Non-Fried Fish Reduces Risk of Pancreatic Cancer

Cancer of the pancreas (aka pancreatic cancer) is the fourth most common type of cancer in the U.S. Cancer is any of a large group of malignant diseases characterized by an abnormal, uncontrolled growth of new cells in one of the body organs or tissues. The pancreas is a long organ behind the stomach that produces several types of hormones and helps digest food with pancreatic juices that contains enzymes.

Unlike some type of cancers (e.g., lung cancer) there are no established guidelines for how to specifically prevent pancreatic cancer. This is unfortunate given the poor prognosis that this disease typically has. There is some evidence that vitamin B can reduce the risk of pancreatic cancer when consumed in food, but not when consumed in vitamin tablet form. Some fish, such as tuna and trout, are high in B vitamins. Fish is also high in a type of “good fat” known as long chain polyunsaturated fatty acids (LC-PUFAs). LC-PUFAs are types of “good fat” because they have many positive health benefits such as supporting normal growth, supporting the immune system, and improving brain and heart health. They may also be beneficial against cancer due to their anti-inflammatory properties (inflammation plays an important role in cancer development).

While fish intake has never been associated with decreased or increased pancreatic cancer risk, the association between types of fish and fish preparation methods and pancreatic cancer is unknown. In an upcoming research article published in the American Journal of Epidemiology, researchers from Indiana University presented the results of a study that analyzed this topic in more detail. It was a very large study, involving 66,616 adults ages 50-76 years. Subjects were followed-up for an average of 6.8 years and during that time, 151 people developed pancreatic cancer.

The researchers found (via questionnaire) that a lower incidence of pancreatic cancer was associated with non-fried (e.g., broiled, baked) fish and LC-PUFAs. Of note, frying fish significantly reduced LC-PUFAs. There are different types of LC-PUFAs and the researchers found that the association between lower pancreatic cancer and LC-PUFAs was greater for docosahexaenoic acid (DHA) than for eicosapentaenoic acid. The authors noted that this may be because DHA is better at reducing inflammation because it is more readily incorporated into tissues.

Consumption of fried fish and shellfish (e.g., shrimp, lobster, crab, oysters) was not shown to help decrease pancreatic cancer. The authors noted that chemical byproducts from frying foods may contribute to the development of pancreatic cancer and that combining non-fried fish with fried fish or shellfish would likely decrease the benefits of eating non-fried fish regarding pancreatic cancer incidence.

Suggested reading: 100 Questions & Answers About Pancreatic Cancer, 2nd ed

Reference: He K, Xun P, Brasky TM, Gammon MD, Stevens J, White E. (2013). Types of Fish Consumed and Fish Preparation Methods in Relation to Pancreatic Cancer Incidence: The VITAL Cohort Study. Am J Epidemiol. 177(2):152-60.

Are You Prepared For Your Child's Potential Health Emergency?

If you think you are protecting your child by simply knowing the 911 digits and having 24/7 access to a phone, then you are not doing enough. Helping your child in a potential health emergency requires you to take immediate action as well; so are you prepared to face a bad day without waiting for the emergency team to arrive?

If you answered no for the above question, it is time for you to learn some important first aid techniques. Our children are our most prized assets, and anything coming in the way of their health is unwelcomed.

You never know when your child would knock over a boiling teapot on themselves, cut their hand, or even have an unforeseen seizure. Be equipped with the essential information needed in such a situation; here are some pointers to remember:

Call the Health Helpline

It is not good to rely solely on the emergency medical teams, but you cannot help your child without professional consultation either. In case of an emergency, your first step should be to call a medical agency like Md Aligne Telehealth Services. If you are busy looking after your child, instruct someone else to do so. Always keep phone numbers of unswerving emergency teams handy, you might never know when the need to dial them arises.

Help Reduce Fear

Calm everyone down in the house, including the child. Panic is your worst enemy in such a situation. Relax, and think what needs to be done foremost. If you are in a state of alarm, you might give your child incorrect medical aid. For example, some burns require you to hold them under running water, whereas others need to be covered under a blanket (depending on the degree and nature of the burn); you might give the wrong treatment under panic.

Know How to Handle Most Situations

This is very important; you must know how to deal with multiple emergency situations including seizures, broken limbs, burns, head injuries, and fainting. Your child might start choking during dinner, or get hurt during playtime. Every parent must know how to handle such emergencies.

Stock your First Aid kits with all the necessary items. Antiseptic ointments, wiping medical towels, bandages, sterilized cotton, instant cold packs, disposable gloves, and aspirin are the basics every household must have. Keep a stock of medicines that are anti-diarrhea, anti-histamines, anti-allergic, anti-burn, and even strong instant pain relievers. Have a first aid manual that tells you about the correct dosages of these medicines.

Note that most First Aid items are for limiting the spread of infection; it is important not to trigger any further infections while you are helping the child. When you are treating wounds, clean them with antiseptic first.

Millions of children receive medical aid every day; you never know when it is your child’s turn. Having someone at home with sound knowledge of first aid emergencies is crucial. The actions taken during the first few minutes of an emergency are most important; ensure that these actions are in your favor!

The above entry is a guest blog entry.

Who Uses the Emergency Room Most? The Answers May Surprise You

There is a stereotype that the most frequent users of emergency rooms (ERs) are those who do not have health insurance and/or who present for non-urgent reasons. While the uninsured do use the ER often, the best way to determine who uses it the most and why is to do a formal research study on the topic.

In an upcoming article in the American Journal of Emergency Medicine, researchers presented the results of such a study.

In the study, frequent use of the ER was defined as 9 or more visits in a one year period. This represented the top 1% of ER use. The researchers administered questionnaires to adults in this group. Of note, patients excluded were those who presented to the ER intoxicated, with altered mental status, or acute (sudden) psychosis (detachment from reality).

Over a one year period from 2009 to 2010, the researchers identified 115 frequent ER users. Twenty three percent had a psychiatric condition (usually presenting for suicidal thoughts). The average patient presented to the ER 22 times. The average age was 44. Regarding gender, 57% were male and 47% were female. Regarding education, 44% had a high school education or GED, 43% had less than a high school education, and 11% had a college education. Lower educational level was not correlated with higher ER use. Regarding race, 92% were black, 11% were white, and 1% were Hispanic.

In terms of annual income, 69% earned less than $10,000 a year. Only 5% earned more than $40,000 a year. Patients used the ER more frequently if they had lower income, transportation problems, problems with shelter, and high prescription costs (32% could not afford prescriptions). Twenty-seven percent reported being unable to afford a clinic visit. Seventy-eight percent reported having adequate health insurance whereas 22% did not. The number of ER visits between insured and uninsured patients was comparable.

Seventy-five percent of patients had one or more chronic medical conditions and identified the ER as the primary place they went for health care. Of the ER users, 63% were admitted to the hospital and 50% were admitted more than once. The most frequent reason for admission was end stage renal disease. Four hundred and sixty hospital admissions were for medical reasons and 22 were for psychiatric reasons.

In terms of the most frequent medical diagnoses, 59% had high blood pressure, 19% had congestive heart failure, 19% had diabetes mellitus, 16% had end stage renal (kidney disease), 12% had coronary artery disease, and 9% had chronic obstructive pulmonary disease (COPD). Congestive heart failure is an imbalance in the pumping action of the heart that causes inadequate blood circulation. In diabetes mellitus, the body is not able to effectively use a natural chemical called insulin, which quickly absorbs glucose (a type of sugar) from the blood into cells for their energy needs and into the fat and liver cells for storage. Coronary artery disease is a narrowing of coronary arteries, which are blood vessels that supply the heart with blood. COPD is a general term for diseases that are characterized by long-term or permanent narrowing of small airways (known as bronchi) connected to the lungs.

The authors noted that their findings echoed prior studies that found that the most frequent ER users have some form of health insurance and access to a primary care provider, but used the ER as their primary source of health care despite such access. The authors noted that it is plausible that the primary health care providers may not be able to meet the needs of these patients which is why they go to the ER. The authors noted that future studies should examine if a medical home may be a better place for these patients to meet their needs to ease the strain on the ER. A medical home (or patient-centered medical home) is a team-centered health care system led by a medical doctor, nurse practitioner, or physician assistant to provide comprehensive and continuous health care. At present, there are not many medical homes in the U.S.

Suggested reading: Confessions of Emergency Room Doctors

Related blog entry: Decreased Child ER Visits after LA Lakers Title Games

Reference: Miller JB, Brauer E, Rao H, Wickenheiser K, Dev S, Omino R, Stokes-Buzzelli S. (2013). The most frequent ED patients carry insurance and a significant burden of disease. Am J Emerg Med. 31(1):16-9.

Endometriosis 101: A Primer

Endometriosis is a condition in which the tissue that normally lines the inside of the uterus (endometrium) is found outside the uterus. This condition, which affects up to 10% of reproductive-age women, is described in detail on MedFriendly.com, which you can access by clicking the previous link. An updated review on endometriosis was recently published in the journal, American Family Physician. In the review, the authors noted that endometriosis occurs in 25 to 40% of women with pelvic pain and 70 to 90% of women who are infertile (not able to reproduce).

While some women with endometriosis do not have symptoms, it can be associated with symptoms such as severe pelvic pain, painful menstruation, and pain during intercourse. While patients with endometriosis may initially present to their family practitioner, a referral to a gynecologist typically occurs, especially if the woman remains infertile and has persisting symptoms.

Diagnosis of endometriosis is based on a medical doctor evaluating the patient’s signs and symptoms and can be aided by a biopsy, in which a tissue sample is removed and analyzed under a microscope.

Initial treatment often included medications to reduce inflammation. Birth control medications are also used that effect levels of progestins and/or estrogen levels. These are both types of hormones. Estrogen is believed to promote endometriosis, which is why use of medications that lower estrogen levels can be used to manage the condition. Progestins thin the uterine lining and suppress the natural cycle of the ovary, the latter of which interferes with the menstrual cycle. The authors of the review article noted that there is some evidence that these medications can be helpful and have few side effects.

There are other treatments for endometriosis such as gonadotropin-releasing hormone agonists (GnRH). These medications produce a massive increase in GnRH which overwhelms the body and causes the ovaries it to shut down estrogen production. Another treatment is Danazol, which also reduces estrogen levels and shuts down the estrogen cycle. Surgery is another option, which involves removal of the endometrial tissue. The authors of the review noted that these interventions may control symptoms better than initial treatments but that they can have significant side effects and limits on how long the therapy can last.

For more detailed information on endometriosis discussed in this blog entry, please see the MedFriendly entry on endometrosis and/or the article below. Also, feel free to leave your comments regarding personal experiences with endometriosis in the comment section below.

Suggested reading: 100 Questions & Answers About Endometriosis

Reference: Schrager S, Falleroni J, Edgoose J. (2013). Evaluation and treatment of endometriosis. Am Fam Physician. 87(2):107-13.

Aquariums for the Treatment of Dementia (Alzheimer’s) in Nursing Homes

Dementia is a disorder characterized by a significant loss of intellectual and cognitive abilities without impairment of perception or consciousness. There are many different cause of dementia such as severe traumatic brain injury, stroke, and progressive neurological disorders.

Of the progressive types of dementia, Alzheimer’s disease is the most common form of dementia in the elderly. Dementia is very common (>50% prevalence) in people living in nursing homes.

There are many signs of symptoms of dementia such as memory loss, language impairment, emotional blunting, decreased energy, and weight loss due to poor nutritional intake. Weight loss leads to many problems in patients with dementia, particularly those with advanced forms of the disease. For example, because the person has less muscle mass, they are more prone to falls and injuries that can result for this such as bone breaks. Due to decreased mobility, weight loss can also increase the risk for pressure sores (skin ulcers), pneumonia, and other health problems. Decreased food intake also results in costly waste of food for uneaten prepared meals.

As a result, interventions are needed to help increase weight in people with dementia. While there are medications designed to increase appetite, they have had mixed results and can lead to numerous side effects including sedation, blood clots, and edema (swelling). Encouraging eating by staff has also produced mixed results and is a costly intervention in nursing homes due to the one on one attention it requires.

To address this issue, researchers from Purdue University studied whether individuals with dementia who observed aquariums increased food intake and maintained body weight. The study involved 70 residents in three extended care facilities in two states. A large aquarium (30 x 20 inch viewing area) was placed in the common dining area of both facilities. Each aquarium had 8 large colorful fish that were quick swimmers. The study found that aquarium placement was associated with a 25% increase in food intake over the 10-week study period. This amounted to an average 2.2 pound weight gain during the study. Eight of the 70 residents (11%) experienced weight loss during the study. A benefit of this intervention is that there are no side effects.

The authors stated that attraction to the natural environment (especially animals) is so innate that it survives dementia. Watching aquariums has been associated with decreased stress, less blood pressure, and increased satisfaction in other studies. It is possible that increased satisfaction and mental stimulation from observing the aquariums leads to increased food intake.

Suggested reading: The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Disease, Related Dementias, and Memory Loss

Reference: Edwards NE, Beck AM. (2013). The Influence of Aquariums on Weight in Individuals With Dementia. Alzheimer Dis Assoc Disord, in press.

CPAP for Sleep Apnea: Is it Worth It?

Obstructive sleep apnea (OSA) is a disorder in which a person does not breathe for periods of time while sleeping due to the presence of an upper airway obstruction. It is believed that one in five American adults have at least a mild sleep apnea. It is common in people who are obese. There are numerous treatment options for OSA, one of the most common of which is CPAP.

CPAP stands for continuous positive airway pressure. It involves placing a mask over the face that blows pressurized air into the airway to keep it open. The mask is attached to a tube and machine.

Typically, sleep studies can provide objective evidence that CPAP is beneficial to the individual by studying them on certain parameters (e.g., oxygen saturation levels) with and without CPAP. Although CPAP can be beneficial, there can be many disadvantages to using the device as described below.

Recently, researchers conducted a study to evaluate the experiences of 15 obese CPAP users via semi-structured interview. The researchers found three common experiences. One theme was being restricted in everyday life. This included consequences on social life (e.g., disruption of bed partners, embarrassment when traveling, difficulty bringing it when travelling, and marks on the face that remained the next day (also causing embarrassment). There were also difficulties noted maintaining some bed routines (e.g., reading in bed before falling asleep).

A second them was coming to terms with wearing CPAP. This was largely due to physical discomfort such as difficulty fitting the mask on, a dry nose sometimes leading to nose bleeds, difficulty using it during a cold, discomfort from the mask or straps, and air leakage. Coming to terms with using CPAP also had to do with difficulties caring for the equipment, getting used to using it, learning how to use it, dealing with the noise of the machine, adhering to use of it each night, and spousal disruption/acceptance. Only 1 of the 15 people interviewed got used to using the machine quickly. However, despite the initial difficulties, participants eventually integrated CPAP into their lives and felt it was worth the trouble.

A third theme was that despite the problems noted above, using CPAP helped the participants get a new life. Specifically, they reported sleeping better, feeling more alert, and having more energy to do things, improved social life, and an improved sense of well-being. The authors noted that incentives were important to support the use of CPAP due to the many disadvantages in brings.

Suggested reading: Sleep Apnea and CPAP - A User's Manual By a User
 
Reference: Willman, M., et al. (2012). Experiences with CPAP treatment in patients with obstructive sleep apnea syndrome and obesity. Advances in Physiotherapy, 14: 166–174

Diabetes Treatment and Management

Despite extensive research, numerous medications that have come to market, and continued scientific advances, a cure for diabetes has yet to be found. However, there are numerous medications and forms of management equipment for diabetes and the future brings great hope for continued progress in the search for a cure.

Bringing new medications and disease managing equipment to market can be slowed by barriers within the pharmaceutical company industry. In addition, the FDA has a whole host of rules, regulations and legal barriers that slow down the research, creation and commercialization of cures. However, the American Diabetes Association is hoping to encourage research with their “Pathway to Stop Diabetes” program.

There has been research done that speculates that type 1 diabetes may be reversed by a tuberculosis vaccine. The vaccine is called bacillus Calmette-Guérin (BCG) and it stimulates production of a protein that kills insulin-attacking cells, according to a study published in PLOS One Journal. The study showed that 2 out of 3 patients given the BCG injection had signs of renewed insulin production. They are now planning on a larger study pending on funding.

No one knows what cures the future will bring. In the meantime, sufferers of diabetes type 1 and type 2 should continue maintenance treatments. The difference between type 1 and type 2 diabetes is how the body produces insulin. In type 1 diabetes, the body does not produce insulin. In type 2 diabetes, the body produces insulin, but it either does not produce enough or it does not utilize it properly. Untreated diabetes can lead to serious conditions such as heart disease, stroke, loss of limbs, and damage to the nerves, eyes or kidneys. A cure for this serious condition would help so many sufferers.

Blood sugar is monitored usually by a finger stick and a portable machine which you can learn more about at http://www.dexcom.com. Such a device will read your glucose levels, indicating how much—if any—insulin is required. Patients should monitor their blood sugar levels at the same time every day for consistency.
Medication treatments include insulin injections or pumps and prescription medications. Common prescriptions include Metformin, Glipizide and Glimepiride.

Lifestyle and knowledge are important factors in treating and maintaining diabetes. Do your research. Be committed to maintaining your diabetes in hopes of a cure someday. Many suffers are overweight. Losing weight helps your body in many facets, including utilizing blood sugar. Eat a diet full of fruits, veggies, whole grains and limit bad fats such as saturated and trans fats. Some professionals recommend the Glycemic Index (GI) diet, which monitors carbohydrate-rich foods by how fast the body turns them into blood sugar versus the “no sugar” diet. Regular exercise is also extremely important. Aim for 30 minutes a day of aerobic exercise. 

You also want to keep up to date with eye and foot examinations, as these can be problem areas for diabetes sufferers. The sooner a problem is detected, the better.

The above entry is a guest blog entry.

The Stomach Bug/Flu in Children: What Works & What Doesn’t

You know of it as the stomach bug or the stomach flu (even though it is technically not related to the actual flu). Medical doctors refer to it as gastroenteritis because it involves inflammation (which is what “itis” means in Greek) of the stomach (gastro) and small intestines (entero). The small intestine is the part of the intestine that takes in all of the nutrients the body needs.

Regardless of what you call this condition, it is not something you want to have. Common signs and symptoms include diarrhea, stomach pain, stomach cramps, and vomiting.  It is a common reason for visits to the doctor, urgent care centers, and emergency rooms.

The stomach bug can occur in adults but it is very common in children. When it occurs in children, it is usually caused by a virus known as rotavirus.  By age five, nearly every child in the world has been infected by rotavirus at least once.

In a new review study published in Europe, researchers presented a summary of the best evidence for treatment of acute gastroenteritis in children. The authors found that oral rehydration (drinking fluids by mouth) is central to treatment.  Specific hypotonic solutions (composed of salt, sugar, and water) are used for this rehydration.  Although effective, oral rehydration is not always used because it does not decrease the amount of bowel movements, does not decrease the length of the illness, and the liquid is not something children enjoy due to the strong salty taste. There are continuing efforts to improve the taste and effectiveness of these liquids for children.

The authors found that the anti-diarrhea medication, Racecadotril  (acetorphan) can be an effective additional treatment along with oral rehydration. The authors also noted that a natural clay known as smectite can be an effective additional treatment to oral rehydration. However, neither smectite nor Racecadotril are available for use in the U.S.

When oral rehydration is not feasible, another option is nasogastric rehydration. In this technique, fluid is directed to the stomach through a tube placed in the nose that connects it to the stomach. This technique is sometimes used over a 24 hour period but newer evidence shows that doing this rapidly over 4 hours is also effective. The authors found that nasogastric hydration can be an effective or better than intravenous hydration, which is when a needle is inserted through the vein and liquid enters the body.  For cases of intravenous hydration, evidence on the amount of fluid to administer was not consistent. The authors considered 20 ml/kg to be appropriate, which is standard intravenous rehydration.

Medications used to stop vomiting are known as anti-emetics. A common medicine used for this purpose is Ondansetron (Zofran). The authors noted that this medication does reduce vomiting in young children with the stomach bug but that there was no evidence that other medications were useful for this purpose. It was noted that the Food and Drug Administration (FDA) recommends heart monitoring in patients receiving Zofran who have potential electrolyte abnormalities (which someone with the stomach bug would) because it can lead to abnormal and potentially deadly heart rhythms. Electrolytes are chemical substances that are able to conduct electricity after they are melted or dissolved in water.

The authors reported on one European study that did not show that the element, zinc, was useful in treating gastroenteritis. Lastly, the authors found that some probiotics are helpful in managing diarrhea gastroenteritis. Probiotics are live microorganisms that provide health benefits to the host. Specific probiotics found to be helpful were Lactobacillus GG and S. boulardii but that others may prove helpful in the future as well as synbiotics. Synbiotics are combinations of probiotics and prebiotics. Prebiotics are undigestible food ingredients that promote growth and/or activity in the digestive system in ways claimed to be beneficial to health.

Suggested reading: Viral Gastroenteritis

Related blog entry: Preventing Rotavirus with Vaccines: Do They Work?

Reference: Pieścik-Lech M, Shamir R, Guarino A, Szajewska H. (2013). Review article: the management of acute gastroenteritis in children. Aliment Pharmacol Ther. 37(3): 289-303.

Ovarian Cancer: Treatment with Avastin

Ovarian cancer is a serious disease diagnosed in over 20,000 women a year in the U.S. alone. Cancer is any of a large group of malignant diseases characterized by an abnormal, uncontrolled growth of new cells in one of the body organs or tissues. As the name suggests, ovarian cancer is cancer of the ovaries. The ovaries are a pair of glands that contain the eggs (female reproductive cells) and produce female hormones. Hormones are natural chemicals produced by the body and released into the blood that have a specific effect on tissues in the body.

Signs and symptoms of ovarian cancer are usually absent or subtle in the early stages of the disease, which is why it often goes undetected initially. Signs and symptoms typically include bloating, increased fluid in the abdomen area, pain in the abdomen, pelvis, or back, a mass in the abdomen, difficulty eating, weight loss, urinary difficulties, constipation, fatigue, and abnormal bleeding from the female reproductive area. Because the condition can go undiagnosed for so long, when the disease is detected in later stages, the prognosis is usually poor.

Treatment of ovarian cancer usually involves chemotherapy medication after surgery. There are many different chemotherapy options and combinations for women with ovarian cancer, which largely depends on the tumor type (when analyzed microscopically). One such chemotherapy medication is Bevacizumab (trade name Avastin). Avastin is known as an angiogenesis inhibitor, which means that it slows the growth of new blood vessels. This is important because tumors (cancerous masses) are highly dependent on blood vessel formation.

Avastin was first made commercially available for the treatment of colorectal cancer in 2004. At the time of this writing, Avastin is approved by the Food and Drug Administration (FDA) to treat additional cancers but is not yet approved to treat ovarian cancer in the U.S. However, Avastin is approved for ovarian cancer treatment in Europe.

Several clinical trials have been conducted in the U.S. to explore the role of Avastin in ovarian cancer treatment. This research was recently summarized by researchers in the medical journal, Advances in Therapy. The authors noted that adding Avastin as part of a first line treatment in advanced ovarian cancer and as maintenance therapy improves progression-free survival (PFS). PFS is the length of time during and after medication or treatment during which the disease being treated (e.g., cancer) does not worsen. Avalide has also shown benefit with respect to PFS in relapsed ovarian cancer that is sensitive to or resistant to platinum-containing chemotherapy.

While benefit to using Avastin in ovarian cancer treatment has been demonstrated, the authors noted that the medication is not without its side effects. Nevertheless, the authors concluded that Avastin represents a new option in treatment for ovarian cancer.

Suggested reading: Memoir of a Debulked Woman: Enduring Ovarian Cancer

Related blog entry: Ovarian Tumors in Children: They Happen

Reference: Heitz F, Harter P, Barinoff J, Beutel B, Kannisto P, Grabowski JP, Heitz J, Kurzeder C, du Bois A. (2012). Bevacizumab in the treatment of ovarian cancer. Adv Ther. 29(9):723-35.

Anti-depressants in Pregnancy: What are the Risks?

Women with major depressive disorder often become pregnant and women who are pregnant often develop major depressive disorder (referred to as depression going forwards). While the safest form of treatment for depression is counseling (usually with a psychologist) another common form of treatment is anti-depressant medication.

Anti-depressant medications, like all medications, have side effects and there is controversy about whether these medications should be used during pregnancy.

Researchers recently published a critical review of the scientific literature on anti-depressant medication use in pregnancy in the journal, Acta Psychiatrica Scandinavica. The authors found that no single type of birth defect has been consistently observed across research studies with any anti-depressant medication that is commonly used.  Some studies suggested associations between some specific birth defects and anti-depressant use in pregnancy but the findings were not consistent. 

These specific medications in which such inconsistent association were noted was in a class known as selective serotonin-reuptake inhibitors (SSRIs). SSRIS work to block the re-uptake of a chemical messenger in the brain known as serotonin. This makes more serotonin available, which improves mood. SSRIs are among the most commonly prescribed anti-depressant medications and are the most studied anti-depressant medications in pregnancy. Since all SSRIs cross the placenta, they can transport increased levels of serotonin to the fetus. The placenta is an organ in the uterus (a hollow organ in which a baby develops) that links the blood supply of the mother to the developing fetus and by which the fetus can release wastes.

Another finding was that postnatal adaptation syndrome (PNAS) occurs in up to 30% of neonates exposed to antidepressants in late pregnancy. PNAS is a cluster of signs and symptoms in infants that includes irritability, lack of energy, decreased activity, decreased feeding,  abnormal rapid breathing, abnormal crying, tremor, and difficulty breathing. PNAS usually lasts for days to weeks (up to 6 weeks) after delivery.  Some studies suggested a small association between persistent pulmonary hypertension of the newborn (PPHN) but others did not (the evidence is inconclusive). Pulmonary hypertension is when more blood than necessary is pumped to the lungs.

The authors cautioned that when evaluating research studies on this topic it is important to consider whether researchers took into account diagnoses of the mother or other factors that can confound the study outcome, whether they used adequate control groups (e.g., infants exposed to no medications or another class of medications), whether the infants were systematically  assessed, and whether those rating the infants knew if they were exposed to anti-depressant medications.

The authors suggested that doctors should have individually-tailored discussions with each pregnant woman about these issues who are considering anti-depressant use during pregnancy. They noted that past medication trials, previous success with symptom remission, and women’s preferences should guide treatment decisions.

Suggested Reading: Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting

Related Blog Entry: Preventing Post-partum Depression in Adolescent Mothers

Reference: Byatt N, Deligiannidis KM, Freeman MP. (2013). Acta Psychiatr Scand. 127(2):94-114. Antidepressant use in pregnancy: a critical review focused on risks and controversies.

Breast Cancer Staging: PET Scans, Ultrasounds, and Biopsies

Breast cancer continues to be a major health problem throughout the world and requires accurate staging to determine the most appropriate treatment and to estimate prognosis. Cancer staging describes the extent or severity of the disease. One way that cancer staging is determined is to assess if the cancer has metastasized (spread) to the lymph nodes. Lymph nodes are small egg shaped structures in the body that help fight against infection. The first lymph node (or group of nodes) that cancer spreads to is known as the sentinel lymph node.

There are multiple ways to assess for lymph node metastasis. The most definitive way is to perform a biopsy of the lymph node(s) where cancer spread is the most likely. A biopsy is the process of removing living tissue or cells from organs or other body parts of patients for examination under a microscope or in a culture to help make a diagnosis, follow the course of a disease, or estimate a prognosis. In breast cancer, the lymph node(s) biopsied are one or more (usually one to three) of the axillary lymph nodes, which are located under the arm pits. A more intensive surgical process is an axillary lymph node dissection, which involves removing at least six of the lymph nodes and having them analyzed at a laboratory to be tested for cancer. In most cases, if the sentinel lymph node biopsy shows metastasis, then a lymph node dissection follows.

Due to the invasiveness of these surgical procedures, there has been increased interest in developing non-invasive ways to detect breast cancer spread to the lymph nodes. One method is to use ultrasound scanning. Ultrasound scanning is a procedure that uses high-frequency sound waves to produce images of internal body structures. Another technique is a positron emission tomography (PET) scan combined with computed tomography (CT). When combined, this is known as PET/CT and can be used to scan the entire body. A PET scan involves injecting the patient with a small radioactive chemical and being placed in a machine that detects and records energy given off by the substance. The computer translates the energy into 3D pictures which provides information about how cells in the body are functioning because normal cells react differently to the chemical than healthy cells. CT scanning is an advanced imaging technique that uses x-rays and computer technology to produce more clear and detailed pictures than a traditional x-ray.

In a recent study published in the medical journal, Acta Radiologica, researchers compared the diagnostic utility of PET/CT scans to ultrasound scanning in detecting axillary lymph node metastases. The authors found that PET/CT scans were more accurate than ultrasounds in evaluating axillary lymph node metastases. The PET/CT scan also detected lymph node metastases in seven out of 91 patients (8%) that had not been detected by another imaging modality. However, because the PET/CT scan still has a low sensitivity (54%) for detecting axillary lymph node metastasis, it was noted that it cannot serve as a substitute for sentinel lymph node biopsy.

Suggested reading: The Mayo Clinic Breast Cancer Book

Reference: Riegger C, Koeninger A, Hartung V, Otterbach F, Kimmig R, Forsting M, Bockisch A, Antoch G, Heusner TA. Acta Radiol. (2012) Comparison of the diagnostic value of FDG-PET/CT and axillary ultrasound for the detection of lymph node metastases in breast cancer patients. Acta Radiologica, 53(10): 1092-8.

Contraceptive Use in Women with HIV

If you are a woman with HIV (human immunodeficiency virus), preventing unintended pregnancy is important to preventing the transmission of HIV to a baby. While abstinence is the best option to prevent further spread of HIV, some individuals choose to use hormonal contraception.

However, there has been speculation that use of hormonal contraception in women with HIV will lead to worsening of disease progression.

 In an upcoming article in the journal, AIDS, researchers conducted a systematic review of the literature to determine if women with HIV who use hormonal contraceptives are at increased risk of disease progression compared to women who do not use contraceptives. Eleven total studies were reviewed.

The authors found that most of the evidence showed that women with HIV can use hormonal contraception without needing to worry that it will result in increased disease progression. Disease progression was measured by mortality (death), increased viral load, time to beginning anti-retroviral therapy, decreased CD4 cell count, and time to CD4 count below 200). CD4 cells are types of white blood cells that help protect the body against disease by fighting infectious organisms. When these levels go below 200, it is an important marker of disease progression. Anti-retroviral therapy (ART) refers to medications designed to suppress HIV and disease spread.

Suggested reading: The First Year: HIV: An Essential Guide for the Newly Diagnosed

Related blog entry: Increased Risk of Sudden Hearing Loss in HIV

Reference: Phillips SJ, Curtis KM, Polis CB. (2013). Effect of hormonal contraceptive methods on HIV disease progression: a Systematic Review. AIDS, in press.

The image above shows HIV (yellow) attacking a human cell. Credit: National Institutes of Health.

"My Child is a Picky Eater!" Is it Normal?

Many parents are familiar with the routine of sitting down with their young child for a meal and finding that the child refuses to eat it for one reason or another. Sometimes, the child does not like a certain ingredient, does not like the taste, does not like the texture, does not like the temperature, or a combination of these.

It can be extremely frustrating the more this happens, particularly when the parent puts a lot of time into preparing the meal. Sometimes, the child may simply be more biologically sensitive to certain tastes and textures and so meals need to be planned around these particular likes and dislikes. Forcing the child to eat these meals while he/she is crying or clearly being repulsed by it (e.g., gagging) is usually counterproductive. Finding a suitable alternative that the child will agree to eat is often the best solution.

A lot of creativity may be required to find ways to get the child to eat nutritious meals, but it can be done by sneaking in small amounts of food into a larger product the child likes (e.g., putting a small amount of pureed carrots in the child’s favorite sauce), creatively building off of foods that the child is known to like (e.g., making a hot Panini sandwich with the same ingredients that the child likes on a cold sandwich), using cookbooks to experiment with certain meals, or giving meals creative names (e.g., Mickey Mouse meatballs for turkey meatballs) based on something the child likes or the food looks like.

Sometimes, parents might rightfully wonder if such eating problems are abnormal and signal a more serious problem. In and of itself, however, eating problems are common in young children, as was recently documented in a study released in the medical journal, Acta Paediatrica, in which researchers in Germany questioned the parents of 1,090 children (544 boys) between ages 4 and 7. Specifically, the researchers found that 53% of children were reported to avoid eating certain foods. This was more common in children who were underweight. Underweight children also ate less food, which makes sense. Twenty-three percent of children were reported to have selective eating preferences (i.e., eating a narrow range of foods) and 26% showed aversions against trying new foods.

The authors found that they were able to differentiate three groups of children in the study. Group 1 (61%) was classified as normal eaters who avoided certain foods, had normal weight, and did not show a high level of anxiety or oppositional behavior. Group 2 (32%) were selective eaters and/or restrictive eaters.
Restrictive eaters are those who eat smaller amounts of food, do not have interest in eating, and do not enjoy eating. Group 3 (5%) were children who were worried about their weight. It was this third group that was most prone to being anxious and to engage in oppositional behaviors.  In the absence of significant weight loss, behavior problems, or emotional problems, the authors concluded that selective eating should be seen as normal in children. If these problems are present, advice and treatment should be offered, such as a referral to specialized outpatient programs to prevent the development of chronic eating problems. In this way, medical doctors and psychologists can play an important role in the early detection of eating and behavioral problems.

Suggested reading: The No-Cry Picky Eater Solution: Gentle Ways to Encourage Your Child to Eat—and Eat Healthy

Reference: Equit M, Pälmke M, Becker N, Moritz AM, Becker S, von Gontard A. (2013). Eating problems in young children - a population-based study. Acta Paediatr. 102(2):149-55.

Treating Sleep Problems in Multiple Sclerosis: An Update

In the current edition of journal Acta Neurologica Scandinavica, researchers presented a comprehensive up to date literature review on the clinical assessment and management of sleep disorders in multiple sclerosis. Multiple sclerosis (MS) is a condition in which people develop multiple areas of abnormal patches (also known as plaques or sclerosis) in the brain and/or spinal cord (depending on the stage of the illness).

There are many others conditions that co-occur with MS, including sleep disorders. The most common sleep disorder in MS is insomnia but others are present as well such as hypersomnia (conditions that causes excessive sleepiness), sleep-related movement disorder (e.g., restless leg syndrome), sleep-related breathing disorders (e.g., sleep apnea), parasomnias, and circadian rhythm disorders. Sleep apnea is a disorder in which the person does not breathe for periods of time while sleeping. Parasomnias are abnormal and unnatural behaviors, feelings, perceptions, or dreams that occur while sleeping, falling asleep, awakening, or between sleep stages. Circadian rhythms are internally controlled biological processes (e.g., sleep) over a 24-hour period.

It is important for doctors to assess for and treat these sleep disorders because they can negative affect the quality of life and functioning for patients with MS. In fact, in their literature review, the authors found that sleep apnea caused by obstructions in MS patients was associated with significant morbidity and mortality (disease and death).  This is why when patients with MS complain of fatigue and daytime sleepiness, a sleep study is recommended by the authors as a matter of routine. However, fatigue in MS can have many other causes such as depression (which is also common in MS) or as a result of the MS-disease process itself.

Common treatments for insomnia and obstructive sleep apnea include techniques that do not involve medications. For insomnia, one example of this is cognitive behavioral therapy (CBT), in which the patient is taught how to change their feelings by altering the way he/she thinks. This, in turn, can improve sleep. In obstructive sleep apnea, a common treatment in continuous positive airway pressure (CPAP) in which a mask is fitted over the face at night so a continuous pressurized airflow can be provided to the body. The authors note, however, that in some cases, a different treatment approach (e.g., steroid treatment) may be needed for patients in which a lesion (abnormal area) is present in the brain that is associated with the particular sleep disorder. Determining if this is the case requires detailed investigation.

Suggested reading: Say Good Night to Insomnia

Related blog post: Improving Sleep in Intensive Care Units

Reference: Lunde HM, Bjorvatn B, Myhr KM, Bø L. (2013). Clinical assessment and management of sleep disorders in multiple sclerosis: a literature review. Acta Neurol Scand Suppl., 196, 24-30. The article is freely available here.

The Medical Miracle of Microbubbles

For the uninitiated, micro bubbles are bubbles that are 50 microns or less (which is several orders of magnitude smaller than traditional bubbles); and it is their remarkably small size and resulting unique physical composition that gives these bubbles their inherently amazing properties. Although micro bubbles can be more or less easily created, they possess many unique properties. For one, their characteristics are not shared with traditional bubbles.

Various physical forces interact with these micro bubbles differently because of their size. A deep understanding of these physical properties has resulted in applications that are far reaching and extraordinary. Micro bubble research is rapidly becoming an applied science in fields such as medicine, manufacturing and wellness. However, the medical advances demonstrated by these tiny miracles are the most promising.

Changing Medicine

Medical uses of micro bubbles are plentiful, yet are just being discovered. They have been proposed for use in cancer treatments, specifically as a drug delivery instrument that penetrates into a cell and implodes, delivering its internal contents. They are also being tested as contrast agents in ultra-sounds as well as in a technique used to detect the early warning signs of heart disease. Per the CDC, about 1 of every 4 people who die in the United States every year die from heart disease. While that may seem like a lot, when extrapolated, it comes out to a staggering average of 600,000 people every year! These numbers reveal that heart disease is the main killer in the United States. Thankfully, micro bubble technology is being tested in order to help combat these incredibly large numbers. Dr. Isabelle Masseau of the University of Missouri has conducted a study to test the feasibility of using micro bubbles to detect the early signs of heart disease. So far, this process has successfully been used to help better detect artery inflammation in pigs and has promising implications.

If Dr. Masseau is able to expand on her existing research and bring this procedure to realization in humans, then early inflammation and other warning signs for heart conditions and diseases could be detected, treated, and then maintained. This would drastically reduce the number of people killed each year. This process seems both simple and amazing at the same time. The process that Dr. Masseau has pioneered involves attaching antibodies to micro bubbles that are then injected into the bloodstream of pigs with heart disease. Because of the inherent properties of micro bubbles and these enhanced antibodies, they are able to better target artery inflammation. By using ultrasound, Dr. Masseau could pinpoint the locations where the bubbles congregated, as the gas within those bubbles reflected back the ultrasound signal. While these early breakthroughs are staggering, the future of micro bubbles looks even brighter.

The above entry is a guest blog entry.

MedFriendly Publishes Comprehensive Scientific Review on Asperger’s Disorder and Violence

In response to the frequent discussion in the media and elsewhere on the association (or lack of an association) between Asperger’s disorder and violence/planned violence, I decided to write an objective comprehensive review of the peer-reviewed published scientific literature on this topic. The review begins with an introduction and then lists and summarizes the relevant studies, which are divided based on study format and year of publication. At the end of the review, ten conclusions are listed based on the current state of the scientific literature. I believe that this is the most objective and up to date comprehensive review of this topic presently available.

As more research on the topic is published, it will be integrated into the article. When updates are made, I will mention it in the comment section below. Others can also feel free to post comments (e.g., suggest other articles for inclusions) but be aware that comments are closely moderated and that inflammatory comments will be rejected.

Click here to access: Asperger’s Disorder & Violence: A Review

How a Psychologist Explained the Newtown School Shootings to His 7 & 8 Year Old Children

The shootings in at Sandy Brook Elementary School in Newtown, Connecticut have been traumatizing for the entire nation. While we have unfortunately become used to hearing about school shootings and other public mass shootings in the U.S., the brutal murder of 20 innocent elementary school children (all ages 6 and 7) is just too much to bear.

In fact, the moment I saw the picture above, it was impossible to hold back the tears any longer because the image of the little boy with the blonde hair reminded me of my precious 7-year-old son. 

In this day and age, I knew that he and his equally precious 8-year-old sister would probably hear of what happened next week in school and my wife and I decided that it would be best if they heard it from us first. This is because if they hear about what happened from their peers, children are prone to misinformation and exaggeration and I did not want them to be misinformed from the outset.  I also wanted to have some control over how and when the message was delivered.

As to the latter point, we had a family day planned with exciting activities scheduled that I knew would make the kids happy. I reasoned that it would be better to tell them the sad news first so that the good events of the day that were to follow would overshadow what I was about to tell them. After all, this is not the type of news one wants to deliver to a child at the end of the day or right before bedtime when they have a lot of time to dwell on it.

The way we have always raised our children is not to hide or shield them from the fact that we live in a dangerous world. They are aware that there are many nice people in the world but they also know that there are many “mean guys” out there who can do harm to them (which is why they know they should not go anywhere with strangers). We also talk to them and read books to them about dangerous things, places, and situations and how best to avoid or deal with such dangers.

So it was that context that allowed me to ease into the conversation somewhat. We brought the children into a comfortable room and we sat down together in close company. I reminded them about the discussions we have had about the world being a dangerous place sometimes and how there are mean guys around. They innocently looked at me and nodded their heads. I then told them that there was something bad that happened yesterday at a school that they may hear about on Monday and that it was best that they hear it from us first. They were told that the school is far away from where we live to make them feel safer. They were then told that there was a mean guy who went into a school with some guns and shot some adults and children and that some of these people died, including the principal. My guiding thought process was to explain the essential facts but not go into unnecessary detail.

After telling them such shocking news, I wanted to immediately counter this by letting them know something good, which is that the mean guy is dead and is not going to hurt them or anyone else anymore. Then came the first question, which was how did the mean guy die. My philosophy in responding was to tell the truth but try to keep it minimal. So my first response was simply that he was shot. The follow-up question was who shot him. The answer was that he shot himself. This is very strange to a young child and provoked a response that that is a very silly thing to do, which we all agreed with. Why would someone do that, my son asked. Again, to keep it simple for a 7-year-old, sometimes crazy people do crazy things that we would never do. While we don’t use the word crazy in clinical settings, you have to adjust the language when talking to children this young.

I then wanted to discuss another positive aspect of the tragedy, which is that there were teachers who saved many of the children’s lives by following proper lockdown drill procedures. My daughter immediately responded that she knows what a lockdown drill is and that they are scary. This reminded my son of the drill as well and they explained some of the things they have to do when one occurs. We explained why going to the corner or in a closet away from the door is the safe thing to do and they wound up having a better understanding of why they have to do these drills. They were reminded that if they have another lockdown drill in school that the teachers will clearly let them know that it is only a drill and not the real thing, so they are not too scared the next time it happens. But this real-life example of lives being saved helped to explain to them why practicing lockdown drills are so important. By practicing the drills, the teachers were much better prepared and lives were saved.

I then told them that I hoped one of the good things that will come out of something so sad is that our country finds a way to not make it so easy for mean guys to get guns. The hope here is that this would allow them to feel that something may happen in our society to make them feel safer. I sure hope this is not wishful thinking on my part because we cannot have another tragedy like this ever again. However, I could not tell them that there was no risk of this ever happening at their school. While I reminded them that dangerous situations can happen anywhere (even dad’s work, mom’s work, the mall, etc) there were told that school shootings are very rare.  Nevertheless, they were told that it is very important for us to be aware of our surroundings, to be as careful as we can, and to try to make smart decisions to keep ourselves safe. 

There were no further questions but they were told that their friends in school may tell them things about what happened that are not true and to check with mom and dad before believing it. We wanted to keep an open forum between us so they feel comfortable asking questions about difficult subjects. They readily agreed to check with us and to ask us questions.

The talk ended with a big family hug. We then proceeded to have a fun-filled family day and they did not bring the topic up once. We chose not to keep the TV news coverage on until they went to bed because we wanted to avoid chronic repeat exposure of this incident.

The difficult part about parenting is that there is no manual that exists on how to explain a tragedy like this to your children. I hope that example above is useful in that regard. Thank you for reading and give your children some extra big hugs.

Suggested reading: Why Kids Kill: Inside the Minds of School Shooters

Related blog entry: Society's Failure to Protect Children: 5 Ways to Improve

The Benefits of Electronic Medical Signatures

These days, more and more hospitals, doctor offices, and medical centers are transitioning from paper medical records to electronic (paperless) medical records (EMR). One of the motivations for this transition is a monetary incentive from the government, provided that certain criteria and reporting standards are met. However, there are other advantages to moving towards an EMR system.

One such advantage is that the days of sloppy, indecipherable, and forged handwritten signatures will be gone and replaced with a legible and secure electronic signature.

Online signatures in the pharmaceutical industry are particularly important because it is necessary to meet new standards set forth by the Food and Drug Administration and the SAFE-BioPharma Association. For electronic signature systems to be effective, they must be secure such as having systems in place to detect and prevent tampering. This involves utilizing a multi-faceted authentication process, which will vary according to the specific system and should be customizable.

Online signatures should also be simple to use for the health care provider such that all that is required to sign is a point and click of the mouse. The online signature system should also be easily accessible for the healthcare provider such that an electronic signature can be made from any secure internet connection. This can improve healthcare delivery because the easier it is to obtain a healthcare provider’s signature, the faster that services can be provided.

Time can also be saved with electronic signatures by allowing the health care provider to sign multiple documents at once and specifically directing the healthcare provider which documents need signing and which do not. This prevents packages of documents from missing needed signatures. Another benefit of EMRs is electronic notification of healthcare providers regarding a needed signature. Of course, reducing paper costs through electronic signatures helps save money.

In the future, the MedFriendly Blog will feature additional articles on various features or EMR systems and how they will affect the patient and provider.

Medical Jobs Specializing in Pregnancy

If you’re looking out to start a career in the medical field, you’ve got many choices. But there are some jobs that are directly related to childbirth, which are usually in demand. Childbirth is a special time for all parents. However, in order to have a safe birth, it’s important to take care during and after pregnancy which is why there are number of medical professionals involved in the 9 months of duration.
In the following article we look into a few careers that you begin with that are focused on helping pregnant women have a safe delivery...

Obstetric Physiotherapist

During the period of pregnancy and childbirth, the body goes through multiple changes. An obstetric physiotherapist works in the area of helping women deal with these changes. They help by teaching relaxation and breathing exercises, and also other activities that can be done during pregnancy in order to stay fit and healthy.

They also offer support even after birth, where they show how postnatal exercises can be done to help tone the muscles. If you choose to become an obstetric physiotherapist, then you will be playing an important role in your pregnant patient's life and helping them have a safe, healthy pregnancy.

Dietitian

Who knows what food is good to eat during pregnancy? A dietitian of course. The job of a dietitian is to mothers to be, find the right diet and let them know what food is bad for their health. Right from planning food/nutrition programs to teaching the right habits, they do it all.

In order to become a dietitian, you need to have a bachelor’s degree. As far as the choices go, you’re not limited to what you can major in. What’s more, since more and more people are getting health conscious these days, the profession of a dietitian will only grow with time.

Medical Sonographer

Ultrasounds or sonograms are commonly used to analyze the fetus in pregnancy. As a sonographer your job would be to assist patients in revealing the baby’s gender and have them see their baby for the first time.

The demand for sonography will definitely grow with time because one, sonography doesn’t use radiation and two, it’s cost-effective and non-invasive. You can receive training as a sonographer in a good, reputed institute such as the Sanford Brown Institute.

Pediatrician

A pediatrician is a doctor who is a child specialist. And a pediatrician whose specialty lies with dealing with newborn babies is called a neonatologist. The job of pediatrician is a sought after one since he is required to be there at the time of the birth in order to avoid any health complications in the baby.

A career as a pediatrician can be a rewarding one, knowing that there is a growing demand for it in the field. In order to become one, you will have to study medicine at a university and gain a bachelor’s degree.

The job options we discussed above may or may not be applicable to you but they definitely are worth considering if you want to build a career related to childbirth.

The entry above is a guest blog entry.

Five Ways to Handle When the Doctor is the Patient

It’s bound to happen if you are a healthcare provider. One day, you will evaluate a doctoral-level healthcare provider in your office, be it a physician or non-physician. Below is a series of tips for handling such a situation to increase the chances that the office visit will be a productive one.

1. Acknowledge the potential awkwardness of the situation during the initial visit: Doctors are used to being in charge and calling the shots (no pun intended). When a doctor becomes the patient, however, the roll is reversed. Now it is the doctor sitting in the waiting room, patient chair, filling out office and insurance forms, etc. When first meeting the doctor-patient, it is helpful to say something like, “Well, I understand that this may feel a little bit awkward, but I’ll do what I can to make the situation as comfortable as possible.” Doctors usually appreciate this and you may be surprised how many will quickly say something like, “I am here as a patient. You are my doctor. And that is how I would like it to be.” This is the best possible situation but in other cases, there may be more resistance. See the next few points for handling this.

2. Allow for some creature comforts: I usually ask doctors how they preferred to be referred to in the clinical note (e.g., Dr. Smith or Mr. Smith) which gives me a good sense of the degree of formalities that will be involved in the case.  Some doctors will insist on being called “Dr.” in the note and during personal interactions. While some evaluators may balk at this under the assumption that it blurs the doctor-patient boundary, the next point will show that this does not need to be the case. In my experience, this is typically not an issue worth having an argument about and is a good creature comfort to provide to help establish rapport.  Another creature comfort that doctor-patients enjoy is conveying their status in a more passive way during the evaluation, such as wearing their professional name badge and/or hospital garb during the appointment (some of which may say Dr. Smith on it). It is best to understand that this allows that doctor-patient to feel more comfortable rather than feeling offended or threatened by it.

3. Make sure that boundary levels are still maintained: While allowing for some creature comforts is ok, one has to be on guard against imbalances in the doctor to doctor-patient relationship. For example, while on may refer to the doctor-patient as Dr. Smith, the doctor-patient should not simultaneously be referring to the treating doctor by his/her first name only. 

4. Maintain control over the evaluation: This is related to point 3 and one of the most challenging aspects of the evaluation. Doctors are intelligent, fluent in medical jargon, and know how to discuss research findings. In fact, the doctor-patient is very likely to be more of an expert in some type of health care area than you are. This can be freely acknowledged in conversation in a way that makes the doctor-patient feel respected. However, always remember that the doctor-patient is coming to you for an evaluation because a) you have expertise in an area that he/she does not have or b) he/she cannot treat him/herself in an area of shared specialty (e.g., a neurologist treating another neurologist in the same sub-speciality area).  Be on guard for the doctor-patient requesting that you to do things (e.g., ordering certain tests, prescribing certain medications) that you do not feel is clinically appropriate given the facts of the case. While patient input should certainly be listened to and incorporated when possible, it needs to be established from early on that the ultimate person responsible for making diagnostic and treatment decisions is the treating doctor.  In cases where a conflict emerges about how to manage the case, the treating doctor will need to clearly convey his/her position with supportive evidence and proceed accordingly (see next point). 

5. Present scientific data when possible: Doctors are trained in the scientific method and are more likely to agree with diagnostic formulations and treatment recommendations when presented with reference to supportive empirical data. This can include reference to laboratory test values, diagnostic imaging results, published diagnostic criteria, empirically supported treatment recommendations, reference to specific research studies, etc.

Suggested reading: A Taste of My Own Medicine: When the Doctor Is the Patient