Dr Shock MD PhD

Friday, February 8, 2008

3 Guidelines for ECT with Adolescents

So far I have found three guidelines about ECT with adolescents for depression. Summarized these guidelines suggest the following recommendations:

ECT is not recommended for children (5–11 years).

ECT should only be considered for young people with very severe depression and either life-threatening symptoms (such as suicidalbehaviour) or intractable and severe symptoms that have not responded to other treatments.

ECT should be used extremely rarely in young people and only after careful assessment by a practitioner experienced in its use and only in a specialist environment

This is roughly the conclusion after reading these three guidelines. This conservative opinion is based on the lack of controlled studies. Most publications on adolescents are reviews of single case studies or case series using variable methodology and variable outcome measures. This makes a positive publication possible, only positive outcomes are published.

Side effects are also not studied in controlled trials but only small retrospective case series and case reports. It seems that adolescents appear to have the same side effects as adults. There are no studies which provide evidence of the impact of ECT in developing brain.

Parents are generally as positive, or more positive in their views on ECT than adolescents who had received the treatment.

The above mentioned recommendations mainly come from the guideline of the National Institute of Clinical Excellence (NICE): Depression in children and young people
Depression in children and young people: identification and management in primary, community and secondary care.
Compared to the Practice parameters for the assessment and treatment of children and adolescents with depressive disorders of the American Academy of Child and Adolescent Psychiatry (AACAP)the NICE guideline is more comprehensive. In the AACAP guideline ECT is only mentioned for psychotic depression.

In adults, electroconvulsive therapy (ECT) is particularly effective for this subtype of depression. Non-controlled reports suggest that this treatment also may be useful for depressed psychotic adolescents.

The AACAP also has a guideline for ECT with Adolescents: Practice parameter for use of electroconvulsive therapy with adolescents.
This guideline has a far broader range of indications for ECT with adolescents.

Diagnosis: Severe, persistent major depression or mania with or without psychotic features; schizoaffective disorder; or, less often, schizophrenia. ECT may also be used to treat catatonia and neuroleptic malignant syndrome.

Severity of Symptoms: The patient's symptoms must be severe, persistent, and significantly disabling. They may include life-threatening symptoms such as the refusal to eat or drink, severe suicidality, uncontrollable mania, or florid psychosis.

Lack of Treatment Response: Failure to respond to at least two adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. Both duration and dosage determine the adequacy of medication trials. It may be necessary to conduct these trials in a hospital setting.

ECT may be considered earlier in cases in which
adequate medication trials are not possible because of the patient's inability to tolerate psychopharmacological treatment;
the adolescent is grossly incapacitated and thus cannot take medication;
or waiting for a response to a psychopharmacological treatment may endanger the life of the adolescent.

I can live with the above mentioned first three points. I would like to develop two or three Dutch ECT centers especially for treatment of adolescents with extensive research protocols.

Ghaziuddin, N., Kutcher, S.P., Knapp, P., Bernet, W., Arnold, V., Beitchman, J., Benson, R.S., Bukstein, O., Kinlan, J., McClellan, J., Rue, D., Shaw, J.A., Stock, S., Kroeger Ptakowski, K. (2004). Practice Parameter for Use of Electroconvulsive Therapy With Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43(12), 1521-1539. DOI: 10.1097/01.chi.0000142280.87429.68
&NA;, . (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1503-1526. DOI: 10.1097/chi.0b013e318145ae1c

Thursday, February 7, 2008

Differences between depression and dementia

We have an elderly patient admitted to our ward for second opinion. She has a history of depressive episodes. Two post partum depressions and one depressive episode about 6 years ago. She is 72 years old.

When I met her the first day she was in a dysphoric mood complaining about her transfer to our department. She already took nortryptiline for 2 months with adequate plasma levels. Her referring psychiatrist said that this had led to some improvement, the patient was less pleased with the antidepressant. According to her this drug was causing memory problems.

She demanded ECT since that was the reason for her transfer.

During the observation period she had depressive symptoms as well as cognitive symptoms.

Dementia and depression are frequently comorbid among older adult patients.Depression is related to cognitive
decrement and can even represent the first signs of a neurodegenerative process.It can be difficult to distinguish
depressed patients exhibiting the first signs of dementia from those whose cognition will improve with treatment.

How can we differentiate between depression and dementia?

Neuropsychological assessment is generally considered the gold standard in differentiating between depression and the early stages of dementia.
- Cognitive impairments in dementia are usually more severe than in patients with depression.
- Patients with depression will do more poorly on tasks that require more effort to complete a task. Patients with dementia score low on tests because of ability-based deficits rather than on the amount of effort needed for the test.
- Patients with depression generally retain the learned information during testing, patients with dementia show a higher rate of forgetting of initially recalled material over time. Besides these retrieval deficits in patients with dementia, memory consolidation is also worse compared to depressed patients as shown with recognition memory tasks.
- Patients with beginning dementia exhibit greater false-positive scores whereas depressed patients usually stay on the save side and produce more false negative errors. Patients with dementia show specific impairments such as practical shortcomings, difficulty with temporal relationships between events.
It is not clear which depressed elderly is predisposed to develop dementia from those depressed elderly that will not. It is suggested from the literature on this subject that depressed patients exhibiting early decrements on tasks of recall memory, visuospatial skills (Visuospatial skills allow us to visually perceive objects and the spatial relationships among objects.), and executive functions may be at greater risk for developing dementia than patients without such a degree of decrement.

The depression symptoms that might predict development of dementia are:
- Apathy during a depressive episode, which is disinterest, low energy, and concentration difficulties is a risk factor for developing dementia later on as shown by a 3-year longitudinal study.
- Apathy is also positively associated with dementia severity, dysphoria has a negative relationship.
- Fewer affective symptoms such as feelings of guild, depressed mood, suicidal ideation, and more agitation and motor slowing are positively associated with dementia.
- Late onset depression, that is a first depressive episode at a later age, is a risk factor for dementia than for early onset depressive disorder.
The presence of white matter and subcortical gray matter hyperintensities in imaging studies are positively related with depression during old age. The boundary between vascular dementia and Alzheimer dementia is less clear than once hypothesized. Patients with hypertension have increased amounts of senile plaques and neurofibrilllary tangles and previous high cholesterol is positively associated with Alzheimer disease. At least a part of the relationship between geriatric depression and dementia can be explained by a vascular compromise to the frontostriatal circuit.

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis is represented by high levels of glucocorticoids during depression. In depressed patients with hypercortisolemia cognitive deficits have been demonstrated together with lowerded hippocampal formation volume and reduced metabolism. There is a possibilty that hippocampal atrophy associated with HPA dysfunction in depression might be a risk factor for developing dementia later on.

Depression as a prodrome of dementia. In a subset of older adults depression can represent the first symptoms of dementia even when accounting for cognitive complaints. It is unknown whether vascular compromise of the frontostriatal regions, structural damage by cortisol dysregulation or both account for this relationship.

Depression as a risk factor for dementia. Due to lack of good prospective longitudinal studies this relationship remains to be seen.

Where does this leave our elderly patient?
Her dysphoric mood and prior history of depressive episodes (no late onset) makes me more optimistic about her cognitive symptoms. Neuropsychological testing is our first goal although her depression might be to severe for a reasonable test outcome.I'll keep you posted.

Based on:

Wright, S.L., Persad, C. (2007). Distinguishing Between Depression and Dementia in Older Persons: Neuropsychological and Neuropathological Correlates. Journal of Geriatric Psychiatry and Neurology, 20(4), 189-198. DOI: 10.1177/0891988707308801

Wednesday, February 6, 2008

What do drug addiction and running have in common?

Running is rewarding, antidepressive. Running has beneficial effects in treatment of depression. Running can increase neurogenesis in hippocampus in rodents.

But what have addictive drugs and exercise in common?

Excessive training can result in fatigue and mood disturbances.This is comparable to withdrawal in substance abusers.

Sudden cessation of running can result in withdrawal with negative mood states comparable to drug withdrawal.

It is for both not known why controlled behavior such as running can change to compulsive running or from recreational alcohol use can change in compulsive consumatory behavior.

In animal it has been shown that genetically modified mice that have similar responses to seeking reward from an addictive drug also seek a more natural rewarding behavior when given the change (wheel running).

Mice prone to addiction will easily change from moderate to high reward consumption of addictive drugs when given the opportunity. For wheel running they show the same behavior.

In animal studies running and antidepressants causes neurochemical and morphological adaptations in brain reward pathways and hippocampus that also are shared by addictive drugs.

Why should we care?
I fully agree with the authors that since running has beneficial effects in the treatment of depression a better understanding of the effects in the brain could lead to novel treatments for depression.

BRENE, S., BJORNEBEKK, A., ABERG, E., MATHE, A., OLSON, L., WERME, M. (2007). Running is rewarding and antidepressive. Physiology & Behavior, 92(1-2), 136-140. DOI: 10.1016/j.physbeh.2007.05.015

Google with new kind of experimental searches

Google has created an experimental search page to let you try out some of their newest ideas. You can read about it on the official google blog.

They have added Map View, Timeline View and Info View to their standard list view.

About Map View

Map view solves this problem by plotting some of the key locations contained in your web results onto a map.

About Timeline View

The graph across the top of the page summarizes how dates in your results are spread through time, with higher bars representing a larger number of unique dates. Click anywhere on the graph to zoom in to that particular period of time, and use the text box to the right to specify any range of years, months, or days.

About Info View

Now you'll notice a new control panel on the right side of the page.
Clicking on the different options in the panel changes the information shown below each result. Usually we show some text from the page that includes a few of the words you searched for. Now you can instead reveal text containing dates, locations, measurements, or images.

ResearchBuzz has a post and example searches but you should check it out, it's cool.

Tuesday, February 5, 2008

Are whales smarter than humans?

A post on Thinking as a hobby about recent articles in Scientific American about the brains of whales and humans.

whales have bigger brains than humans. I've made the argument here before that the human neocortex expanded through evolution finding a scalable modules (the minicolumn) and largely increasing the number of those modules.

Flickr adepts are not amused

People using flickr are not amused by the possible take over of yahoo by microsoft. They fear their favorite photo site will suffer from this merger.

They have formed a group on flickr: MICROSOFT: KEEP YOUR EVlL GRUBBY HANDS OFF OF OUR FLICKR. And they have uploaded photos to make their point, mostly not very friendly about Microsoft.

This is one of my favorites.

What is yours?

Related topic
Photos from Dr Shock on Flickr

Thanks techcrunch.com

Monday, February 4, 2008

Do patients have an obligation to participate in student teaching? Why and How?

Patients participate in teaching students in many ways. For instance during lectures. We usually choose a patient very carefully trying to find someone that may even enjoy it. Before the lecture I will explain the purpose of the lecture, the questions I will most certainly be asking and the number of students and equipment used in order to prepare the patient. At the end of the demonstration I give the patient a small token of appreciation: a cup from the university or a pen, something small but with the logo on it. After the lecture I will again talk with the patient about the experience, see whether there are questions about the lecture or anything else and thank them.

According to this article on BBC NEWS HEALTH patients must participate:

At the moment, patients have to give explicit permission before medical students are allowed to become involved in their treatment or care.

What we are trying to do is move towards a situation where the default answer from a patient is 'yes'
Professor Jim Parle, Birmingham University

The researchers said this should be replaced by a system that starts with the premise that there is no reason why students who are competent in carrying out a procedure, such as taking a blood sample, should not be doing so.

How?
If you want patients to participate you should to my opinion fulfill the following conditions:

Students should train with people who are as healthy as possible before moving to more vulnerable patients, a careful selection

Consider some form of compensation. This could be in the sense of a small present, but there is also the question of financial compensation for these matters.

Provide a controlled supervised environment. If one of the students is way out of line during the interview, arrives late or is deliberately not paying attention he has a huge problem with me.

Consider videos, computerized systems, the use of models if possible.

Patients must be able to draw personal boundaries, retain privacy and consider the risks and benefits of student participation in their care.

Watch out for these adverse effects

Marginalization of the patient in the doctor's duties

Strain in the doctor patient relationship, as a patients who expects to see the doctor is instead seen by a student

Exposure of the patient to potential harm, discomfort and invasion of privacy.

Arguments used to justify an obligation

Patients may feel obliged out of simple pragmatism. Most people prefer a doctor who has learned skills in a supervised environment before they have to do it on their own.

Necessity of participating in teaching, research and quality assurance because without this obligation the system would collapse. But the system could be set up in many different ways not always needing the participation of patients.

If a student learns the procedure with a patient, then both the patient and future patients will benefit.

Communitarian argument that as we all benefit from the presence of a medical system, we should all be prepared to contribute to it.

Statements as: "well it is a teaching hospital after all", are used to justify the notion that those who use the public hospital get something for nothing

There is no a convincing argument that patients have an obligation to participate in medical teaching.

The challenge for educators is to develop an authentic process of consent whereby the risk of student participation are acknowledged but contained, and whereby patient altruism is encouraged but not assumed

Patients don't have an obligation they participate out of altruism.

Article used:

.
Med Educ. 2008 Jan 24 [Epub ahead of print]
Do patients have an obligation to participate in student teaching?
Lowe M, Kerridge I, McPhee J, Hart C.
PMID: 18221270

Sunday, February 3, 2008

French Lesson in Election Time, Sicko revisited?

What can we learn from the French?

10 tips to Retain More of What You Read Online

With a Medblog you search other blogs and the web for posts, news and other interesting stuff for your readers. There are different ways to store this information and use it later on. You need to process all this info. On Vandelay Website design there is a list of 10 tips to retain more of what you read online.

Here are some that appealed to me:
Read at times when you can focus

Be aware of visual cues

There are also some tips on the software you can use to help with the information overload. Read the comments for suggestions. I mostly use Google Notes for keeping notes and Del.icio.us for storing bookmarks, what do you use?

Thanks Lifehacker.com

Here are some more tips to cope with information overload: How to split an Atom

iMedix Search for Health Information

Find relevant medical articles ranked by the iMedix community members for you. Chat with other people just like yourself who are dealing with the same issues.
Share your knowledge & experience with thousands of people in a 100% private and secure place.

iMedix is a community powered health care search engine. It evaluates health care sites. You can search for information on disease, medication or even symptoms. I tried it and the results are very impressing.

It also has a social aspect. You can sign up for free and create a profile. You can chat with other participants with the same interests.

Thanks Cybernetnews.com

Seems a promising search engine for health care, Medic goes WEB 2.0

Saturday, February 2, 2008

rapid Transcranial Magnetic Stimulation (rTMS) in Bulimia Nervosa

rTMS for Bulimia Nervosa does not exert additional benefit over placebo. Bulimia Nervosa is a disease strongly influenced by sociocultural influences and psychological factors. In the past this has led to preliminary optimism about efficacy of fluoxetine in this eating disorder. The efficacy was based on the trial effect (Hawthorne Effect). Being in a trial with appointments, rating sessions, diagnostic sessions has effect on well being especially in diseases with a strong origination in sociocultural and psychological factors.

Bulimia Nervosa is accompanied by several psychiatric disorders as co morbidity. Some believe that Bulimia Nervosa and Depression share a common aetiology, that they are both part of the affective spectrum disorder model.

The authors had hoped that high frequency rTMS modulated the feeding suppression area in the frontal lobe.

Fourteen women were randomized into two groups of outpatients of either active or placebo stimulation after a week of placebo wash-out. Stimulation was placed on the left dorsolateral prefrontal cortex. Stimulation was delivered for 3 weeks (3 x 5 days) with an intensity of 120% motor threshold using 20Hz, in one session a day.

There was a considerable improvement in binging and purging as well as depressive and obsessive-compulsive symptoms. However no significant difference between active and sham treatment.

The high placebo response is again established in this group comparable to the placebo response to selective serotonin reuptake inhibitors in this group. This effect could be due to increased awareness and the regular documentation of the binge behavior.

Limitations:
Small group
Presence of additional personality disorder interferes with outcome

Walpoth, M., Hoertnagl, C., Mangweth-Matzek, B., Kemmler, G., Hinterhölzl, J., Conca, A., Hausmann, A. (2008). Repetitive Transcranial Magnetic Stimulation in Bulimia Nervosa: Preliminary Results of a Single-Centre, Randomised, Double-Blind, Sham-Controlled Trial in Female Outpatients. Psychotherapy and Psychosomatics, 77(1), 57-60. DOI: 10.1159/000110061

Friday, February 1, 2008

Does a surgeon make more steps a day in the hospital than an internist?

Age and Body Mass Index (BMI)were the most important variables that predicted the number of steps taken per hour by doctors. Each year older corresponded with a decrease of 5 steps per hour and each point rise in BMI resulted in an average decrease of 20 steps per hour on the job.

There was no difference in the number of steps taken in the hospital by general surgeons and internists. There wasn't even a difference between housemen, registrars and members of the staff. The average number of steps taken per day was 5325, per hour 548. For comparison flight attendants take 842 steps per hour and patients with a total hip replacement 143. A 7 year old school boy on average made 13.050 steps per school day, almost three times higher than the average specialist.

This study was done in 13 teaching and academic hospitals on the departments of internal medicine and general surgery. 131 subjects participated. Each recorded the steps with a pedometer for at least 4 to 10 days. Information about worked hours, weight, length and sex and age were recorded.

The average work day lasted 9.8 hours with no significant difference between subgroups.

If confounding factors are taken into account surgeons do more than only operating and staff members don't just sit on their ass the whole day. The mobility of the older staff members was the lowest not because of their status but due to their higher BMI and age.

Goosen, J. (2008). How many steps does a doctor take in the hospital? No difference between internist and genral surgeon, but a relationship with age and BMI. Nederlands Tijdschrift voor Geneeskunde, 152(4), 203-206.

Thursday, January 31, 2008

Deep Brain Stimulation for Alzheimers Disease.

Electrical stimulation of areas deep within the brain could improve memory, early research suggests. A team of doctors in Canada were attempting to treat a morbidly obese man through deep brain stimulation (DBS) for his obesitas. Their long-standing interest in functional neurosurgery and DBS made them consider the possibility of a neurosurgical treatment. They wanted to stimulate the hypothalamus for appetite control. Hypothalamic lesion surgery had been used previously to treat obesity. Hypothalamic stimulation was proposed based on experimental studies of appetite control in rodents, dogs, and nonhuman primates.

DBS electrodes were implanted bilaterally in the ventral hypothalamus with the patient receiving local anesthesia without sedation.
During stimulation the patient vividly remembered a situation from the past:

being in a park with friends, a familiar scene to him. He felt he was younger, around 20 years old. He recognized his epoch-appropriate girlfriend among the people. He did not see himself in the scene, but instead was an observer. The scene was in color; people were wearing identifiable clothes and were talking, but he could not decipher what they were saying. As the stimulation intensity was increased from 3.0 to 5.0 volts, he reported that the details in the scene became more vivid.

These recollections were tested under double blind conditions.

The effects of stimulation on memory were further characterized using recognition tasks with high sensitivity and specificity for hippocampus-dependent retrieval processes. Each task was performed twice, with the stimulator on or off in a double-blinded fashion.

Shortly after recovery of the operation as well as after a year the patient performed better in memory tests than he had previously done.

The patient performed well in memory tests when the electrodes were stimulated, but less well when they were switched off.

The results suggest it might be possible to use deep brain stimulation directly to boost memory.

Maybe a new treatment for Alzheimer? Sounds to good to be true. I remember ECT and Morbus Parkinson. ECT can help but as the disease progresses the results diminishes.

The conclusion of the authors:

Electrical stimulation in this high-density area could be affecting a number of neural elements. We cannot be sure how much of the effect is related to stimulation of nuclei versus axons coursing in the hypothalamus. At this time, we believe that the results are consistent with driving the activity of the hippocampal memory circuit through stimulation of the fornix. The effects of hypothalamic stimulation on memory shown here represent an unanticipated collateral effect in the context of a putative treatment for morbid obesity.

Thanks to BBC News Health

Hamani, C., McAndrews, M.P., Cohn, M., Oh, M., Zumsteg, D., Shapiro, C.M., Wennberg, R.A., Lozano, A.M. (2008). Memory enhancement induced by hypothalamic/fornix deep brain stimulation. Annals of Neurology, 63(1), 119-123. DOI: 10.1002/ana.21295

Nintendo Wiis Keeping the Elderly Fit

Elderly residents in a care home are being given Nintendo Wiis to help keep them physically and mentally active.

They hope it will especially help those with dementia.

On BBC NEWS

Firefox 3.0 comming up

Dr Shock is a Google adept. Fortunately Firefox and Google match well together. For blogging I solely rely on Google reader, Google notes and Blogger, all integrated in Firefox. Off line so now and then I use Marsedit and Devonthink for blogging.

What do you use, let me know in the comments

Mozilla just announced that they are planning on having the first Release Candidate build of Firefox 3 Beta 3 coming next Monday.
Two new features:

new Windows themes

Add-ons manager for finding extensions without ever going to the add-ons site

For screen shots see Cybernet

Wednesday, January 30, 2008

Risk Factors for Recurrence in Depression

On Vicarious Therapy there was an important question raised: Early Medical Intervention for Major Depression. I kept thinking about it, the answer is: I don't know.
Here is the problem:

Now, six plus years into this MDE I'm still searching for something that will help me, but I believe I at least FINALLY, in the psychiatrist I see, have the knowledgeable and completely supportive help I needed all along.

I often wonder, had I received help at 18 or 19, instead of 36, would I be better today? Would I be struggling so hard to find something to help me?

That is why I got interested in a long article in Clinical Psychology Research about Risk of Recurrence in Depression.

Some facts about Recurrent Depression:

50% of patients who recover from their first episode will have one or more additional episodes in their lifetime.

80% of patients with a history of two episodes will have another recurrence during their life

On average , patients with a history of depression will have five to nine separate depressive episodes in their lifetime

90% of those with recurrent depression report "very much" impairment, limiting work productivity and social interactions.

This review article considered studies that were identified through literature searches. The focus is on psychological and clinical risk factors not on biological measures.
Depression in this review can be a diagnosis by DSM or ICD criteria but also a score above a cutt-off on the BDI or Hamilton. Especially this last method of defining depression is very controversial, a high score on one of these severity scales doesn't always imply the existence of a depression.
They studied risk factors for recurrence these are different from risk factors for first episode depression.

Causes of recurrence

Female gender is not a significant risk factor for recurrence

Age at first onset (younger age) and lifetime number of depressive episodes (more numbers of episodes) appear to be related to increased risk of recurrence , although further research disentangling these variables is necessary

A severe first episode as indicated by a severe symptom picture is also a risk factor

Longer duration of first depressive episode is not a risk factor

In adults co morbidity is also associated with higher risk of recurrence. Co morbidity such as dysthymia, alcohol or drug abuse, anxiety disorders

Transmission of genetic risk from parents to children is a risk factor of recurrence.

Negative cognitive styles is a risk factor for recurrence.

High levels of neuroticism are a risk for recurrence

Stressful life events are risk factors for recurrence

In women social support is a protective factor against recurrent episodes of depression

Studies on psychosocial scarring and personality scarring due to depressive episode have largely been negative

The Scar Hypothesis of Depression

People who have recovered from an episode of clinical depression have an elevated risk for developing a new episode of depression compared with those not previously depressed. One possible explanation for this finding is that depression may leave ‘scars’—enduring psychological changes resulting from depression.

This hypothesis has been refuted several times.The role of personality in depression [of moderate duration and severity] is more consistent with the vulnerability model than with the scar hypothesis. See also Depression fails to scar personality - introversion, neurotism and dependency tend to predispose individuals to depression rather than result from depression - Brief Article

This is the conclusion of the authors in their abstract:

Our review suggests that recurrent depression reflects an underlying vulnerability that is largely genetic in nature and that may predispose those high in the vulnerability not only to recurrent depressive episodes, but also to the significant psychosocial risk factors that often accompany recurrent depression.

The problem with risk factors is the casual relationship with the depression. Is the depression the cause for these risk factors having an effect or are these risk factors of significant influence on the course of the disease. The only solution to this question is a large prospective study with adolescents at risk followed over a long period of time compared to adolescents without risk (genetic risk).
Nevertheless the authors did a large and comprehensive review of the subject, their conclusions are well-founded by the data. This review doesn't answer the question posed by the author of Vicarious Therapy. To my knowledge there is no evidence of early intervention and course of recurrent of depression. Anyone else?

Related post on this blog:
Risk Factors for Psychiatric Disorders

BURCUSA, S., IACONO, W. (2007). Risk for recurrence in depression. Clinical Psychology Review, 27(8), 959-985. DOI: 10.1016/j.cpr.2007.02.005

Tuesday, January 29, 2008

Archive the WEB, write a book on the web or use livescribe offline

Some tech talk now. The web has very useful information about health, medication, and illness to name a few.
Problem:Del icio.us is ideal for storing all the links for these websites. Nevertheless the web is also rapidly evolving, links can vanish, so clicking the link in del.icio.us delivers a blank page, link gone.
Solution: Diigo: a social bookmarking service that caches a full version of each bookmarked page with all the graphics and formatting intact. No more lost links. Moreover it is much faster than del.icio.us according to the comments on this post about Diigo at LifeClever. Also some suggested uses from Diigo: in research, a want list, recipes and yes Blogging:

Blogging. One of the big advantages of a social bookmarking service is the social part. Diigo makes it easy to share your links, post them to your blog, or even do an automatic daily post of links to your site.

Problem: Wrting a book online has several advantages: work from anywhere, quick use of the internet for links or texts.
Solution: Google Docs. On Google Blogoscoped there is a whole article about using google docs for writing a book online. With the outline, naming documents, workflow, you name it it's there.
Maybe I will switch from using wikis or word to using google docs with this article as instruction

There are many other differences between the two programs. Google Docs is free, for instance, whereas Word isn't. There may be smaller differences in start-up times (Google documents could really use a speed boost in this regards). One other thing I like about Google docs, or most web applications, is that I can switch to the English interface; this makes it much easier to, for instance, communicate about the application in help groups, or search for certain things in regards to the application.

OK not everyone is into using online applications for their notes. In comes Livescribe with the pulse smartpen. A pen that can record what you are writing as well as record and sync audio with whatever you write, so you never miss a word. With Paper Replay, users can tap on their notes written on paper to hear exactly what was said. They can also fast forward, rewind, jump ahead, pause, and even speed up or slow down their audio recordings using controls printed on the bottom of each page. Yes your notes on the computer screen as well as on paper. You will have to see it to believe it Have a look at the demo video's at livescribe.com
You can't buy it yet, takes a couple of months.

From Gizmodo.com

Monday, January 28, 2008

Top 10 Non Drug Addictions

Curious about these addictions? Is chocolate in them? These addictions account for a large share of addictions-related online searches.

The most common substances found in online searches for addictions on clearhavencenter.com

While many of these searches may spring from harmless situations, the pattern of abusing substances to cope with stress is a more common social issue than addiction to one specific substance.

Sunday, January 27, 2008

Beta NEJM Site an Excellent Resource

For a while now the New England Journal is testing a new website with all kinds of widgets and many Web 2.0 and interactive features.

I liked the specialised RRS feeds: NEJM Online Feeds. You can select: Current Issue Feed, Four Most Recent Issues Feed and Image of the Week Feed.

The “Image of the Week” feed contains information about, and a link to the most recent Image in Clinical Medicine. Four times a year, this feed will also contain information about a current “Medical Mystery.”

Another thing I liked is the: Drag and Drop Images to Create a PowerPoint Slideshow

Search NEJM Online for medical images, then drag and drop to create a PowerPoint slide set you can save to your desktop.

And yes I did put RSS feeds of the major medical journals -- NEJM, JAMA, BMJ, Lancet and Annals on my iGoogle Home Page on a Separate Tab

Thanks Clinical Cases and Images

DSM V citeria for Depression for Dummies

In an Editorial in the American Journal of Psychiatry the author recommends the use of five psychological symptoms of depression as sufficient for the diagnosis of Major Depression. Diagnosing Major Depression on the basis of a restricted symptom set.

Moreover, the justification for this restriction according to the author, is based on studies that showed that psychiatry and primary care trainees could not remember the nine symptoms.

That's why they are trainees

He replicated the findings of Zimmerman et al, using the 12 month version of the Composite International Diagnostic Interview (CIDI), famous for the inclusion of false positivies.

In the process this also means loosing classifications such as atypical or psychotic or melancholic depression. Diagnosing major depression has serious consequences, not a trifle matter. It could mean prescribing antidepressants for months, admittance or even other major interventions.

Dr Shock is not very keen on this development, what do you think?

Symptoms proposed, three or more of these five should be enough according to the author:
1. Depressed mood
2. Lack of interest
3. Worthlessness
4. Poor concentration
5. Thoughts of Death

They used data from the 10,641 respondents to the Australian National Survey of Mental Health and Well-Being (free full text), which used the 12-month version of the Composite International Diagnostic Interview, Version 2.1. Nineteen percent of respondents reported 2 weeks of either depressed mood or loss of interest in the past 12 months, and all of these respondents were asked questions about every DSM-IV symptom for criterion A of major depressive disorder. Six percent met criteria for major depressive disorder during the year; one-half were current cases. The first replication included all respondents and showed 99.6% agreement between the full and restricted definitions. The large number without major depressive disorder could have inflated the measures of agreement. In order to recreate the clinical characteristics of the Zimmerman et al. sample, we focused on the 1,013 people from the Australian survey who met criteria for current mood, anxiety, or substance use disorders. This second replication (Table 1) showed 96.8% agreement between the full and restricted definitions. Substantially the same people were diagnosed by the full and restricted definitions in both replications.

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Andrews, G., Slade, T., Sunderland, M., Anderson, T. (2007). Issues for DSM-V: Simplifying DSM-IV to Enhance Utility: The Case of Major Depressive Disorder. American Journal of Psychiatry, 164(12), 1784-1785. DOI: 10.1176/appi.ajp.2007.07060928