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Thursday, July 17, 2008

The Last Post

The Last Post at least on Blogger. Dr Shock is now writing on his own domain name. So please update your bookmarks, RSS Feeds and e-mail subscriptions on or for Dutch readers easier to remember:

Hope you enjoy the new lay-out and blog, thanks Dr Shock

Wednesday, July 16, 2008

The Brain in Love

Why do we crave love so much, even to the point that we would die for it? To learn more about our very real, very physical need for romantic love, Helen Fisher and her research team took MRIs of people in love -- and people who had just been dumped.

This talk starts slow but soon the information becomes very interesting. More about the Science of Love on the BBC, thanks Dr Confabula
Key Points from the science of love:

  • There are three phases to falling in love and different hormones are involved at each stage

  • Events occurring in the brain when we are in love have similarities with mental illness

  • When we are attracted to somebody, it could be because subconsciously we like their genes

  • Smell could be as important as looks when it comes to the fanciability factor. We like the look and smell of people who are most like our parents

  • Science can help determine whether a relationship will last

The last key point I am not so sure!

Grand Rounds The Tabloid Edition is Up

EXTRA, EXTRA, READ ALL ABOUT IT! That’s right folks, this week I shall be dishing as much dirt on the latest rumours, gossip and scandal that the blogosphere can handle, and all from a rather slanderous angle!

A promising introduction for this weeks Grand Round on Unprotected Text

Tuesday, July 15, 2008

4 Liters of Cola is not Healthy

Coca Cola
Chronic hypokalemia due to excessive cola consumption, a case report in Cases Journal

A 52-year-old man was noted to have severe chronic hypokalemia despite discontinuation of diuretic treatment for hypertension and aggressive oral potassium supplementation. His serum potassium normalized temporarily when he was hospitalized, but hypokalemia recurred after discharge. He complained of generalized weakness and fatigue, and occasional loose stools. Physical examination showed mild generalized muscle weakness. Laboratory testing ruled out renal potassium wasting. A dietary history revealed that he was consuming 4 liters of cola per day, with a calculated fructose load of 396 grams per day. Since fructose absorption in the small bowel is relatively inefficient, this probably led to an osmotic diarrhea and GI potassium wasting. Physicians should ask their patients about soft drink consumption when they encounter unexplained hypokalemia.

Antidepressants have Limited Efficacy in Juvenile Depression

Forest plot of rate ratios (RR, with 95% CI) of responses to drug or placebo in 30 randomised double-blind placebo-controlled comparisons of rates of ‘response’ to antidepressants v. placebo, with overall pooled RR (1.22; 95% CI 1.15–1.31; blue diamond)
A recent systematic review and meta-analysis shows that at worse antidepressants are not effective for juvenile depression and at best better research might proof this conclusion wrong.
Juvenile meaning depression among children and adolescents.

The figure above is the forest plot of this systematic review:Forest plot of rate ratios (RR, with 95% CI) of responses to drug or placebo in 30 randomised double-blind placebo-controlled comparisons of rates of ‘response’ to antidepressants v. placebo, with overall pooled RR (1.22; 95% CI 1.15–1.31; blue diamond).

Antidepressants of all types showed limited efficacy in juvenile depression, but fluoxetine might be more effective, especially in adolescents. Studies in children and in severely depressed, hospitalised or suicidal juvenile patients are needed, and effective, safe and readily accessible treatments for juvenile depression are urgently required.

  • there were 30 contrasts arising from 29 randomised controlled trials for meta-analysis

  • All studies included provided drug doses consistent with contemporary paediatric practice, based on body-weight-adjusted daily dosing (mg/kg) considered standard for treating adult major depressive disorder

  • average exposure time of 8.7 weeks (median=8, range 1–12)

  • primary outcomes for meta-analysis a priori as responder status, based on changes in clinical ratings from intake to last observation point (as defined in each trial) involving substantial improvement, typically a 50% or greater reduction in symptomatic ratings of depression on standardised scales. This is a weak outcome measure, remission should be the aim of treatment mostly defined as a score of 7 or lower on the Hamilton Depression Rating Scale

  • pooled overall effect size, based on meta-analysis to determine a pooled rate ratio and its confidence interval for all 30 trials, yielded a value of 1.22 (95% CI 1.15–1.31)

  • There was no difference in efficacy between different antidepressant classes such as SSRI's or TCAs. Moreover analysis fail to support the possibility that SRIs may be superior in efficacy to tricyclic antidepressants

  • The three age groups yielded an interesting progression in rate differences and corresponding decreases of NNT by age (about 21 for children, 10 juveniles of mixed ages and 8 for adolescents)

Explanations for the disappointing results:

  • Relatively high rates of response to placebo or other non-specific interventions

  • Age-inappropriate or insufficiently sensitive outcome measures

  • Inadequately powered trials

  • Adverse case selection (e.g. minimally ill, uncertain or heterogeneous diagnoses, previous treatment failures, poorly cooperative participants)

  • Incomplete control of substance misuse

  • Inadequate dosing or duration of treatment

  • Simple lack of efficacy in juvenile v. adult mood disorders

My opinion is that selection of juveniles with relatively heterogeneous illnesses can explain the lack of efficacy. Maybe only juveniles with melancholic or psychotic depression respond to antidepressants. This is comparable to depression in adults.
sampling of young patients with depression may include a high proportion of relatively mildly ill patients, who have most probably never received in-patient treatment, and who are more likely to improve spontaneously with or without additional effects of placebo treatment

Moreover, it remains to be seen whether the brain of juveniles is as susceptible to antidepressants as with adults. Depression in a developing brain may be different from depression in an adult brain and the influence of antidepressants on a developing brain might be lacking. This is supported by the finding in this meta-analysis that older juveniles respond better than younger ones. Here is a video about teens and their developing brain, thanks PsychCentral

Importantly, prepubertal children with depression may differ biologically from adolescents or adults, and it remains unclear whether depression in prepubertal children is a substantially different disorder from that found in adolescents or adults, perhaps including developmental differences in either the pharmacodynamics of antidepressants or in their clinical effects.

Related posts on this blog:
Adolescents Brain and Depression
Finally some good news about antidepressants and adolescents
7 Posts about Adolescents and Depression
FDA Warning doesn't put Youth at Increased Risk
Tsapakis*, E.M., Soldani*, F., Tondo, L., Baldessarini, R.J. (2008). Efficacy of antidepressants in juvenile depression: meta-analysis. The British Journal of Psychiatry, 193(1), 10-17. DOI: 10.1192/bjp.bp.106.031088

Wine is Healthy

red wine

Digestion breaks down lipids into hydroperoxides. (Cooked meats are worse.) The stomach acts as a "bioreactor"-- the longer time the food/fat spends there, the greater the lipid peroxidation. An experiment with rats found that eating a meal soaked in red wine completely blocked the the generation of malondialdehyde, a common lipid peroxidation cytotoxin.Humans who ate the meal and drank a 200ml (1/4 bottle) of wine had a 75% reduction in MDA as compared to no wine.

From The Last Psychiatrist

He also explains why wine is not healthy due to it's antioxydants, but luckily he found another "healthy" mechanism of action.

So Dr Shock not only has to eat chocolate after dinner but also drink more red wine, or is Port even better? I wonder.......

Monday, July 14, 2008

Visible Magnetic Fields

rTMS is using electromagnetic fields to influence the brain,on this video you can see magnetic fields although not related to rTMS. The comment is very technical but the video is amazing, even scary.
From: Environmental graffiti

Combining their scientific experience with artistic instinct in sound, animation and programming they have created a ‘magnetic magnum opus’ - a ‘tour de force’ of immense invisible force brought down to human scale. And it is precisely the meeting of scale that makes the work so fascinating - to think that these tiny pulsating currents surround our planet on a scale inconceivable to man is not only a humbling thought, but an uplifting one. The inherent beauty of nature is again, in Wordswoth’s words, too much with us.

Sunday, July 13, 2008

22 iPhone Apps for (Med) Nerds

iphone 2.0
The two most important med apps for the new iphone are:

  • Netter's Anatomy Flash Cards: Need some help with your anatomy and physiology class? Check out this slick native app that lets you test yourself on how the knee bone connects to the thigh bone. There's a neuroscience version, too. (iPhone 2.0, $39.99)

  • ePocrates: This app for drug dosing, interaction and pricing is a boon for doctors. (iPhone 2.0, Free)

iPhone is everywhere on the net and blogosphere,couldn't resist posting about the new iphone. Yes, Dr Shock has one, already for 6 months although the iphone came available only 2 days ago in The Netherlands. Where is The Netherlands anyway, who cares.

More apps on Wired Science (thanks)

If you know of any apps for the iphone 2.0 for med nerds please let me know.

Identify brain structures with BrainInfo

brain info

BrainInfo is designed to help you identify structures in the brain. If you provide the name of a structure, BrainInfo will show it and tell you about it. If you don't know the name but can locate the structure in the Template Atlas of the Primate Brain, BrainInfo will tell you its name and other facts about it.

This is what BrainInfo can do for you:
If you type in the name of a brainstructure you can see were it is, you can read recent literature about the structure on PubMed, which species have it and of course you can see it in anatomical pictures. From some structures you can learn about the internal structures, the cells it contains, which genes are expressed there, or the connectivity to other structures.

Thanks Dr Confabula

Saturday, July 12, 2008

Friday, July 11, 2008

Medical Animation by Hybrid

Hybrid's illustrations and animations extend beyond the boundary of highly informative graphics: they enter the realm of high art, achieving a combination of Truth and Beauty.
If you're looking for people who will go the extra yard, deliver on time and make you look good, Hybrid Medical Animation is your first stop

These picture are stills from the demo made by Hybrid Medical Animation. It is beautiful. It takes some time to load the site but it is worth your time.

Idiomorf Infographics a Dutch illustration company
Idiomorf is a Graphic Design Company that specializes in designing graphic diagrams, detailed charts, tables, maps and technical illustrations, which are used to illustrate an idea. These illustrations and animations are used to relay information quickly and without words, minimizing the need for costly writing and translation.

Thursday, July 10, 2008

Cocoa Beneficial for Medicated Diabetic Patients

Chocolate rich in flavanols reverses vascular dysfunction in diabetes type 2 diabetic patients between ages 50 and 80 years, highlighting therapeutic potentials in cardiovascular disease. Moreover, flavanol-containing chocolate was well tolerated.

The chocolate condition was a cocoa drink with 321 mg of flavanols thrice daily for 30 days, not your average candy bar. The control condition only contained 25 mg flavanols. In this research CocoaPro cocoa powder made by Mars was used.

How does it work?

We observed the absorption of flavanols in diabetic patients, accompanied by increases in plasma flavanol metabolites, leading to a dose-dependent improvement of endothelial function, corroborating our findings from previous studies in nondiabetic populations

Impaired endothelial function is a key factor for the development of atherosclerosis and its complications in diabetic patients. That's why this is important.

This could be an alternative approach to the prevention of atherosclerosis in this population which is highly needed.

This was a study well done. First the researchers conducted a feasibility study on 10 patients to determine the appropriate dosing, assess safety and tolerability, and measure the effect size of the intervention in order to calculate the appropriate sample size of the subsequent efficacy study.

The efficacy study was undertaken using a randomized, doublemasked, parallel-group design and included 44 patients randomly
allocated to a treatment group (321 mg of flavanols per dose; 3 doses per day) or a control group (25 mg of flavanols per dose; 3 doses per day). Each group ingested a single dose of either treatment or control 3 times a day over a period of 30 days. The authors assessed the acute effects, 2 h after ingestion of the control or the cocoa drink, and the long-term effects, on days 8 and 30.

The accompanying editorial concludes:
These findings expand previous observations to patients with type 2 diabetes and represent a further step in our understanding of the vascular effects of flavanol-rich cocoa.
However, although endothelial function has been shown to predict future cardiovascular events (20), randomized, large scale clinical trials assessing relevant clinical outcomes are necessary before any recommendations are made regarding dietary supplementation with flavanol-rich cocoa.

Related post on this blog: Chocolate and Diabetes, new research
BALZER, J., RASSAF, T., HEISS, C., KLEINBONGARD, P., LAUER, T., MERX, M., HEUSSEN, N., GROSS, H., KEEN, C., SCHROETER, H. (2008). Sustained Benefits in Vascular Function Through Flavanol-Containing Cocoa in Medicated Diabetic PatientsA Double-Masked, Randomized, Controlled Trial. Journal of the American College of Cardiology, 51(22), 2141-2149. DOI: 10.1016/j.jacc.2008.01.059

CAMPIA, U., PANZA, J. (2008). Flavanol-Rich CocoaA Promising New Dietary Intervention to Reduce Cardiovascular Risk in Type 2 Diabetes?⁎. Journal of the American College of Cardiology, 51(22), 2150-2152. DOI: 10.1016/j.jacc.2008.02.058

Wednesday, July 9, 2008

Grand Round on The Blog that Ate Manhattan

grand round medblog

Most things in life can be related, one way or another, to an episode of Seinfeld.

It's true. That TV show which claimed to be "about nothing" pretty much said everything that needed to be said about, well, everything.

Take this week's Grand Rounds, the best of the Medical Blogosphere. It's totally Seinfeld. Every post. Why I can hear Jerry, even now...

This weeks grand round is related to episodes of Seinfeld, never heard about this sitcom but the connection to the posts is well done. Love the video's related to the posts, great job, go and read at The Blog that Ate Manhattan

Carefull with the combination SSRIs and NSAIDs


When both SSRIs and NSAIDs are concomitantly used, it would be sufficient to treat 250 patients per year for 1 case of upper gastrointestinal (GI) tract bleeding to be attributed to such combination, and 500 patients per year if SRIs are concomitantly used with antiplatelet drugs.

SRIs: SSRIs, including sertraline hydrochloride, fluoxetine hydrochloride, fluvoxamine maleate, paroxetine hydrochloride, citalopram hydrobromide, and escitalopram oxalate; selective serotonin and norepinephrine reuptake inhibitors (SNRIs), including venlafaxine and duloxetine hydrochloride.

NSAIDs: ibuprofen, and naproxen.

The authors of this study were the first to point out the dangers of combining SSRIs with NSAIDs in 1999.

In the present study they found an increased risk although smaller than in their previous publication. Increasing use of acid-suppressing medication and declining cohort prevalence of Helicobacter pylori infection and its widespread treatment might account for this smaller risk. They used the same method with another United-Kingdom based general practitioner database in a more recent study period.

Dosage and duration of using these medications was not associated with GI tract bleeding

Use of acid-suppressing agents limits such increased risk.

With SRIs alone it would be necessary to treat approximately 2000 patients per year with SRIs for 1 case of upper GI tract bleeding to be attributed to them, which indicates that the risk is rather low in the general population.

But when they are combined with NSAIDs or antiplatelet drugs, the number of patients needed to be treated per year for 1 case of upper GI tract bleeding decreases remarkably. These data indicate that in such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.

So when you have to use both drugs be careful out there. This is not about the occasional NSAID for a headache while taking antidepressants but using both medications at least for weeks could have these side-effects. Even than some people will not get these kind of complications while others will get them after 2 weeks of medication use. Vulnerability is the explaining factor in these matters.

Vulnerability to gastrointestinal side-effects is that recognizable to some of you? Please let me know in the comments.
de Abajo, F.J. (2008). Risk of Upper Gastrointestinal Tract Bleeding Associated With Selective Serotonin Reuptake
Inhibitors and Venlafaxine Therapy.
Archives of General Psychiatry, 65(7), 795-803.

Tuesday, July 8, 2008

Neurostimulation update

On Medpage today a summary of a variety of alternative approaches that apply electrical currents to the brain are in the research pipeline, and one is FDA approved. A summary of VNS, rTMS, magnetic seizure therapy, deep brain stimulation , TDCS and Implantable cortical stimulation. Never heard of that last one, a new form of neurostimulation?

Implantable cortical stimulation

Another early-stage investigational technology takes vagus nerve stimulation a step farther. Instead of delivering electrical pulses to a nerve, it sends them to the surface of the brain. Seattle-based Northstar Neurosciences is testing a system that, like vagus nerve stimulation, inserts a pulse generator in the patient's chest. An electrical lead is passed into the skull through a surgically drilled hole, terminating on the dural membrane over the cortex.

A nice overview.

On Psych Central: Brain Pacemaker Shows Potential
A short description of the history of deep brain stimulation and two case reports with exceptional indications for deep brain stimulation: one patient was treated for body dysmorphic disorder and the other was treated for debilitating headaches.
Body dysmorphic disorder is excessive preoccupation with minor or imagined flaws in appearance. Dr. Anderson’s patient was a 20-year-old man who obsessed on perceived flaws with his nose and other facial features. He had attempted suicide once, and described his life as a “living hell.” Eight months after DBS surgery, the patient reported mild depression and obsessive compulsive disorder, but no symptoms of body dysmorphic disorder.
The second patient was a 43-year-old woman who suffered paroxysmal hemicrania headaches around the orbit of her right eye. She would typically get 10 to 20 attacks per day, each lasting 2 to 20 minutes. The headaches did not respond to either medications or a nerve block. But as soon as the DBS device was turned on, the woman reported the pain went away.

Monday, July 7, 2008

14 Observations on Fatigue and Depression

  • Physical fatigue or loss of energy is included as a single item in the DSM–IV criteria for major depressive disorder

  • Some think of lack of concentration as a mental form of fatigue and lack of concentration is also a symptom of depression

  • Anhedonia is an inability to experience pleasure from normally pleasurable life events. This is considered to be a core symptom of depression. Some describe it as emotional fatigue

  • Atypical depression is associated with hypersomnia, weight gain or increase in appetite, inertia, and leaden paralysis (i.e., severe lethargy and fatigue; heavy, weighted-down feeling in arms and legs)

  • Patients with atypical depression are significantly more likely than patients with other forms of depression to report fatigue

  • A recent twin study showed that fatigue during a severe major depressive episode is more likely to be reported by women than men

  • Fatigue is common in major depressive disorder

  • Fatigue is more common especially in the atypical subtype

  • Fatigue is the depressive symptom that correlates most strongly with diminished functioning

  • Fatigue is a common prodromal symptom in patients with their first major depressive episode

  • Fatigue strongly predicts progression to a chronic course of depression

  • Fatigue is one of the symptoms that appears to be less responsive
    to antidepressant treatment

  • After remission of major depressive disorder, approximately
    10%–35% of patients continue to experience fatigue

  • Pharmacological augmentation of antidepressant therapy has shown promise in the treatment of residual fatigue. Modafinil and bupropion are the only two augmentation strategies published on this subject

Now lets' be careful, these observations about depression and fatigue were published in a review, not a systematic review. You could at best consider these observations as the opinion of an expert, not the scientific truth about the relationship between fatigue and depression. Moreover most of these observation are recognizable but don't have to be true. I have linked as much as possible to the references used by the author.

To my opinion does fatigue play an important role in depression but you can't say that fatigues always implies depression. Even in science this mistake is often made. It is comparable to using depression severity scales in somatic ill patients and concluding that a large part of these patients have a depression because they have a high score on these scales. They have a high score due to their medical illness not due to a depression, you need a diagnostic scale for that.
Arnold, L.M. (2008). Understanding Fatigue in Major Depressive Disorder and Other Medical Disorders. Psychosomatics, 49(3), 185-190. DOI: 10.1176/appi.psy.49.3.185

Sunday, July 6, 2008

Lou Reed and ECT, or A Perfect Day

Born in 1942 into a Jewish family in Brooklyn, the teenage Lou Reed was subjected to electroconvulsive therapy to "cure" his homosexuality. He worked as a house songwriter for Pickwick Records before finding cult fame with art-rock band The Velvet Underground. Post-VU, he released a succession of acclaimed albums, most significantly 1972's 'Transformer', whose themes of drug use and cross-dressing chimed with the mood of the glam-rock movement spearheaded by his friend David Bowie.

Since recent I am participating in the update of the guidelines for ECT in The Netherlands. That gave me the privilige to meet patients treated or being treated with ECT, mostly continuation ECT. In a meeting with them a couple of weeks ago they made remarks about the treatment and how the new guideline could improve ECT. Their experience, critique will be used for the new guidelines. Discussing ECT with these hands on experienced patients was a pleasure and very informative.

A week after that I had a meeting with (ex)patients of Mental Health Care and their significant others. Some of them had experience with ECT in the past. Comparable to Lou Reed some of them had been treated in the sixties with ECT for comparable absurd indications. We had a very lively and instructive discussion about ECT in the past and how ECT is used nowadays. To me these meetings are of immense importance, it changes your perspective on what your doing and how your doing it.

This post was inspired by an article on The Independent on Sunday about Lou Reed, Royal Albert Hall, London Beck, Guildhall, Southampton

He reviews a recent performance by Lou Reed of one of his best albums: Berlin.

Saturday, July 5, 2008

3-D Mammograms: A Better Way to Check for Cancer


In a recent study, radiologists gave nearly 1,500 women at an increased risk of breast cancer both a mammogram and a stereo mammogram. As a result, the stereo mammograms increased detection of cancer by 23 percent and decreased false alarms by 46 percent.

The stereo mammogram
U.S. scientists are experimenting with new ways to view breast X-rays in 3-D, so that today's mammograms can provide a clearer picture of any existing tumors. Some of those methods include wearing special 3-D glasses as well as using a new camera.

On CBS News

On Gearlog

Transcranial Direct Current Stimulation, Brain Boost and Side-Effects

Transcranial direct current stimulation (TDCS) could improve memory in participants asked to learn and then recall a list of 12 words. The effect was significant in the early learning stages: in the first few trials, in which participants were given the same list over and over again, people in the treatment group could remember more words. But the learning curve for those working without the device quickly caught up to the zapped learners.

This conclusion of a recent research on TDCS published on Technology Review: Want to Enhance Your Brain Power?

At first the encoding of of the words is better in subjects treated with TDCS. Improving the encoding by training this test catches up after a while. The treatment with TDCS was done prior to the learning task, what if it was done during the test?

What is TDCS?
The device is simple: a nine-volt battery that's been approved by the Food and Drug Administration for delivering drugs across the skin is connected to large flat sponges that are moistened and then applied to the head. It delivers a gentle 2 to 2.5 milliamps of current spread over a 20 to 50 square millimeter area of the scalp for up to 15 minutes. Little of that current actually reaches the brain--about half is shunted away from the target area, and the other half quickly dissipates as it gets farther from the scalp. The target in this research was the part of the brain known as the dorsolateral prefrontal cortex, a brain area involved in higher-level organization and planning, as well as in working memory. Because activity in this region has been shown in previous imaging studies to predict an individual's ability to recall information, the idea is that giving it an electrical boost will enhance memory function.

TDCS is something completely different than ECT. It is not used to elicit a general seizure, it doesn't require anesthesia and it is not tested properly for the treatment of depression.

Side-effects of TDCS
In the afore mentioned article only a slight dizziness was reported as side effect. In a upcoming publication in Brain Stimulation other side-effects are reported with TDCS. In 4 out of 4 patients treated with a higher dose (2mAmpere) during each active TDCS session with over 20 minutes (15-second ramp in and ramp out each) of stimulation on 5 days per week during a 2-week period, skin lesions were present. Generally, these lesions occurred after the fourth or fifth DC-stimulation, showed stable superficial extensions during further tDCS, and healed without scars about 1-3 weeks after the end of tDCS treatment.

The occurrence of lesions may depend on the intensity and duration of TDCS as well as on the impedance between electrode and skin.

Thanks Neuromod Blog

Related post on this blog: tDCS electrifying?
PALM, U., KEESER, D., SCHILLER, C., FINTESCU, Z., REISINGER, E., PADBERG, F., NITSCHE, M. (2008). Skin lesions after treatment with transcranial direct current stimulation (tDCS). Brain Stimulation DOI: 10.1016/j.brs.2008.04.003

Friday, July 4, 2008

Psychotic Depression, ECT and Continuation Treatment in the Elderly

depressed elderly
After remission on ECT for psychotic depression the combination of nortriptyline and ECT prevented relapse or recurrence in 11 of 16 patients during follow-up of 2 years, of the 17 nortriptyline treated patients only 5 were considered without relapse or recurrence. The mean survival time until relapse was 23 months in the ECT with nortriptyline group and 16 months in the nortriptyline group.

ECT or electroshock is the only treatment in psychiatry that is stopped when successful. Usually treatment is continued with an antidepressant or the combination of an antidepressant with lithium. Tricyclic antidepressants are mostly used because most research on continuation treatment after ECT is done with these antidepressants.

Most research is done with adults not specifically with elderly. When a severely depressed elderly is admitted to our ward and recovers I usually advice them not to stop their antidepressants. I have seen to many relapse when tapering or stopping their antidepressants. There time left is to valuable to spent on psychiatric wards.

A severe form of depression, psychotic depression usually warrants ECT treatment in the elderly. This severe form of depression leads to deterioration fast which can be interrupted effectively by ECT.

In this research a group of elderly with psychotic depression was treated with ECT and nortrityline. When remitted (33/38, 86.8%) they were randomized single blind to continuation ECT with nortriptyline or nortriptyline alone. The high percentage of remitters is no exception with ECT for psychotic depression.

The combination of continuation ECT with nortriptyline is exceptional. In adults a recent trial comparing continuation ECT to nortriptyline with lithium showed no significant difference in relapse during a 6 month follow-up. You can read about this study published in the Archives of General Psychiatry in a post on this blog. Nevertheless both treatments were well tolerated although cognitive side effects were not adequately monitored.

Other limitations of this study are the small sample size, only 14 had initially received pharmacotherapy for their episode before ECT.
Navarro, V. (2008). Continuation/Maintenance Treatment with Nortriptyline Versus Combined
Nortriptyline and ECT in Late-Life
Psychotic Depression: A Two-Year Randomized Study. American Journal of Geriatric Psychiatry, 16(6), 498-505.

Thursday, July 3, 2008

Video Games in Health Care

It's becomes clear that games can have a positive effect on health, whether by helping to improve kids' fitness levels, or by being used as physical rehabilitation tool for the elderly.

These are just two examples of video games used in health care in a recent post on BBC News: Video games get into shape.

In summary video games are used in:

  • A motivational and education tool towards a healthier lifestyle

  • Virtual reality games as a form of pain control for burns patients

  • Virtual environments can be very useful for treating patients suffering from "phantom limb" experiences following amputations

  • Virtual reality systems to help treat some of the many Iraq war veterans who return home with post-traumatic stress disorder

  • Games are being used to treat migraine, based on research into neurofeedback treatment techniques

  • Virtual clinic for training doctors and nurses to deal with the injuries caused by large-scale natural disasters or on the battlefield

  • Surgeons who frequently play ordinary videogames make more than a third fewer mistakes in simulations of laparoscopic surgery than those who don't

You can read more about these roles of games in health care here

Wednesday, July 2, 2008

Medical Grand Rounds on The Covert Rationing Blog

independence day
This week the medical grand rounds is on The Covert Rationing Blog.

This week, bloggers from across the Internet have submitted articles that will help us celebrate the 232nd birthday of the United States of America.

Go read the finest and newest posts on the medical blogosphere.

Tuesday, July 1, 2008

Drug Use Not Related To Drug Policy

drug use drug policy

Drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g., The Netherlands).

This is the conclusion in a recent publication in PLoS Medicine: Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys.

The researchers set out to collect basic patterns of alcohol, tobacco, cannabis, and cocaine use in different countries. They documented lifetime use of these substances in each county, focusing on young adults. They also wanted to examine the age of onset of use and whether the type of drugs used was affected by one's social and economic status.

Other important results of this survey:

  • In the Americas, Europe, Japan, and New Zealand, alcohol had been used by the vast majority of survey participants, compared to smaller proportions in the Middle East, Africa, and China

  • The US has the highest levels of both legal and illegal drug use among all countries surveyed

  • Males were more likely than females to have used all drug types: legal and illegal

  • Younger adults were more likely than older adults to have used all drugs examined

  • Higher income was related to drug use of all kinds

  • Marital status was found to be linked only to illegal drug use

  • The use of cocaine and cannabis is more likely in people who have never been married or were previously married

PLoS Medicine is an excellent open journal , you can read the whole article or the editors'summary here
Degenhardt, L., Chiu, W., Sampson, N., Kessler, R.C., Anthony, J.C., Angermeyer, M., Bruffaerts, R., de Girolamo, G., Gureje, O., Huang, Y., Karam, A., Kostyuchenko, S., Lepine, J.P., Mora, M.E., Neumark, Y., Ormel, J.H., Pinto-Meza, A., Posada-Villa, J., Stein, D.J., Takeshima, T., Wells, J.E., Hay, P. (2008). Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys. PLoS Medicine, 5(7), e141. DOI: 10.1371/journal.pmed.0050141

How to protect and improve chocolate

"Sequencing the cocoa genome is a significant scientific step that will allow more directed breeding of cocoa plants and perhaps even enhance the quality of cocoa, the key ingredient in chocolate," privately held Mars said in a statement.

In order to protect the cocoa bean and improve survival from diseases such as pest due to a higher disease resistance, MARS and IBM join together in exploring the cocoa genome.
"Sequencing the genomes of agriculture crops is a critical step if we want to better understand and improve a crop,"

Thanks The Great Beyond

Monday, June 30, 2008

Sensual Cloud in Florence

The Cloud was build by MIT. It is now part of the “Redesigning Fashion Trade Shows” in Florence, Italy (map here). So if your in the neighborhood go and see. Never thought lights could be this sensual (see clip).

An organic sculptural landmark that responds to human interaction and expresses context awareness using hundreds of sensors and over 15,000 individually addressable optical fibers. Constructed of carbon glass, spanning over four meters, and containing more than 65 kilometers of fiber optics, the Cloud encourages visitors to touch and interact with information in new ways, manifesting emotions and behavior through sound and a dichotomy of luminescence and darkness.

Thanks Bright

The Eye of Science

As a two-person team of photographer and biologist, our aim is to combine scientific exactness with aesthetic appearances, and thereby help to bridge the gap
between the world of science and the world of art

Biologist Nicole Ottawa and photographer Oliver Meckes utilize Scanning Electron Microscopy (SEM). They expose a fascinating world beyond human vision.

Beautiful pictures of bacteria, viruses, from medical science, zoology crystals and many others. Have a look at Eye of Science

Blood, erythrocytes.

Bacteria: E. Coli

Thanks Divine Caroline

Sunday, June 29, 2008

The Evil of Science: Clonie

In this song Nellie McKay sings about the creation of the ultimate companion, clonie.

Listen closely, she sings awfully fast for non native english speakers.

Saturday, June 28, 2008

The Limits of fMRI

fMRI or functional magnetic resonance imaging is the measurement of activity in the brain or more precise it measures the haemodynamic response related to neural activity in the brain or spinal cord of humans or other animals. It is one of the most recently developed forms of neuroimaging.

Often results of research with fMRI have promised that we can now look inside the brain and really see what is happening in the brain during certain tasks such as memory tasks and many others.

Although brain scanner technology is often described as a "window into the brain," Logothetis, in this most recent article, makes it clear that the metaphor of transparency is inappropriate. He cites a long list of factors that complicate the interpretation of fMRI data, from the challenge of distinguishing between excitation and inhibition to the difficulty of measuring the relative activation of different brain areas. If brain scanners are like a window, then the window has some very dirty glass.

In a recent article in Nature these claims are said to be very limited by technical shortcomings of this kind of neuroimaging. The article is written by one of the experts that helped develop the fMRI technique.

Now I am not the first one to write about this nature article, but this news looked important to me so that is why I wanted to point out the other excellent descriptions of this nature article in the blogosphere:

Pure Pedantry, he also describes an excellent example of misuse of fMRI.

The Frontal Cortex

Mind Hacks

Friday, June 27, 2008

How does Chocolate protect the Heart?

A number of studies have shown cardiovascular benefits of eating flavanol rich cocoa. In this post I will discuss the possible underlying mechanisms of these cardioprotective properties of chocolate as published in a recent review article: Flavanol-rich cocoa, a cardioprotective nutriceutical.

  • Cocoa flavanols as antioxidants. Antioxidants are substances that may protect cells from the damage caused by unstable molecules known as free radicals.Oxidation of low-density lipoprotein (LDL) has been implicated in atherogenesis. Or LDL, a form fat in your blood that plays an important role in harming especially your larger blood vessels can lead to hypertension, lack of oxygen supply to the heart with as complication a hart attack. Antioxidants such as flavanols in chocolate that prevent LDL from oxidizing may reduce atherosclerosis. Although the precise mechanism of flavanol’s antioxidant action has not been agreed upon, research findings do suggest that the consumption of cocoa flavanols in the diet can significantly improve the
    oxidative defense system.

  • Modulation of vascular function. Impaired arterial endothelial function or impaired function of the inner layer of blood vessels has been shown to be a significant early event in atherogenesis and has been associated with an increased cardiovascular risk. Other diseases such as stress, ischemia (short oxygen supply), atherosclerosis, diabetes mellitus, and hypertension, can disrupt endothelial function. As a result, a dysfunctional endothelium may lose its protective effects on the vascular system. The acute consumption of dark chocolate by healthy volunteers have shown the acute dilatation of muscular arteries and an increased arterial elasticity

  • Inhibition of platelets. Platelet aggregation or the forming of small blood cloths is the critical event occurring during the initiation of coronary thrombosis which can lead to cardial infarction. Several studies have provided strong support for the antiaggregatory effects of cocoa flavanols.

  • Antihypertensive effects. The results of 2 separate studies in healthy subjects and later in hypertensives have shown possible benefits of cocoa in blood pressure lowering.This also can be considered as cardioprotective since hypertension leads to an overload of the heart.

  • Anti-infammatory effect. Cocoa flavanols have also been shown to have potential anti-inflammatory activities that are relevant to cardiovascular health. With inflammation, substances are formed which can produce adverse cardiovascular effects.

Now, Dr Shock will never let a change to promote chocolate consumption slip although lack of positive effects are also published on this blog in: Short-term Chocolate Effects on Health.

Moreover, it should also be noted that the evidence for any cardiovascular benefits of cocoa flavanols has been gathered predominantly from short-term and uncontrolled
studies. Therefore, additional research in well-designed, long-term human clinical studies using cocoa would be most helpful in assessing whether flavanol-rich cocoa
could be a potential candidate for the treatment, or possible prevention of cardiovascular disease. The beneficial effects of chocolate also need to be balanced against its high caloric and high fat contents.
Mehrinfar, R., Frishman, W.H. (2008). Flavanol-Rich Cocoa. Cardiology in Review, 16(3), 109-115. DOI: 10.1097/CRD.0b013e31815d95e2

Thursday, June 26, 2008

Light Therapy And Depression

light therapy depression
Light and depression is of interest in recent scientific publications. On Science Daily the use of bright light elderly group care facilities in the Netherlands leads to improvements.

The use of daytime bright lighting to improve the circadian rhythm of elderly persons was associated with modest improvement in symptoms of dementia, and the addition of the use of melatonin resulted in improved sleep, according to a new study.

According to one of the authors dr Eus van Someren: "elderly are somewhat less depressed and more active due to the use of bright light in the facilities for the elderly". "Even melatonin level in the elderly in the bright light facilities was significantly higher during the night". You can read the abstract in a recent JAMA issue.

A recent systematic review examined the efficacy of light therapy in nonseasonal depression. Light therapy is efficacious in seasonal depression but its role in non seasonal depression is unclear. The authors identified 62 reports from which 15 were selected according to their selection criteria. The sample sizes were small, blindness is a troublesome issue in this kind of research and publication bias is probable. Negative results are seldom published especially in such a difficult fieled of research. Their conclusion about light therapy for nonseasonal depression:
Overall, bright light therapy is an excellent candidate for inclusion into the therapeutic inventory available for the treatment of nonseasonal depression today, as adjuvant therapy to antidepressant medication.

So there is more to see that meets the eye with light and depression. Bright light therapy alone for the treatment of nonseasonal depression is not efficacious according to results to date. Further research especially with nonseasonal depression and circadian rythm disturbaces are needed.

What are your experiences with light and depression?

Related posts on this blog:
4 Nonseasonal Depressive Disorders treated with Light Therapy
Chronotherapeutics what is it good for?
8 articles about seasonal affective disorder
Riemersma-van der Lek, R.F., Swaab, D.F., Twisk, J., Hol, E.M., Hoogendijk, W.J., Van Someren, E.J. (2008). Effect of Bright Light and Melatonin on Cognitive and Noncognitive Function in Elderly Residents of Group Care Facilities: A Randomized Controlled Trial. JAMA: The Journal of the American Medical Association, 299(22), 2642-2655. DOI: 10.1001/jama.299.22.2642

EVEN, C., SCHRODER, C., FRIEDMAN, S., ROUILLON, F. (2008). Efficacy of light therapy in nonseasonal depression: A systematic review. Journal of Affective Disorders, 108(1-2), 11-23. DOI: 10.1016/j.jad.2007.09.008

Wednesday, June 25, 2008

Shrink Rap Grand Rounds: The iPhone 3G Edition

iphone 3G
The three shrinks of Shrink rap did an amazing job with this Grand Rounds, Volume 4, #40. Since the anticipated release of the Apple iPhone 3G is just around the corner (July 11), they asked for submissions to have some connection to the iPhone, no matter how twisted the logic is to make the connection.They made nice graphics and icons to go along with their update of the medical blogosphere.

They even supplied graphics for links to their grand round, see the picture above this post. The red circle is the contribution of Dr Shock, on their site you can click this icon to read the post. Enjoy....

Tuesday, June 24, 2008

Dramatic Decrease in ECT use in Edinburgh

worried doctor

In the years 2006 and 2007 the rates of usage of ECT in Edinburgh were only 0.82 and 0.88 patients per 10 000 total population. This is approximately a third less than the rate in 2005, and three-quarters less than the rate in 1993

For comparison in Belgium in 2000, the ECT rate was 4.8/10,000 inhabitants. By 2006 it had increased to 6.6/10,000 inhabitants. In Spain in 2007 the ECT rate, measured in patients per 10,000 inhabitants, was 0.61. In Portugal in 2007 the ECT-rate was 0.5-1.2/10.000 inhabitants. In The Netherlands in 2000 it was 0.22 per 10.000 inhabitants

The authors suggest that this might be due to the ECT guideline by the NICE. The guideline published in 2003 was very restrictive in indicating ECT. This guideline was controversial and the Royal College of Psychiatrists subsequently published its own ECT guideline.

The other suggestion that ECT is less needed because of all the other therapies available for treatment of depression is to my opinion nonsense. The authors cite the STAR*D trials to oppose this notion with which I can fully agree. Even after four treatments only 67% of patients remitted from their depression.

I fear less patients with severe depression get the right treatment. It also has implications for clinical research, psychiatric ECT clinics have to join forces in order to be able to do future research with ECT. These are the worries of ECT researchers in Edinburgh with a long and excellent history of ECT research.

I will be in Edinburgh on October 8th attending a meeting of the Scottish ECT Accreditation Network (SEAN) with a Dutch delegation. Will ask them about this development and their opinions there on, will let you know.
Scott, A.I., Fraser, T. (2008). Decreased usage of electroconvulsive therapy: implications. The British Journal of Psychiatry, 192(6), 476-476. DOI: 10.1192/bjp.192.6.476

Monday, June 23, 2008

Read Medblogs instead of News Media for Health Issues


After almost two years and 500 stories, the Health News Review project has found that journalists usually fail to discuss costs, the quality of the evidence, the existence of alternative options, and the absolute magnitude of potential benefits and harms.

In the US as well as Canada and Australia health news is reviewed by non profit organizations because an imbalanced picture of health care interventions may have a profound impact on the decision making of American consumers who rely on these news stories.

In a recent article in PLoS Medicine the results of the evaluation of 500 news stories in newspapers, television and weekly magazines were published.
between 62%–77% of stories failed to adequately address costs, harms, benefits, the quality of the evidence, and the existence of other options when covering health care products and procedures

They used a rating instrument including ten criteria used by the Australian and Canadian Media Doctor sites. All of the criteria are addressed in the Association of Health Care Journalists' Statement of Principles.

How does this high rate of inadequate reporting on these health news topics from the news media come about?

  • Many newsrooms across the US have eliminated health and medical reporting positions because of a drop in profits

  • Lack of research time for reporters

  • Lack of sufficient space or time in the newspaper or on broadcast. To much information has to be left out due to insufficient space or time when reporting

  • No training for reporters on medical statistics or on the subject of health care

  • Sensationalism in medical science stories wherein journalists find it easier to get attention for their stories and scientists see “the practical value of media attention to a successful scientific career”

So read medblogs instead, professionals on the topic, some even do requests and there are lots of medblog from all different species.
Schwitzer, G. (2008). How Do US Journalists Cover Treatments, Tests, Products, and Procedures? An Evaluation of 500 Stories. PLoS Medicine, 5(5), e95. DOI: 10.1371/journal.pmed.0050095

Sunday, June 22, 2008

Have mercy on the NHS Doctors

singing detective nhs
Darzi, the minister in charge of a review of the NHS has accused some doctors of being “laggards” for obstructing the introduction of new treatments. But that is not all he even proposed some "innovative measures".

Doctors and nurses should treat there patients as costumers.

He says that if patients don’t like the quality of care they are receiving they should go elsewhere.

His report will include proposals to routinely invite patients to grade the quality of nursing care they receive during their hospital stay, including how comfortable they were made to feel on the ward and if they were treated in a kind and compassionate manner.

Darzi is to set up a new website featuring all the latest innovations in medicine to encourage hospitals to adopt new treatments more quickly.

Donaldson, who as chairman of the World Health Organisation world alliance for patient safety will this week launch an airline-style danger checklist for surgeons

Personally I like the medblog by the NHS Blog Doctor. He writes witty readable posts about "the pleasures and pitfalls of family medicine in the modern British National Health Service." As I think of the NHS in the UK I usually get flash backs from the singing detective. From colleagues who went to the UK for their residency I always got the impression that health care in the UK is in a deplorable state. After Labor being in power for such a long time I had hoped it would improve. Reading Times Online about: Laggard doctors ‘put block’ on new treatments made me understand the problems our colleagues across the Canal are facing.

It is the plague of our times based on a basic mistrust of all professionals by politicians and bureaucrats looking for votes, money and trying to hold on to their jobs no matter what, even by trampling on their "customers" (=patients) backs.

This basic mistrust leads to endless measures of bureaucratic forms and procedures waisting a lot of time not only from doctors but also from the "customers".
By the way it is a flagrant mistake to think of patients as customers. A customer is not suffering from an illness, his or her cure or treatment doesn't depend on good health care, he or she is not in a dependent relationship. A patient hasn't got the knowledge or information beforehand to make the right choices. He or she needs to be informed, taken care of etc.

The only consolation I have for the NHS Blog Doctor: You are not alone

Saturday, June 21, 2008

Putting Numbers into Images

Elective breast augmentation surgery in the United States is performed on 384.000 women per year. It is the most frequent high school graduation gift for girls in the US. How do you picture 32.000 elective breast augmentations a month? Watch this video.
He translates the enormous numbers and statistics in a visual language. A language that can be felt so that they matter.

Artist Chris Jordan shows us an arresting view of what Western culture looks like. His supersized images picture some almost unimaginable statistics -- like the astonishing number of paper cups we use every single day

Related post on this blog: Performance Index UEFA Euro 2008 Championship