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Comment: Re:Dunno (Score 1) 747

by dmr001 (#46482967) Attached to: Measles Outbreak In NYC
Complications of measles depend on the setting - and though it's hard to surmise about your case in particular (you were "pretty sure" you had measles) the case fatality rate is up to 4-10% in developing countries (probably due to poor nutrition, but other folks at risk include being pregnant, old, or very young) due to brain inflammation or pneumonia. In developed countries the risk is lower, and we have nice expensive ICU's to care for people in - until we don't - in my city, we were running out of ICU beds for folks with influenza pneumonia this past year.

Cherry JD. Measles virus. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, et al (Eds), Saunders, Philadelphia 2009. p.2427.

Bernstein DI, Schiff GM. Measles. In: Infectious Diseases, Gorbach SL, Bartlett JG, Blacklow NR (Eds), WB Saunders, Philadelphia 1998. p.1296.

Comment: Re:Money (Score 3, Insightful) 366

by dmr001 (#45874031) Attached to: Why a Cure For Cancer Is So Elusive
It's an interesting claim that apparently all cancer researchers feel there is so much money to be made in grants, they are careful to reject novel ideas that might lead to cure for cancer so they can securely remain on the gravy train. By interesting, I mean for what it reveals about how people think. Hanging around the parking lots of university-based research facilities did not yield a surfeit of expensive cars. And while a good argument can be made for the plodding progress of research despite all the pink ribbons, breast cancer mortality is in fact steadily decreasing - even for women with tumor that's spread to lymph nodes. From the same website, you'll see even more impressive progress in colon cancer mortality, lung, and prostate cancer, which rounds out the list of the most common fatal cancers.

In some sense, increasing cancer mortality likely results from people in industrialized nations being killed less often by other stuff (cars, emphysema, smallpox, contaminated water). And walking 10 km (on a regular basis) probably has significantly decreased cancer mortality, probably by changes in hormone balance and metabolism. Cancer research may not always be flashy, but they do seem to dig up useful stuff over time.

Comment: Re:Erase all button (Score 2) 96

ECT gets a bad rap because it looks sadistic and no one quite knows how it works. On the other hand, it's effective - more effective than most other forms of depression treatment, and has the benefit of working when nothing else does. (Remission is severe depression is 70-90% with ECT vs 30% with a typical SSRI pill.) I've had patients who desperately wanted to be dead because each passing moment was filled with unbearable psychic pain, who after 3 treatments of ECT (with pulses lasting a few milliseconds) were smiling and chipper. (Albeit with some unpredictable holes in their memories.)

Moreover, contrary to One Flew Over the Cuckoo's Nest, modern treatment insists patients have voluntary, informed consent. This data isn't exactly hard to come by - Google ECT PubMed. In the US, unfortunately, ECT can be hard to come by, given attitudes such as that expressed by the parent poster, and I suspect reimbursement isn't that great (patients get general anesthesia for a few minutes, which isn't cheap, but US Medicare reimbursement for psychiatry is notoriously poor such that most psychiatrists don't take Medicare).

Comment: Re:Good luck (Score 1) 218

by dmr001 (#45762835) Attached to: Ask Slashdot: Working With Others, As a Schizophrenic Developer?
I suspect the parent poster and I are in some sort of agreement: if you've got a trustworthy clinician and you both agree it's reasonable to go off of antipsychotics with careful monitoring you'd have my best wishes. As a physician caring for community-dwelling (as opposed to institutionalized) patients with schizophrenia and other significant mental illness, I don't get to see too many such patients, and though I cannot locate trial data my experience tells me such patients are relatively rare. I do get to see a fair number of folks with active hallucinations and prominent paranoia who do not want to take their pills, and who have what the average person would consider to be impaired judgment and insight - e.g., I will not take the pills as the CIA has placed GPS beacons in them to beam thoughts into my mind because I am a prophet and they are agents of darkness. (See, it's tricky when some non-bizarre delusions over time increasingly resemble the truth.)

For some patients (perhaps about half) long-term outcomes for schizophrenia are reasonably functional. (Harding CM et al, The Vermont longitudinal study of persons with severe mental illness, Am J Psychiatry 1987: 144: 718.) For the other half, even on medication, they progressively deteriorate. It's a bummer for probably all of the latter and many (most?) of the former to not take their medicine, for everyone - they don't seem any happier, as agitation and paranoia tend to increase, and unmedicated psychosis is where ideas about pushing people in front of buses ferment. My sympathy is firm: I wouldn't want to take the pills either, what with varying degrees of fatigue (though this usually abates in most patients after a few weeks), weight gain, increasing cholesterol and blood sugar. I feel bad about the guys gesticulating wildly on the street, and though it's arguable their fate is better off than when us North Americans routinely institutionalized such people, it's hard not to feel they've been abandoned.

I'm not aware of antipsychotics causing physical or psychological dependence (using the clinical meaning of drug dependence), and I'm not aware of habituation either. I'd be interested in any such references. If I can get patients to take the pills, they do not seem to need more antipsychotics over time, nor do they withdraw when they stop taking them. I'm truly happy for people who can safely manage their hallucinations without medication, but for a great many patients - probably most - they really seem better off on antipsychotics.

Comment: Re:Good luck (Score 4, Insightful) 218

by dmr001 (#45760847) Attached to: Ask Slashdot: Working With Others, As a Schizophrenic Developer?
Attempting to treat an honest-to-goodness thought disorder like schizophrenia without medication is akin to treating near-sightedness with counseling. There's a place for cognitive therapy in schizophrenia but it's considered adjunctive treatment (among mainstream practitioners). There are a smattering of schizophrenics who can ignore auditory and visual hallucinations that are the hallmark of the disease, and anti-psychotics may indeed make some people feel less sharp (though that isn't universal). I'd wager that most people with schizophrenia are more capable of getting things done when they aren't beset by what are typically very vivid and often intrusive hallucinations. There are, of course alternative viewpoints, such as that of the Church of Scientology.

Comment: Re:I agree... (Score 1) 279

by dmr001 (#45321297) Attached to: Why Organic Chemistry Is So Difficult For Pre-Med Students
Something like 20 new medical schools have opened in the US since 2005. Moreover, non-physician providers (including physician assistants, nurse practitioners, and naturopaths) are joining the system of both primary care providers and specialists. (I get to co-manage patients, now, with naturopathic oncologists, for example.)

I have not noted any downward pricing trend.

I have noted a lot of advertising from medical groups, however - in newspapers, sponsoring the weather on television, on billboards, and stadium walls. Not from new doctors coming to town, for the most part, since in most metropolitan areas small practices are increasingly being replaced by larger groups with more negotiating power or owned by hospital systems. That also doesn't seem to have improved pricing.

In most primary care practices I know of, you can typically make a same day appointment. I'd rue the day, however, you found an empty waiting room - that doesn't seem like the most efficient use of resources (especially given that physicians nearly all go through federally financed residencies in the US, and medical school itself elsewhere).

Comment: Re:4 years (Score 5, Insightful) 682

by dmr001 (#44989801) Attached to: Ask Slashdot: Suitable Phone For a 4-Year Old?

I know this is an incredibly unpopular thing to say right now, but consider that the first thing we do to a new child born into this world is to slap them in the face. Why would we do that? Willingly induce pain to a brand new life that literally hasn't even been in the world a minute? It's to induce breathing. To get that child sucking down yummy nitrogen-oxygen mixtures. The pain is for the benefit of the child. All too often, letting a child learn something "the hard way" is seen as child abuse, but the reality is that human beings don't learn things by being told, they learn things by doing. And a lot of doing involves screwing up and getting hurt.

I'm all for experiential learning, but I don't know anyone who slaps newborns in the face to get them breathing. (N.B.: I deliver newborns for a living, and work with a bunch of other people who do as well and am aware of their practice patterns.) Babies usually squall on their own just fine, and for those that don't we'll vigorously towel-dry them. For the even smaller subset who're affected by maternal drugs or other conditions and haven't gotten it together to breathe, we'll flick their feet with a back of a finger (along with verbal encouragement, albeit mostly for our own amusement and by way of explanation to concerned parents). If they're still not sucking down oxygen after a couple of minutes then they get a mask to the face or a tube down the trachea. The previous practice of slapping newborns on the ass to kickstart them has been out of fashion ever since I started practice. Of course, practice patterns vary and maybe you live in a face-slapping place.

The ass-slapping turns out to be unnecessary, though I have stood by while my own children attempted to snort juice up into their noses for an experiential lesson in why we might not do that.

Comment: Re:Oh, look! Just what the economy needs! (Score 1) 600

by dmr001 (#44180925) Attached to: Obamacare Employer Mandate Delayed Until After Congressional Elections
New Zealand, Australia, and Chile all have compulsory government-mandated healthcare (and still manage to spend less than we do with reasonable outcomes). I suppose it's possible that Obama came up with the ACA in order for it to fail so he could move us to a socialized system - supposing he could convince Congress based on that failure to pass such a system. Which doesn't seem real likely when think about it, does it? I think you can make some arguments about tyranny in the US, but I don't think the ACA is a very convincing argument. (More than, say, compulsory car insurance.)

Comment: Re:anti-fat stigma (Score 2) 446

by dmr001 (#43827245) Attached to: Med Students Unaware of Their Bias Against Obese Patients
Citations, please.

Cognitive behavioral therapy compared with active control has been shown in multiple studies to produce persistent benefits, including decreased fatigue and better physical function. One trial even showed Internet-based cognitive therapy helpful (including 85 vs 27% absence of severe fatigue, and 78 vs 20% normal physical functioning).

Graded exercise therapy has been shown in randomized trials to improve fatigue and physical functioning (albeit not always with overwhelming success, such as 51% vs 27% self-rated improvement).

I'm always happy to challenge my assumptions, but I cannot find any references in a brief search of the literature to suggest that appropriate exercise in chronic fatigue is harmful or worsens cognitive functioning, or that it decreases energy or promotes anhedonia (lack of enjoyment in life). It's possible exercise had these effects on you, but I confess I'd wonder if you might benefit from a more organized graded exercise regimen perhaps with the initial supervision of a physical therapist conversant with chronic fatigue - it may not be something you can start out on your own - graded exercise really means starting out more gently than people may otherwise think is beneficial.

White PD, Goldsmith KA, Johnson AL, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011; 377:823.
Sharpe M, Hawton K, Simkin S, et al. Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. BMJ 1996; 312:22.
Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry 1997; 154:408.
Deale A, Husain K, Chalder T, Wessely S. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study. Am J Psychiatry 2001; 158:2038.
Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ 1997; 314:1647.
Sharpe M, Wessely S. Putting the rest cure to rest--again. BMJ 1998; 316:796.

Comment: Re:anti-fat stigma (Score 1) 446

by dmr001 (#43826957) Attached to: Med Students Unaware of Their Bias Against Obese Patients
Your doctor may indeed be a dick, and if he's truly blaming you he's certainly not being fair or helpful. Among my patients with reactive arthritis, they find exercise challenging and they complain of pain but it doesn't seem to be much more of a barrier to them than patients with non-inflammatory arthritis - for whom the most useful therapy I probably prescribe is appropriate exercise. For chronic fatigue syndrome (I suspect that's the CFS you're talking about) the mainstays of treatment are cognitive behavior therapy and exercise. As you might expect, lack of exercise in chronic fatigue sufferers worsens the symptoms of physical weakness. Overly ambitious exercise can worsen symptoms in chronic fatigue sufferers, but that's a prescription for graded exercise regimens. Everyone feels more tired after exercise - more so in chronic fatigue - which makes initiation and maintenance of an exercise regimen more challenging.

Your doctor may be frustrated because he doesn't know how to help you, or because he doesn't have enough time to provide the help you need. Most of us really did get into this profession to help people (in my experience anyway) and when a patient can't readily be helped despite our efforts I confess you may see my frustration leaking through.

I hope you can find someone more sympathetic, but I suspect what's going to be most successful for you is someone who can help figure out a way for you to effectively exercise without making you more miserable.

Comment: Re:anti-fat stigma (Score 1) 446

by dmr001 (#43826881) Attached to: Med Students Unaware of Their Bias Against Obese Patients
Probably the most common underlying cause of post-operative infections in the typical C-section incision is obesity. If much of the subcutaneous tissue is fat (easier for fluid collections to form), or there is a large pannus (fold of fat at the bottom of the belly) leading to poor wound drainage and colonization with various skin bacteria, one is asking for trouble. Other risk factors for surgical site infections in general include age, smoking, and diabetes.

1.SHEA, APIC, CDC, SIS. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:599.
2.Cruse PJ. Surgical wound infection. In: Infectious Diseases, Wonsiewicz MJ (Ed), WB Saunders Co, Philadelphia 1992. p.758.

Comment: Re:Why are they getting 6 (Score 2) 83

by dmr001 (#42738917) Attached to: Polymer Patches May Enable Effective DNA Vaccines
As time goes by, we've come up with more vaccines. See the current CDC vaccination schedule (http://www.cdc.gov/vaccines/schedules/). Many vaccines arrive in one syringe now (like combined diphtheria-pertussis-tetanus-polio-H flu in Pentacel). Some folks miss a bunch of appointments and need to get caught up, in which case under rare circumstances I've been known to give up to 6 at once. In routine visits, though, it's usually 4 at the 2 month visit, 3 at the 4 month visit, etc. Recommendations vary somewhat in different countries. As there is no evidence that giving multiple vaccines is harmful (as any human child is exposed to billions of antigens a day just crawling around the carpet), but plenty of evidence that missing vaccines is risky, we sometimes end up giving a bunch at once to err on the side of safety.

Comment: Re:Question: (Score 1) 439

by dmr001 (#41864081) Attached to: Massachusetts May Soon Change How the Nation Dies
As a physician who frequently attends my patients of dying of cancer and other terminal conditions, working closely with our hospice service, I assure you can be varying levels of suffering among those in their last weeks. Most people (but not all) can be made more comfortable with opiates for pain and air hunger (especially those dying of pulmonary disease); benzodiazepines (like diazepam and lorazepam) can provide relief for anxiety, and anti-cholinergics can help with excessive secretions. We try to have the patient in control to the extent possible. Here, in Oregon, where the Death with Dignity Act has been playing out for years with a marked lack of apocalypse, one of its attractions and advantages is that doomed patients can control their own destiny without devolving it onto family members and the medical system. One claim is that this also substantially decreases another form of suffering: the loss of control of your own misery (and destiny).

Comment: Re:The dead as demi-gods (Score 2) 48

by dmr001 (#41747821) Attached to: The Virtues of the Virtual Autopsy
In my experience (as a physician) most objections to an autopsy are from family members who don't like the idea of their loved ones being opened up and disassembled.

But there are major religions which objections to autopsy as well, including Islam and Judaism, though as usual it seems to depend on the local imam/rabbi.

I'm sure they are out there, but I've never actually known a case of a physician objecting to an autopsy for fear of uncovering their errors. The egotistical among us I suspect feel they would likely be exonerated, and many (perhaps most others in these parts anyway, among my colleagues in the US Pacific Northwest) honestly would want to learn from their mistakes. Nevertheless, it's hard to figure out who funds them, and many families tend to feel it's a final act of violence. Still, it's hard for me to wrap my head around getting a more accurate, cost-effective answer from a CT scan than a old-fashioned postmortem.

Comment: Re:Here we go (Score 1) 293

by dmr001 (#39736931) Attached to: In Calif. Study, Most Kids With Whooping Cough Were Fully Vaccinated
While flu vaccines with adjuvants have been used in Europe over the last few years, I am not aware of any vaccines with adjuvants licensed or used in the United States in several decades (including intramuscular and nasal vaccines). See N Engl J Med. 2010;363(21):2036, http://www.nejm.org/doi/full/10.1056/NEJMra1002842. This is regrettable, as increased complication rates appeared to be minimal or none (on the order of increased redness at the injection site for some patients), and vaccines with adjuvants seem to be a lot more effective. The reason vaccines with adjuvants aren't available in the US is because of concerns of safety, not all of which are well-informed.

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