Tuesday, October 21, 2008

ADHD: Back To Nature?

In The Cockroach Catcher:

“It has to be one of the few most enjoyable things in life to be able to watch wildlife in its natural habitat. Most will agree that going to the zoo, watching Discovery or National Geographic channel is not going to be the same. Others argue that your presence alone or with a group of like minded people would have made the situation unnatural. I have no argument with the latter view, but there can hardly be a better alternative. If more of us can see wildlife in its most natural setting, then we can begin to see the need to preserve nature for the generations to come, not just building zoos or aquariums and ignoring the natural environment in which these animals thrive.”

Sights like this one?

Now someone might have found another useful effect of "NATURE”.

The New York Times headline on October 17, 2008:
A ‘Dose of Nature’ for Attention Problems

A study, published online in the August The Journal of Attention Disorders, found that children were able to focus better after the "green" walks compared to walks in other settings.

"After each walk, concentration was measured using Digit Span Backwards. Results: Children with ADHD concentrated better after the walk in the park than after the downtown walk or the neighborhood walk. Effect sizes were substantial and comparable to those reported for recent formulations of methylphenidate.”

In my clinical practice I’ve come across many parents trying to look for a non-drug based approach to deal with the problem. Unfortunately one can see how unpopular such a study would be for drug firms.

The study conducted at the University of Illinois only evaluated 17 children with attention deficit hyperactivity disorder, who all took part in three 20-minute walks: in a park, in a residential neighborhood, and in a downtown area. This is in essence a small scale study and I doubt if it would really make any impact on our own NICE guidelines.

The Times article stated:
"Although the study is small, the data support several earlier studies suggesting that natural settings influence
psychological health. In 2004, a survey of parents of 450 children found that "green" outdoor activities reduced A.D.H.D. symptoms more than activities in other settings.

"Despite the small size, the study is important because it involves an objective test of attention and doesn’t rely on children’s or parents’ impressions. During the walks, all of the children were unmedicated — participants who normally took medications to control their A.D.H.D. symptoms stayed off the drugs on the days of the walks.

"The researchers found that a ‘dose of nature’ worked as well or better than a dose of medication on the child’s ability to concentrate. What’s not clear is how long the nature effect can last.

"Dr. Kuo said it’s notable that parents themselves consistently report benefits for their children from green settings.”

Well, as far as The Cockroach Catcher is concerned, he is all for any management approach that is obviously harmless. Even if it does not substantially help ADHD sufferers, a dose of nature is beneficial for anyone, and good news for those of us who believe that we should preserve as much of nature as possible for generations to come and perhaps for treating future ADHD cases.

Or this one?
Dr. Kuo will have the last words:
"We can’t say for sure, ‘two hours of outdoor play will get you this many days of good behavior,’ but we can say it’s worth trying. We can say that as little as 20 minutes of outdoor exposure could potentially buy you an afternoon or a couple of hours to get homework done.”

LINK: MENTAL NURSE---This Week in Mentalists (52)

Sunday, October 12, 2008

Hiccup Boy: A Reflection

In The Cockroach Catcher, in a Chapter called Hiccup Boy:

"Johnny was referred by his GP to me because he had been having non-stop hiccups for the better part of six months. It was unusual for the problem to have gone on for this length of time before being referred to me. His doctor was one of those who seldom referred anyone. He tended to believe that there must be a physical reason, especially for a condition like hiccups. The boy had even been to the National Hospital for Nervous Diseases at Queen Square and Great Ormond Street. Both sent him back to the GP saying that his problem was probably psychological and perhaps the local psychiatric clinic might be of help.”

In one session, I managed to get the boy to stop his hiccup.Bullying has to be recognized early and yet many parents fail to grasp how nasty other children could be.Schools do not want to acknowledge the existence of bullying either as that could be bad for the name of the school. Also, recognition requires action: action on bullying.

In the case of the “hiccup boy”, it is clear that the victim did not help himself. He was fat (like his mother) and he probably lacked in social skills. Not all intervention in our work needs hours and hours of therapy or talking treatment.

I reflected in the book:

“Child psychiatry is not about asking questions, but about feeling the answers. It is a discipline where empathy rules. It is important that you know within ten minutes or so what is wrong.”

“So within the first few minutes, I knew what to do.”I sent everybody away including my junior, Dr Zola.

“Dr Zola, would you mind taking mother to the other room to get some history?”

Training rules as dictated by managers nowadays would mean that I might be subject to disciplinary action for not allowing my junior to observe what I did. But then my plan required me to be alone with the boy. No matter. Modern management has no heart.

I had to save his face, I needed authority and he needed to believe that I could deliver. Imagine the modern day doctor desperately “Googling” for a NICE guideline in front of everybody and still failing to come up with anything other then: “We will try and do another MRI, have a conference and perhaps ask the psychologist to look into him and then meet with school.”
Meetings and conferences later, the boy could still be hiccupping.No, my intervention took less than 5 minutes and the whole session less than 40 minutes, including the time taken to pacify the junior so that she would not complain.

The Hiccup was cured. The boy was saved from further bullying. Work that followed included dietary advice, weight reduction for the obese mother and boy pair, and then, of course special educational arrangements.It was not difficult to pacify my junior doctor, as she trusted me and liked my style. We put up with some bad tempered teachers in our medical school days because these professors were good at what they did, and here I was not even bad tempered.

Further thoughts:

They say it is a tough world and kids need to learn early on. Maybe! But this boy was hiccupping for 6 months for a good reason. It was his defence and in a way it worked for him. He was not killed, nor did he commit suicide.

Could mum have done anything different? Sure, don’t indulge the boy in the wrong foods and drinks. But we all know it is easier said than done.

What about his family doctor? Here his belief that the hiccup had an organic origin led to six months of no progress, although I doubt if my intervention would have been as dramatic if he had only been hiccupping for a day or two. Most parents prefer a non-psychological diagnosis.

“It is often better though if you can somehow get the parents to do the magic cure.”

Indeed it should be the aim of most intervention in the specialty of Child Psychiatry. It is of course the principle of psychoanalysis that a patient should be able to gain insight without being told; unfortunately the patient could wait a life time for that to happen.

Thursday, October 9, 2008

Chinese Shared Nobel Prize in Chemistry

The three winners of the Nobel Prize for chemistry are (from right) Roger Tsien of the University of California, San Diego; Osamu Shimomura, a Japanese citizen who works at the Marine Biological Laboratory in Woods Hole, Mass.; and Martin Chalfie of Columbia University. AP

NPR provided the most concise report on this years Nobel Prize in Chemistry:

“Three scientists who created a method for unveiling the previously invisible machinery inside living cells, using a protein that glows in the dark, won the 2008 Nobel Prize for chemistry.

The winners are Osamu Shimomura, a Japanese citizen who works at the Marine Biological Laboratory in Woods Hole, Mass.; Martin Chalfie of New York's Columbia University; and Roger Tsien of the University of California, San Diego.”

“In the 1960s, Shimomura isolated what became known as the ‘green fluorescent protein,’ or GFP, from a kind of jellyfish. This protein glows bright green when it is exposed to ultraviolet light.


“Thirty years later, when scientists developed tools for cutting and splicing genes, Chalfie took the gene that produces this glowing substance and inserted it into cells of other living creatures, starting with bacteria. He was able to use this inserted gene as an easily detected tag, or visual marker. By attaching it to other genes, he was able to make specific proteins inside living cells glow green under ultraviolet light .

“Scientists cannot normally observe the complex dance of proteins that forms the basis of life, but GFP opened up a previously invisible world, revealing a wealth of detail about where, and how, those proteins work.

Nancy Kedersha

“Tsien expanded the technique, creating an entire toolbox of glowing genes. He tinkered with the GFP gene, creating new versions that glow cyan, blue and yellow. This allows researchers to tag different proteins with distinctive colors and observe their interactions.”

Most English speaking papers did not report on the fact that Tsien is of Chinese decent and is the nephew of the famous Tsien Hsue-shen 錢學森 who was the co-founder of JPL Jet Propulsion Laboratory at the California Institute of Technology. Iris Chang who wrote Nanking wrote a book called Thread of The Silkworm about Tsien Hsue-shen.

Roger Tsien 錢永健 was born in New York, in 1952. Both of Tsien's parents came from Zhejiang Province, China.

From the Howard Hughes Medical Institute Website:

"Tsien has always been drawn to pretty colors. 'Your science should ideally feed the deeper parts of your personality, to provide some intrinsic pleasure to tie you over the inevitable periods of discouragement,' he says. Tsien grew up among a number of engineers in his extended family, and even from a young age he seemed destined for a career in science. Childhood asthma often kept Tsien indoors, where he spent hours conducting chemistry experiments in his basement laboratory and was first exposed to the chemistry of pretty colors. At 16, he won top prize in the nationwide Westinghouse Talent Search. He later attended Harvard College on a National Merit Scholarship, graduating at age 20 with a degree in chemistry and physics."

From the Marshal Scholarship Website:

"Roger Tsien attended Harvard University on a National Merit Scholarship and graduated summa cum laude with a Bachelor of Science in chemistry and physics in 1972. After completing his bachelor's degree, he joined the Physiological Laboratory at the University of Cambridge in Cambridge, England with the aid of a Marshall Scholarship. He received his Ph.D in physiology from the University of Cambridge in 1977 and was a Research Fellow in Gonville and Caius College, University of Cambridge from 1977 to 1981."

Notable Nobel Laureates at HHMI included Eric Kandel (2000-Medicine).

Here is a slide show from the WSJ Blog. Fascinating.

Links: Tsien Website, HHMI

Tuesday, October 7, 2008

Nobel Prize: Morality and Medicine

From left, Dr. Harald zur Hausen, 72, of Germany, and French virologists Dr. Françoise Barré-Sinoussi, 61, and Dr. Luc Montagnier, 76.

               Thomas Kienzle/AP, Stephane De Sakutin/AFP— Getty Images, Luc Gnago/Reuters

The Nobel Prize in Medicine was awarded Monday to three European scientists who had discovered viruses behind two devastating illnesses, cervical cancer and AIDS.

Half of the $1.4 million award will go to a German physician-scientist, Dr. Harald zur Hausen, 72, for his discovery of
H.P.V., or the human papilloma virus. Dr. zur Hausen of the German Cancer Research Center in Heidelberg “went against current dogma” by postulating that the virus caused cervical cancer, said the Karolinska Institute in Stockholm, which selects the medical winners of the prize, formally called the Nobel Prize in Physiology or Medicine.
The link between human papilloma virus and cervical cancer took years to gain acceptance.

The Cockroach Catcher:

“Certain conditions were said to be linked to morality. Once upon a time cervical cancer was considered a sign of promiscuity and multiple partners. In medical school we were taught that circumcision was definitely related to very low or zero incidence of this amongst the Jews. It was a convenient way of fitting findings to a view. Little was said of other religious groups with similar circumcision rituals that had the same cancer rate as non circumcised communities. Now that high risk HPVs have been identified and a vaccine manufactured, we can look forward to a complete eradication of the condition.”

The New York Times reported on the Nobel Prize in Medicine for 2008:
"In the 1980s, an American researcher said that financing agencies in the United States had rejected as unpromising his grant proposals to study links between papilloma viruses and cancer. The
National Institutes of Health did not reply on Monday to questions about such proposals.
"In 1983, Dr. zur Hausen discovered the first H.P.V., type 16, among biopsies of women who had cervical cancer. He went on to show that more than one H.P.V. type could lead to cervical cancer, in part by cloning H.P.V. 16 and another type, 18. Further research has shown that the two H.P.V. types are consistently found in about 70 percent of cervical cancer biopsies throughout the world, the institute said.
"The United States Food and Drug Administration has approved one papilloma virus vaccine, Gardasil, for girls and women ages 9 to 26 and with advice that they get immunized before sexual activity begins. Because the vaccine was developed recently, doctors do not know for how long it will last. (GlaxoSmithKline produced Cervarix that is approved in Europe.)
"Since its discovery in 1981, AIDS has rivaled the worst epidemics in history. An estimated 25 million people have died, and 33 million more are living with H.I.V.
"In 1983, Dr. Montagnier and Dr. Barré-Sinoussi, a member of his lab at the Pasteur Institute in Paris, published their report of a newly identified virus. The Karolinska Institute said that discovery led to blood tests to detect the infection and to anti-retroviral drugs that can prolong the lives of patients. The tests are now used to screen blood donations, making the blood supply safer for transfusions and blood products.
"The viral discovery has also led to an understanding of the natural history of H.I.V. infection in people, which ultimately leads to AIDS and death unless treated."
Dr. Montagnier and Dr. Barré-Sinoussi share the other half of the Nobel Prize in Medicine, traditionally the first Nobel to be awarded each year.

Friday, October 3, 2008

It Pays To Be A Taditionalist: Seroxat

In an earlier blog---Seroxat and Ribena

……“The Cockroach Catcher, Dr Am Ang Zhang had an interesting discussion with his Junior who had just transferred from one of the top London teaching hospitals:

“Do you agree that Leroy has Social Phobia ? Everything fitted in with the criteria in DSM IV.” My junior plucked up courage to ask me during supervision. It was good to keep oneself on one’s toes with juniors who had just arrived from London and who read up on everything.
“What’s wrong with shyness?” I joked, “Do you want me to put him on SSRI (Selective serotonin reuptake inhibitors)?”
“It is supposed to work.”
“If he starts taking SSRI at thirteen, what is he going to do for the rest of his life?!”
“The newer short acting ones are supposed to be better.”
Take one advice from me; think the opposite, the opposite to what the big Pharmas tell you. In pharmacology, shorter acting drugs are more addictive. That was what I learned in Medical School and is still true if you think carefully about it.”……

Reuters on the 2nd of October reported:
Glaxo settles U.S. Paxil lawsuit for $40 million.
LONDON, Oct 2 (Reuters) -
"GlaxoSmithKline has agreed to settle a long-standing U.S. case over its antidepressant Paxil by paying insurers $40 million to reimburse health plans that paid for children and adolescents to receive the drug.

The agreement ends class-action litigation against Glaxo over the issue, after the British-based drugmaker was sued for allegedly suppressing studies showing the drug was not suitable for children.

Last year, Glaxo agreed to pay $64 million to consumers in another class-action settlement. In both cases Glaxo did not admit liability. Although Paxil was never approved for use by children, doctors could prescribe it on an 'off label' basis, although Glaxo was not allowed to promote it for this purpose.

Stricter warnings were issued for the drug, however, after clinical trial data raised doubts about the safety of antidepressants for those under age 18 and the risk that the medicine -- and others of a similar type -- might increase suicidal behaviour.

Under the latest settlement, Glaxo will reimburse insurers who paid for a Paxil prescription for use by a minor between 1998 and 2004. Insurers may claim a refund of 40 percent of their actual costs of the drugs prescribed to children and adolescents diagnosed with a major depression, or 15 percent of the cost if the diagnosis was unknown."

Paxil(US) and Seroxat(UK) are the tradenames of paroxetine manufactured by GlaxoSmithKline (GSK) and belongs to the group of shorter acting SSRIs-(selective serotonin reuptake inhibitor) that The Cockroach Catcher’s junior referred to.

Perhaps it pays to be a traditionalist.

GSK is also involved in a fresh new case of a prominent psychiatrist claiming he received $34,998 when it was in fact $960,488; the New York Times reported on the 4th of October.

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