certain indications, such as obsessive-compulsive disorder and for some patients with anxiety. But many people believe they're not often effective for serious depression, even though they fit wonderfully with the heterogeneous concept of "major depression." So, hand in hand, these antidepressants and major depression marched off together into the sunset. These were drugs that don't work for diseases that don't exist, as it were.

The latest draft of the DSM fixes none of the problems with the previous DSM series, and even creates some new ones.

A new problem is the extension of "schizophrenia" to a larger population, with "psychosis risk syndrome." Even if you aren't floridly psychotic with hallucinations and delusions, eccentric behavior can nonetheless awaken the suspicion that you might someday become psychotic. Let's say you have "disorganized speech." This would apply to about half of my students. Pour on the Seroquel for "psychosis risk syndrome"!

DSM-V accelerates the trend of making variants on the spectrum of everyday behavior into diseases: turning grief into depression, apprehension into anxiety, and boyishness into hyperactivity.

If there were specific treatments for these various niches, you could argue this is good diagnostics. But, as with other forms of anxiety-depression, the SSRIs are thought good for everything. Yet to market a given indication, such as social-anxiety disorder, it's necessary to spend hundreds of millions of dollars on registration trials to convince the FDA that your agent works for this disease that previously nobody had ever heard of.

DSM-V is not all bad news. It turns the jumble of developmental syndromes for children into a single group of "autism spectrum disorders," which makes sense because previously, with Asperger's as a separate disease, it was like trying to draw lines in a bucket of water. But the basic problems of the previous DSM series are left untouched.

Where is psychiatry headed? What the discipline badly needs is close attention to patients and their individual symptoms, in order to carve out the real diseases from the vast pool of symptoms that DSM keeps reshuffling into different "disorders." This kind of careful attention to what patients actually have is called "psychopathology," and its absence distinguishes American psychiatry from the European tradition. With DSM-V, American psychiatry is headed in exactly the opposite direction: defining ever-widening circles of the population as mentally ill with vague and undifferentiated diagnoses and treating them with powerful drugs.

—Edward Shorter is professor of the history of medicine and psychiatry in the Faculty of Medicine of the University of Toronto. His latest book, written with Max Fink, "Endocrine Psychiatry: Solving the Riddle of Melancholia," is forthcoming from Oxford University Press.