Thursday, February 16, 2012

The Heart Attack Grill

If you go to Las Vegas, one of the many restaurants you will encounter is the Heart Attack Grill. It is probably the most extreme and unhealthy place to eat in the United States and deliberately courts controversy with its use of extreme menu item names, unusual promotions, and unique themes. An example of the extreme food names include Flatliner Fries (French fries made with pure lard), Butter-Fat Shakes, and the Bypass Burger (which comes in Single, Double, Triple, or Quadruple Bypass sizes), the latter of which contains 12 slices of bacon, two pounds of beef, and four layers of cheese. No lettuce is allowed. Burgers can be as high as 8,000 calories (i.e., 4 days worth of calories in one burger). Obese customers over 350 pounds eat for free if they weigh in with a scantily clad “nurse” (waitress) or “doctor” (waiters). Orders are called “prescriptions” and customers are called “patients.” Finishing a triple or quadruple bypass burger allows customers to be wheeled out to their car by their own personal nurse. On 2/11/12, one customer was wheeled out a real stretcher when he suffered an apparent heart attack after eating a triple bypass burger.

The knee jerk reaction to the Heart Attack Grill concept is to either laugh or become angry. Either reaction plays into the hands of the owner (Jon Basso), which is to gain attention by purposely and cleverly courting public controversy by turning political correctness about medical issues on its face.

For those who are upset by the Heart Attack Grill concept, it is important to remember that the owner is at least being blatantly out front and honest about the food he serves, rather than other fast food restaurants that do not take this approach. For example, should you be more upset at The Heart Attack Grill’s Bypass Burgers that blatantly indicates how bad it is for you based or at Burger King’s Triple Whopper Sandwiches which requires some searching to find out that they are 1140 calories?

To be clear, I am not saying people should not be bothered about the Heart Attack Grill. Personally, I have mixed and vacillating feelings about it. On the one hand, it is certainly justified to be upset that someone would sell an 8,000 calorie menu item but on the other hand we do live in a free country where people have the right to eat unhealthy if they want to.

While eating one burger during your life time from the Heart Attack Grill on vacation will likely not kill you, eating these burgers on a regular basis likely will, a point the owner readily admits. However, if someone does dies from eating at the Heart Attack Grill regularly the primary blame falls to the patient for doing so despite knowing the risks. After all, the slogan of the Heart Attack Grill is “Taste Worth Dying For.” All of thie being said, Basso cannot absolve himself from all blame because he is peddling this type of extreme food to the public.

Ultimately, the success or failure of the Heart Attack Grill depends on market forces. That is, if enough people decided not to eat there due to the health risks, then the company will go out of business. If people flock to the restaurant, then it will flourish. It’s as simple as that. The Heart Attack grill has been open since 2006, indicating that the concept attracts customers.

Wednesday, February 15, 2012

Heart-shaped lesion in the brain: Neurosarcoidosis

Yesterday was Valentine’s Day. A day of love and happiness, often symbolized by Cupid, chocolate, and of course hearts. Just about everything you can imagine can be found in a heart shape for Valentine's Day. While heart-shaped objects are expected within this context, it is not something you expect to see when taking a picture of the inside of someone’s brain. But that is exactly what two neurologists from Baylor School of Medicine found when a 27-year old man underwent a brain MRI (magnetic resonance imaging) scan.

The picture to the left shows an axial slice of the brain, which is a top-down view. The heart shaped lesion (abnormal area) can be seen on the bottom. The picture to the right is a saggital slice of the brain, meaning it shows the brain from the side. The heart-shaped lesion is clearly visible in white towards the right of the image.

So what are these heart shaped areas? They are areas of inflammation caused by an inflammatory condition known as neurosarcoidosis. Headache is the most common symptom but seizures can also occur. Both occurred in this patient. The final diagnosis in this case was made upon a biopsy. The condition is treated with medications that reduce inflammation (corticosteroids) such as Prednisose but chemotherapy drugs or medications that suppress the immune system are used in some cases that do not respond to corticosteroids.

The reference for the study is: Suárez Zambrano GA, Hutton GJ. (2008). Heart-shaped lesion secondary to neurosarcoidosis.Arch Neurol. Oct;65(10):1388-9. The images are copyrighted by the American Medical Association.

Monday, February 13, 2012

The Trick to Low Sodium Chicken Soup

It’s winter in Syracuse in NY, and although it has been a very mild winter, a nice bowl of chicken soup always feels good this time of year. I headed off to the grocery store this weekend to make a batch of chicken soup for the family. Obviously, one of the key ingredients in chicken soup is broth. Chicken soup recipes almost always call for chicken broth and if you are not going to make your own broth, then you need to purchase some in the store. So I was looking at the sodium levels for every chicken broth brand I could find (including the one reduced sodium item), including those in the all-natural section of the store. On average, each product had about 500 mg of sodium per serving (some over 700 mg), with each product containing 4 to 5 servings. If you are making enough soup for a small family that means you will use about 24 ounces of broth. That translates to a whopping 4000 to 5600 mg of sodium in the soup, which is completely unnecessary.

Then I picked up a box of low sodium vegetable broth, which only contained 140 mg of sodium per serving with 4 servings per 12 ounce box. That’s only 1120 mg of sodium for 24 ounces of soup. Compared to 4000 to 5600 mg of sodium for chicken broth, that is a big difference. So, I figured why not just toss all the ingredients into the vegetable broth, let the natural juices of the chicken cook out, which would then make the broth taste like chicken broth anyway, with much less sodium. I tried it out and it was a rousing success. The broth was delicious, was infused with the juices of the chicken, and best of all, I knew I was feeding my family something much healthier. Please pass this on to others, try it yourself and comment here on how it went, and feel free to pass on your own health eating tips for others.

Friday, February 10, 2012

Progeria: Children with an Elderly Body

If you have ever seen the movie, The Curious Case Of Benjamin Button, you may have been under the impression that it has no connection to reality. In fact, however, there a medical condition known as progeria (technical name = Hutchinson-Gilford Progeria Syndrome).


Old Before My Time: Hayley Okines' Life with Progeria
Old at Age 3, the story of Zachary Moore

Progeria comes from the Greek words “pro” meaning “before” and “geras” meaning “old age”. It is a reference to a disorder in which the signs of old age are present before they should be -- when the person is a young child. In essence, in progeria, an elderly person is present in a child’s body, both physically and genetically. Progeria is extremely rare, only occurring in one out of every 8 million births. There are only 80 known children with progeria in the entire world.

Diagnosis of progeria is based on clinical examination of the child and can be confirmed with a genetic test. Signs of progeria include hair loss, wrinkles, missing teeth, delayed growth, lack of weight gain, dry scaly skin, vision loss, fragile bodies, pinched nose, and a small jaw. As the child ages, signs of progeria become more advanced. Interestingly, cognitive impairment is usually intact despite the increased risk of cognitive impairment in the normal aging population. Motor functioning is usually also preserved. Most children with the condition only live until 12 years of age. The main cause of death is atherosclerosis (hardening of the arteries), which can lead to a heart attack or stroke. Ninety percent of children with progeria die from one of these two causes.

The cause of progeria itself is caused by a mutation (change) in the LMNA gene. This gene provides instructions for the Lamin A protein, which holds the skeleton of the cell’s nucleus (headquarters) together. The changed gene alters instructions to the Lamin a protein, causing instability of the cell’s nucleus, which leads to premature aging. Unfortunately, there is no treatment of cure for progeria although attempts are made to reduce cardiovascular problems.

Thursday, February 09, 2012

Ayumu the Chimpanzee, Incredible Memory, and Skepticism

One of my Facebook friends recently posted an article about Ayumu the chimpanzee, who is world renowned for his memory feats in the laboratory setting. If you watch the video of what Ayumu can do in the laboratory, it seems absolutely incredible and is no doubt impressive. You can see a good demonstration that is well worth watching below of what Ayumu can do.

As impressive as this video is, I could have sworn I remembered some controversy over this after seeing this several years ago. So I went to PubMed, which is the best online repository for peer-reviewed research articles and I found the following.

Silberberg A, Kearns D. Anim Cogn. 2009 Mar;12(2):405-7. Epub 2008 Dec 30.  

Memory for the order of briefly presented numerals in humans as a function of practice.

Inoue and Matsuzawa (Curr Biol 17: R1004-R1005, 2007) showed that with an accuracy of approximately 79%, the juvenile chimpanzee Ayumu, could recall the position and order of a random subset of five Arabic numerals between one and nine when those numerals were presented for only 210 ms on a computer touch screen before being masked with white squares. None of nine humans working on the same task approached this level of accuracy. Inoue and Matsuzawa (2007) claimed this performance difference was evidence of a memorial capacity in young chimpanzees that was superior to that seen in adult humans. While the between-species performance difference they report is apparent in their data, so too is a large difference in practice on their task: Ayumu had many sessions of practice on their task before terminal performances were measured; their human subjects had none. The present report shows that when two humans are given practice in the Inoue and Matsuzawa (2007) memory task, their accuracy levels match those of Ayumu.

Moral of the story: When sometimes seems very out of the ordinary, approach with a degree of skepticism. Nevertheless, I'm still very impressed with Ayumu!

Wednesday, February 08, 2012

Neurocysticercosis: Tapeworm Infestation of the Brain

One of the most frightening medical conditions in the neurosciences is neurocysticercosis. In this condition, the brain becomes infested with the larvae of the pork tapeworm, known as Taenia solium. It is called a pork tapeworm because it infects pigs as well as humans. It has several hundred segments that are capable of releasing thousands of eggs when it reaches maturity. To the top left is a picture of the pork tapeworm under the microscope.

Pigs eat the eggs of these tapeworms when they eat food contaminated with feces. The eggs hatch in the pig intestines and develop into cysticerci in the muscles. Cysticerci are the larval form of the tapeworm.When people eat undercooked meat that is contaminated by cystocerci, they develop into adult tapeworms in the small intestines of humans and release thousands of eggs. Cysterici can also travel to the brain and form cysts when this happens it is known as neurocysticercosis. To appreciate what this looks like, first, here is a picture of a normal slice through the middle of the brain:

Here is a picture of a similar area of the brain contaminated with the pork tapeworm showing cysts:

On the left is a normal picture of the brain on a brain MRI (magnetic resonance imaging) scan. On the right is a brain MRI showing neurocysticercosis:

The appearance of neurocysticercosis in the brain depends on which of the four stages the person is in. In stage 1 (vesicular stage), the worm is alive and there is not a significant response from the immune system so there is minimal edema (fluid build up). In stage 2 (colloidal stage), the worm dies, causing the cyst to weaken, the worm to leak out, and the immune system responds, causing significant inflammation. In stage 3 (granular nodular stage), the immune response causes the cysts to harden and collapse. In stage 4 (calcified stage), the cysts calcify and the immune response/inflammation decreases. At any point, abnormal areas in different parts of the brain can be all in one stage or at either of the 4 stages.

Neurocysticercosis is the most common parasite disease of the nervous system and the main cause of acquired epilepsy (repeated seizures) for people in developing countries. This is because of poor hygiene in many developing countries, especially where pigs and humans live close together. The condition rarely happens in Muslim countries, where eating pork is forbidden. In addition to seizures, other signs and symptoms include headaches, dizziness, stroke (rupture or blockage of a blood vessel in the brain), increased blood pressure in the brain, severe impairment of thinking skills, double vision, difficulty speaking, weakness and/or sensory loss on one side of the body, increased or decreased reflexes, difficulty walking, movement disorders, and increased fluid in the brain.

Neurocysticercosis is treated by administering medications to kill the tapeworms, although these medications are often not used in patients with severe edema because the medication causes additional inflammation. Corticosteroids are administered to reduce inflammation. If seizures occur, anticonvulsants will be used to treat them. In some cases, neurosurgery is performed to remove accessible cysts.

Related Story: Stupid Diets: Infesting Yourself with Tapeworms

Tuesday, February 07, 2012

Bizarre Images of Cutaneous Horns

If you thought that people could only have horns growing out of their body in science fiction movies, think again. Many people do not know that some people can literally grown horn-like projections out of their body. The reason many people are unaware of this is because the stigma associated with the condition leads people to try to conceal it from others with clothing, bandages, or becoming a recluse until they can be surgically removed. When horn-like structures grow out of people’s skin, they are referred to as cutaneous (skin) horns and sometimes referred to as Devil’s horns. Below is a picture of a 69-year old lady with a 17-cm cutaneous horn protruding from her forehead. This is why she is known as The Unicorn Lady.

RECOMMENDED BOOK: Skin Disease Diagnosis and Treatment

Cutaneous horns are a mysterious medical condition but they may be caused by radiation exposure since they occur more in sunlight exposed areas (face, hands). They could arise from burn scars and some have reported an association with a common disease known as human papillomavirus (HPV). Probably the largest cutaneous horn was the one that was on Madame Dimanche, a French woman from the 19th century whose forehead horn measured 9.8 inches (24.9 cm). It was successfully removed via surgery. A wax model of her head was taken before surgery and is pictured here:

Cutaneous horns are benign in 80% of cases but malignant (cancerous) in 20% of cases. Pain at the bottom of the horn usually indicates malignancy. Believe it or not, these horns can also be present on the penis and when this happens, it presents almost double the risk of cancer. Here is one example of a cutanoeus horn growing out of a 102-year-old woman’s head in China. As of last year, this horn measured 10-cm in length.

Cutaneous horns are made of keratin, which is the same substance that hair and fingernails are made of. While the horns can be removed with a sterile razor, the underlying condition still needs treatment.
The most severe case, however, is that of The Tree Man, whose real name is Dede Koswara and lives in Indonesia. His body has been taken over by warty growths and cutaneous horns because of a genetic defect that prevents his body from containing them:

As you can see, the horns also took over the feet and toes:

Related blog entry: Lionel the Lion Man: A Case of Hypertrichosis 

Monday, February 06, 2012

Superbowl Loss for Your Team? You May Be Dead in Two Weeks Research Suggests

If your team lost in the Superbowl last night, research suggests that you are at increased risk of dying in the next two weeks. One known risk of cardiac failure is acute stress, be it physical stress, emotional stress, or both. This is because puts part of the nervous system into overdrive and causes a release of chemicals known as catecholamines that prepare the body for the “fight or flight response.” The result can be increased heart rate, blood pressure, blood sugar (i.e., glucose), abnormal heart rhythms, too many platelets (leading to blood clots), and/or contractures of the heart’s ventricles (which pump blood to the body). Increased oxygen demand can occur and oxygen supply to the heart can be decreased. If a person has a buildup of plaque in the arteries (a condition known as atherosclerosis) increased blood pressure can shear off a piece of plaque and lead to a heart attack or ischemic stroke. In an ischemic stroke, there is a blockage of an artery, preventing enough blood from getting to the brain.   

Researchers have noted that there was an increase in total deaths and cardiac related deaths in Los Angeles when the L.A. Rams lost the Superbowl on 1/20/1980. Of note, that game was played locally in Pasadena, California. The game was high-intensity, involved 7 lead changes, and the game was decided in the last quarter (final score 31-19). The team was much loved by the fans and had been in the city since 1946. By contrast, the number of total deaths in Los Angeles decreased when the L.A. Raiders won the Superbowl on 1/22/1984. The L.A. Raiders had only been in the city since 1982 (having moved from Oakland) so there was less emotional attachment by the L.A. fans. The game was not played locally (it was played in Tampa, FL) and was also a blow-out, with the Raiders winning 38-9.

Researchers from Los Angeles studied the degree to which age (65 or older vs 65 or less), sex (men vs women), or race (white vs Hispanic) played a role in deaths shortly after the Superbowl. They examined death certificates from 1980 to 1988. They considered Superbowl days (days in which the effects of a the Superbowl may be felt) to be the date of the Superbowl and the next 14 days. The other days in January and February of 1980, 1981, 1982, and 1983 were considered non-Superbowl days. The same analyses were done for the 1984 Superbowl. Total and cardiac deaths from January 1 to January 14 were not analyzed due to a known increase in deaths around the holidays.

The researchers used statistical techniques to assess if there was a difference in total and cardiac related deaths on Superbowl days vs non-Superbowl days. They also used a statistical procedure known as regression analysis to determine which variables best predicted death rate: Superbowl days vs non-Superbowl days, race, sex, age, or combinations of race, sex, and age with Superbowl vs non-Superbowl days.

The results showed that after the Superbowl loss, daily death rates increased for both males and females. The circulatory death increase was 15% for men and 27% for women. People aged 65 or older had a larger increase in all causes of death during Superbowl days compared with those who were less than 65 years old. Whites and Hispanics had increased death rates on Superbowl loss days. There were statistical trends suggesting less death in older patients and females associated with a Superbowl win but the findings were not statisitically strong enough to state this association more firmly.

The researchers concluded that a Superbowl loss triggered increased deaths in both men and women and especially in older patients, whereas a Superbowl win reduced death more in those aged ≥65 years and in women.

However, Dr. Viktor Culic from Croatia was not so impressed with these conclusions based on a criticism with how the study was conducted. Specifically, he published a response saying that the 2-week post-Superbowl period was too long for one to reasonably be able to associate deaths during that period to the Superbowl. He stated that the true risk of death after an emotionally related stressor is one to two hours after the stressor. He stated that any extension of the period to two weeks would be purely based on hypothetical disease mechanisms. He stated that cold weather and air pollution could be associated with the increased deaths after the Superbowl, especially in the elderly. He stated that perhaps the weather was colder and the air more polluted in two weeks after the Superbowl loss than the comparison days. He also stated that there may have even been more deaths in the weeks that were excluded before the Superbowl because it may have been even colder then.

The authors of the original study replied that they picked a 14 day period after the Superbowl because they believed that the emotional effects may linger after the day of the game. They stated that most of the deaths occurred in the first week after the game. They disputed the usefulness of examining death rates in the weeks before the Superbowl. They stated that cold weather and air pollution could not explain their findings. They correctly point out that the two Superbowl games were played at nearly identical times of the year, yet there were different death rates. The temperatures were also mild in L.A. both times, with an average of 52.9 on the day of the 1980 Superbowl and 54.5 on the day of the 1984 Superbowl. Temperatures were also very close in January and February of 1980 and 1984. In addition, analysis of air pollution data did not show more air pollution in 1980 than 1984.

The reference for the original study is:

Kloner RA, McDonald SA, Leeka J, Poole WK. Clinical Cardiology. 2011 Feb;34(2):102-7. Role of age, sex, and race on cardiac and total mortality associated with Super Bowl wins and losses.

The reference for the response and author reply are:

Culić V. Clinical Cardiology. 2011 Jul;34(7):461-2; author reply 462. Response to 'Role of age, sex, and race on cardiac and total mortality associated with Super Bowl wins and losses'.

Friday, February 03, 2012

Women's Health and Politics: Planned Parenthood vs Susan G. Komen

Despite the adversarial political climate that divides so many Americans, there are some topics that most people can agree on regardless of politics. One of those is that early detection and screening for cervical cancer and breast cancer are important initiatives that should be supported because early detection leads to earlier treatment which, in turn, saves lives. While many women have such exams paid for by their health care insurance, those without insurance often rely on funding from non-profit organizations to fund these types of early clinical, screening, and diagnostic exams.

Problems emerge, however, when one of these health care organizations takes a position on a topic as controversial as abortion, either pro or con. For example, Planned Parenthood is a non-profit organization that relies heavily on donors to fund women’s healthcare services, which includes clinical breast exams and mammograms. However, the organization also conducts about 300,000 abortions a year and lobbies for pro-abortion legislation. In doing so, Planned Parenthood intertwines funding for activities that almost everyone would support (breast exams) with funding for an activity (abortions) that deeply divides Americans.

When this happens, such an organization can expect to be the target of people who have strong opposing views on abortion. This is exactly what has happened to Planned Parenthood, as they have been frequently audited and targeted for defunding by Congressional Republicans. Most recently, the largest breast cancer organization in the U.S. (Susan G. Komen for the Cure) decided to cut its funding to Planned Parenthood. Although the money donated from Susan G. Komen was for clinical breast exams and mammograms, Republicans criticized the group for supporting a group that supported abortions. Susan G. Komen claimed that the reason for their decision was because they developed a new rule prohibiting donations to organizations that are under congressional investigation. However, critics claim that this is a contrived excuse, especially since it only affected funding of Planned Parenthood.

Delving into the politics of this issue in more detail gives reason to suspect that this was a contrived excuse by Susan G. Komen when the real issue involved giving into political and financial pressures. Specifically, the founder of Susan G. Komen is Nancy Brinker, who has long-standing connections to the Republican party, served as an Ambassador for George W. Bush, donating money to the Republican party (including George W. Bush’s first presidential campaign), and partnered with the policy-making branch of the George W. Bush presidential library. In fact, the decision to cut off funding to Planned Parenthood was made soon after the latter partnership was established. To make the situation even more politically interesting, the leader of Planned Parenthood is Cecile Richards, who was the daughter of former Texas Democratic governor, Anne Richards. Richards is widely remembered for ridiculing George W. Bush when he ran against her for governor. Thus, it is not much a stretch to imagine that a condition for partnership with Susan. G. Komen (which is worth 3 million dollars and is funded by Merck, a known campaign donor to current Texas governor, Rick Perry) could have been dependent on defunding Planned Parenthood. Susan G. Komen has denied that their decision has anything to do with politics, which is hard to believe, and this brings me to my last point.

If Susan G. Komen truly wanted to defund Planned Parenthood because they did not want to support a group that also funded abortions, that is well within their right to do. Planned Parenthood has to understand that when they fund both non-controversial healthcare services and controversial services, that the non-controversial services will suffer funding cuts from organizations who are pressured to stop contributing to them. Separating these services into different groups would at least prevent this problem from occurring, regardless of one’s position on abortion. In cases where funding is cut off, it is misleading to paint the organization that cuts the funding as creating barriers to women’s health because the problem would not exist if Planned Parenthood did not simultaneously fund controversial and non-controversial health services. They are within their right to do so, but it will cause problems as a result.

At the same time, it is not a mystery that Planned Parenthood pays for abortions. Thus, if another organization is truly opposed to abortions, they should simply not make a contribution in the first place. Once an organization makes a contribution and then stops contributing after known pressure and associations with opponents of Planned Parenthood, the decision is going to appear politically and financially motivated even if by some chance it was not. Interestingly, due to political pressure (particularly on social media), Susan G. Komen announced a restoration of funds on 2/3/12. Komen had successfully been cast as an organization not committed to saving women's lives and did what they had to do to reverse what had become a public relations nightmare. This is an excellent case study on how politics on both sides of the aisle affects women's health care.

Thursday, February 02, 2012

Birth Control Recall and the Impact of Litigation on Medication Costs

On 1/31/12, the world’s largest research-based drug company, Pfizer, announced that an automated packaging error led to a recall of the birth control medication, Lo/Ovral-28 and the generic counterpart, Norgestrel/Ethinyl Estradiol. The packaging issue had to do with the placebo pill being placed in the wrong order in the 28-day cycle and an inexact number of placebo (should be 7) or active forms (should be 21) of the medication. The placebo pill is one that does not contain the drug’s active ingredient, and thus, does not lead to birth control. The placebo pills are a different color than the active pills. This led a consumer to detect the error when she noticed a discolored pill in the middle of the package. Pfizer has advised that women who have taken these medications over the last several months to talk with their physician about beginning a non-hormonal barrier method (e.g., condoms) of birth control immediately. Switching pills would be another option of course, although Pfizer does not mention this for obvious reasons.

One million packs were recalled throughout the U.S. even though only 30 packages were affected and there are no known immediate health risks besides according to Pfizer. However, Pfizer does acknowledge that an unplanned pregnancy could result. An unplanned pregnancy does come with possible health risks, with the worst case scenario being death of the mother and/or child. Pfizer stated the following in a press release the next day:

“Because of our high quality standards, should we identify even one package that does not meet our high standards, we will voluntarily recall the entire lot.”

While this quote sounds good from a customer relations perspective, one is left to wonder if this recall still would have happened if it was not for the threat of litigation. Plaintiff attorneys did not waste any time trying to find women to sue Pfizer who may have suffered an unplanned pregnancy or health problems as a result of the unplanned pregnancy. Imagine, for example, the type of lawsuit that would emerge from a man alleging that he is widowed due to his wife dying in labor as a result of a pregnancy caused by a packaging error? Or the type of lawsuit that would emerge from a parent claiming that they want Pfizer to reimburse them for the entire cost of raising a child, including a college education?

Examining this in more specific financial detail, one online drugstore sells a pack of Lo/Ovral for 59.99. Other sites charge more and generics will cost less so for the sake of this example, take $60.00 as the average cost per package. This means Pfizer takes a roughly 60 million dollar loss as a result of this recall. A 60 million dollar loss for 30 packs? A 60 million dollar loss to maintain high quality business standards? Or a 60 million dollar loss to reduce the chance of one or more (e.g., class action) lawsuits for hundreds of millions of dollars that could literally end a company's existence. Lawsuits regarding unplanned pregnancies from faulty vasectomies, for example, have sought awards of over 600 million dollars. If you are the largest drug company in the world, would you rather take a 60 million dollar loss or increase the risk of a 600 million dollar loss? The answer is easy, especially for a drug marketed as being almost 100% effective in eliminating pregnancies.

Although Pfizer will take a temporary financial loss in this instance, the cost of the recall will likely be made up for by increasing the prices of other medications in the future. This is one reason why medications in the U.S. are generally more expensive than they are in other countries. One can have cheaper medications if they are willing to accept less research on their safety and efficacy and fewer attempts to quickly correct packaging errors when they arise.

Wednesday, February 01, 2012

The Top 5 January 2012 MedFriendly Blog Entries

January was a terrific month for the MedFriendly Blog. Articles from the blog continue to be featured on KevinMD and recently formed the basis of a news article on whether or not healthcare providers should hug patients. This month also featured the most popular MedFriendly Blog article to date, with well over 2000 page views. More people are retweeting blog posts on Twitter or posting them on Facebook. Please note that all MedFriendly Blog posts are always accessible to read by clicking in the Blog Archive to the right. Just click on 2011 and then the month and you will see the blog posts for that month listed.

Without further ado, the most popular MedFriendly Blog Posts in January 2012 were:

1.    New York Neuropsychologists Leave State Neuropsychological Association: This entry was so popular because it benefitted from mass distribution by members of my profession. Result: 2438 page views to date.

2.    Have You Seen the MedFriendly Message Board?: Reintroducing the MedFriendly Message Board (the largest medical message board in the world) brought in 180 page views.

3.    The Bizarre “Morgellon’s Disease,” Psychosis, and Exaggeration. This is one of the most interesting blog entries to date as it shows how science can be used to explore bizarre medical claims. Result: 114 page views.

4.    Why Sports Leagues Need to Pay Attention to Malingering: An interesting entry with several video clips documenting the problem of faked injuries in sports. Result: 112 Page views.

5.    What Is Trisomy 18: An Explanation of Rick Santorum’s Daughter’s Condition: Just posted a few days ago, this medical explanation entry already has 100 page views and counting.

Tuesday, January 31, 2012

Cyber Bullying to a Dying Child with Huntington's Disease: A New Low for Society

In the old days, bullying used to consist of name calling and/or physical aggression from someone in a position of power over another, typically from a roughly similarly aged peer group. The bullying could be mild such as occasional name calling and having one’s books knocked down when walking in the hallway.

This does not mean the effects of the bullying were mild but comparatively speaking, this is generally not regarded as significant as being thrown off a bicycle on the way home from school and being kicked and punched by a group of older children while others stand around, watch, and laugh.

As communications technology progressed, new forms of bullying emerged. One form was phone bullying in which an anonymous caller would call someone’s house and make mean and degrading comments to someone and/or that person’s family. This form of bullying increased the feeling of powerlessness because unlike more traditional forms of bullying, the victim did not know for sure who the offender was. The victim may have suspicions but often lacked definitive proof. Fortunately, phone bullying was vastly curtailed with the invention of caller ID.

While writing letters was largely replaced by phone conversations, phone conversations have largely been replaced by internet communications (such as Facebook posts, Twitter posts, YouTube postings) and text messages (which often contain links to internet posts). Along with this form of communication has come a new form of bullying known as cyber bullying. Cyberbullying is the use of the Internet and similar technologies (e.g., cell phones) to hurt others in a deliberate, repetitive, and hostile manner. Common examples include spreading false rumors, ridiculing comments, editing photographs of someone in an embarrassing and humiliating manner and posting them online, making anonymous threats, and disclosing highly personal information (such as private medical information).

What makes cyber bullying so different from other forms of bullying is that it exposes the victim to potentially millions of people with the push of the button as opposed to it being a localized event within one class or school. In addition, whereas other forms of bullying can be seen as temporary events in time, cyber bullying is often permanent in the sense that once something has been posted to the internet there is usually always a trace of it that can be found (e.g., through archival caches) if it has been posted online long enough. Even if there is a way to permanently remove the offensive online content, the victim may initially perceive otherwise.

While cyberbullying is most common from one child to another, it sometimes occurs between adults, and can have deadly consequences. One example was the death of Tyler Clementi, 18, a freshman at Rutgers University who committed suicide by jumping off a bridge in 2010, days after his romantic encounter with another man was recorded secretly by his roommate and streamed over the internet.

While all of these examples of cyber bullying are wrong, harmful, and should be repudiated, I find that the most disgraceful form of cyberbullying comes in when it is directed from an adult to a child. This is because the adults should know better and because the adult is already in a much higher position of power with no need to resort to bullying. One famous case was that of Megan Meir, a teenager with major depressive disorder and attention deficit hyperactivity disorder who had poor self-esteem due to being overweight. The mother of a friend allegedly created a MySpace account under a fake name and sent her demeaning messages such as those that said everyone hated her and that the world would be a better place without her. Twenty minutes after receiving one these messages over an internet instant message service, she killed herself via hanging in a closet.

Of all of the cases of cyber bullying though, one of the most despicable is what happened to a cute, 9-year-old girl named Laura Edward. Laura, along with her mother, suffered from a deadly condition known as Huntington’s disease. Huntington's disease is a genetic motor disorder that results in chorea and deterioration of mental functioning. Chorea is involuntary, irregular, dance-like movements of the arms, legs, and face. The condition normally affects young adults but in 6% of cases, people under age 21 can be affected.

One of Laura’s neighbors (Jennifer Petkov) got into a dispute with Laura’s grandmother over a birthday invitation and tensions escalated from there. To express her anger and hurt the family’s feelings, the neighbor posted pictures on the internet of Laura and her (now) deceased mother in a skull and crossbones being embraced by the grim reaper. The pictures and original interview with Jennifer Petkov where she brazenly admits doing this with no remorse ignited can be seen here in the embedded video. In addition to the cyber-bullying, the neighbor would reportedly drive a truck with a coffin in it back and forth in front of the house to taunt the girl and her mother, opening the casket and gunning the engine.

No matter what kind of dispute two adults have, a child (let alone one who is dying and/or medically ill) should never be used as a pawn as part of that dispute. Adults need to act like adults and resolve problems between themselves without involving children in such a manner. Unfortunately, with society being so more and more focused on impersonal forms of communication, some people may lack the ability to resolve disputes through person to person interactions. But more impersonal communication is not the only factor leading to such incidents. At the end of the day, people need to follow common sense, a sense of moral decency, and the Golden Rule. Unfortunately, many people never develop these as guiding principles due to a faulty upbringing combined with immautrity.

If you are interested in fighting cyberbullying, please stop by the website STOP Cyberbullying to learn more. For those wishing to donate money to find a cure for Huntington’s disease, you may do so at the Huntington’s Disease Society of America.

Suggested reading: Cyberbullying: Bullying in the Digital Age

Related blog entry: Adult Psychiatric Effects of Childhood Bullying

Monday, January 30, 2012

What is Trisomy 18? An explanation of Rick Santorum's Daughter's Condition

For those who follow politics, you may have heard Republican presidential hopeful talk about his daughter, Isabllea (Bella), and how he never expected her to live to her first birthday but that she is now three years old. On Sunday, it was announced that Santorum had to cancel some planned appearances because his daughter was hospitalized at the Children’s Hospital in Philadelphia for double pneumonia (pneumonia in both lungs).

What is not often mentioned on television is what condition his daughter is actually suffering from and why it is so serious.

The name of the condition that Bella suffers from is a genetic disorder called trisomy 18 (also known as Edward’s syndrome). To understand trisomy 18, it is helpful to understand the importance of the word “trisomy.” Trisomy is when there is an extra set of chromosomes so that there are three chromosomes of a certain number instead of the usual two. This is where the word “trisomy” comes from since “tri” mean “three.” Chromsomes are structures that contain genes. Genes are units of material contained in a person's cells that contain coded instructions for how certain bodily characteristics will develop. Each person normally has 23 pairs of chromosomes, meaning that there are 46 chromosomes in total. A person with trisomy has 47 chromosomes, since there is one extra chromosome. One of each pair of chromosomes is inherited from the mother and one of each pair is inherited from the father.

Conditions in which there is an extra chromosome are medically defined based on where the extra chromosome is. For example, the most common trisomy is trisomy 21 (also known as Down’s syndrome) because there is an extra 21st chromosome. In trisomy 18 (Edwards syndrome), the 2nd most common trisomy, there is the presence of all or part of an extra 18th chromosome. The condition was named after John H. Edwards (not the former Democratic presidential candidate) who first described the condition in 1960.

Like Bella, about 80% of children affected by trisomy 18 are females. The older the mother at the time of conception, the greater the risk of trisomy 18. Santorum’s wife was 48 when she gave birth to Bella, well past the recommended age for child conception. About 1 in 6,000 live births have a diagnosis of trisomy 18. The average age of mother’s who give birth to children with trisomy 18 is 32.5.

The reason why trisomy 18 is so serious and often deadly is because it causes damage to the heart, kidneys, intestines (which can protrude outside the body), and/or other internal organs. Other problems can include but are not limited to overlapping fingers, restricted growth, an abnormally small head (microcephaly), webbing of the 2nd and 3rd toes, an upturned nose, narrow eyelid folds, underdeveloped thumbs and nails, clenched hands, low-set and malformed ears, mental retardation, widely spaced eyes, droopy eyelids, difficulties breathing, eating, and drinking. In males, there can be undescended testicles.

Most fetuses with this condition die before birth.  Common causes of death are heart damage and respiratory problems. Half of children born with this condition do not live past the first week. About 8% live longer than one year. Only 1% will live to age 10, although these are the less severe cases. Fortunately, after being in and out of the hospital for most of the first year of her life, Bella has not been hospitalized since this most recent event and is reportedly improving.

For those wishing to make a donation to the Trisomy 18 Foundation, you can do so at this link.

Suggested reading: I Am Not a Syndrome - My Name is Simon

Friday, January 27, 2012

The Bizarre "Morgellons Disease," Psychosis, and Exaggeration

If you are like most people, you have probably never heard of “Morgellon’s disease” or “Morgellons.” The first reason you have likely never heard if it is because it is so bizarre and uncommon. Most of what is known about it is based on rare case reports or anecdotal stories. The second reason is because it is not recognized in the medical community as a legitimate medical disease. It is a layperson’s term coined by a child’s mother (see end of entry).

People who claim to have this once mysterious condition report that all sorts of substances are excreted from their skin such as colored fibers, specks, dots, fuzzballs, worms, eggs, grainy substances, and other assorted solid materials. They report that they develop sores that are slow to heal and feel like bugs are crawling under their skin or have sensations of being bitten, stung, or experience pins and needles.

In addition to the dermatological (skin) symptoms reported, there are other non-specific symptoms reported (meaning they can have many possible causes) such as fatigue, concentration problems, memory difficulties, and depressed mood. Some of these patients have documented psychiatric disorders, some have genuine neurological conditions such as multiple sclerosis, and others have more controversial diagnoses such as fibromyalgia. Some of these patients claim to be disabled by their condition. No known medical cause has ever been discovered.

Most dermatologists consider the condition to be a psychotic disorder, which means that the person is detached from reality. Specifically, it is widely considered to be a form of delusional parasitosis, in which a person falsely believes they are infested with parasites.

Perplexed, the Centers for Disease Control and Prevention (CDC) ordered a study based on a request from Democrat Senator Dianne Feinstein due to an increasing number of people reportedly having this condition in her state of California.

A set of researchers conducted a search for patients in a managed care system with 3.3 million enrollees. 115 patients were found. The average age was 52 (range = 17-93), 77% were female, and 77% were Caucasian. 70% reported chronic fatigue. 54% reported poor health. 50% had drugs detected in hair samples. 78% reported solvent exposure. 24% had clinically significant histories of past or present drug or alcohol use.

But the most interesting part of the study was an analysis of skin samples. The most common finding was increased skin elasticity due to sunburn. Abnormal areas on the skin were most consistent with insect bites and scratched skin. There were no parasites or bacteria found. If there was something on the skin, it was usually was cotton from clothes.

When psychologicaly tested, 59% were reported as having cognitive deficits on a full battery of neuropsyhological tests in at least one area. Attention and memory were the most common areas assessed. Unfortunately, no tests were reported on that were used to confirm the reliability and validity of the cognitive test results and so one is left to wonder to what degree these poor test results are the result of poor effort to do well. This is important to consider because it is unknown how many of these patients were seeking compensation for these symptoms (e.g., litigation, disability application), which would increase the possibility of exaggeration.

Along these same lines, while a personality test known as the Personality Assessment Inventory (PAI) was administered, the authors only reported the results of the clinical scales (showing a high focus on physical symptoms). The results of scales on the test designed to measure the reliability and validity of the test results were not reported. Thus, it is unknown the degree to which some symptoms are over-reported, accurately reported, or underreported. Some of the test performance was almost certainly exaggerated, especially when one considers that of those patients with clinically significant somatic complaints on the PAI, 50% had elevated personality test scores that were at the 99.99%ile, meaning that such scores are essentially never seen in the normal population. In fact, these scores represent extreme symptom endorsement even for patient populations.  Researchers, as well as clinicians, should almost always include methods to assess whether the test performance and symptom presentation is reliable and valid.

Overall, Morgellons shares a number of features with delusional infestation beliefs and based on my read of the study, there is very likely to be an exaggerated component to the condition (at least in some people). It is interesting to note that over 75% of patient’s symptoms occurred after 2002, which was around the time that Internet postings about the topic began. This indicates that there is a suggestible or copy-cat component to Morgellons symptoms in some individuals, although some cases may truly represent psychosis (detachment from reality). The condition can also be considered a form of somatoform disorder, in which psychological distress is converted into physical symptoms that cannot be explained by a medical cause.

As to the origin of the term, it was coined in 2002 by Mary Leitao, who stated she had noticed "balls of fiber" coming out of her 2-year-old's skin prior to sores developing. She found the word "Morgellons" in a 17th century book describing an condition in which black hairs were said to appear on the backs of children in France. However, there is no evidence that the two conditions are related.

Source: Click here to read the research study.

Thursday, January 26, 2012

Why Was Demi Moore Hospitalized?

Famous actress, Demi Moore, was recently hospitalized and the media has been busy trying to figure out why. It has been reported that there are three main problems: 1) substance abuse, 2) anorexia, and 3) collapsing due to a seizure.

Anorexia is excessive weight loss associated with an obsessive fear of weight gain. Pictures such as this one lend credence to the anorexia claim because she appears extremely thin.

A seizure is an overexcitable state of nerve cells in the brain. Seizures sometimes manifest as sudden, violent, involuntary contractions of a group of muscles but can also manifest as brief periods of loss of awareness and blinking. Seizures have many possible causes such as a very high fever, bleeding in the brain, drug overdose, and withdrawal from drugs, and anorexia. 

Due to alleged infidelity, Moore released a statement on 11/7/11 that she intended to divorce her much younger husband, Ashton Kutcher. Being a spouse who is the victim of infidelity, especially when placed in the public spotlight, is a very stressful experience. The same is true for divorce. Combine this with the wild Hollywood lifestyle and all of the factors are present for someone to turn to substance abuse as a maladaptive way to ease emotional pain. Anorexia involves the control of food and provides the individual with a sense of control when coping with uncontrollable events (e.g., infidelity). This is another maladaptive coping mechanism, however. Eventually, the body can no longer take the strain of such an unhealthy lifestyle (such as reported exhaustion), brain cells become desynchronized and over-excitable, and a seizure can result. Fortunately, once the underlying cause is treated in cases of substance abuse and anorexia, the person would be expected to become seizure free. She is reportedly being treated for anorexia. Treatment for anorexia involves psychological counseling, medications to reduce obsessions and increase weight, and dietary changes to increase weight gain. Substance abuse treatment primarily relies upon psychological counseling and she is reportedly receiving such treatment. 

Source: article

Wednesday, January 25, 2012

Only .01% of the State of the Union Speech Mentioned Healthcare

Last night, President Barrack Obama delivered a 6,944 word State of the Union address to the American people. Of the speech, less than .01% was devoted to healthcare, which is remarkable considering the major changes in healthcare that are on the horizon if Obamacare survives a challenge in an upcoming U.S. Supreme Court case. During the speech, there were only three sentences that mentioned healthcare. The first was this…

“I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.”

While the President is correct that nobody likes when an insurance company cancels their policy, denies you coverage, or charges women differently from men, there are sometimes legitimate business reasons why this happens. I will use a personal example to explain this. Recently, I applied for a long-term disability policy. The insurance company paid the costs for me to have a physical exam and have routine blood tests. After a few weeks, they sent me a letter saying that they would give me the insurance, but that they would not pay me for any type of disability related to my back since I have a history of low back pain. On the one hand, I was disappointed because I would have preferred a policy without any conditions like this.

On the other hand, I understood the insurance company’s perspective. That is, the insurance company realized that I was at increased risk to claim disability per their statistics because I have a history of low back pain. Low back pain is one of the main reasons people claim disability in the U.S., and many of the cases are exaggerated or malingered. Insurance works when most people paying into the system can reasonably be expected to be healthy because those funds are needed to pay for those who become disabled. If the number of disabled patients outweighs those paying the insurance premium, then the insurance company will lose money. Thus, they seek to identify those at risk before granting coverage and add exceptions to the contract.

In my case, I decided not to accept the deal. It is a free market and I can shop around for different policies. I realize that if I find that an insurance company that is willing to give me a disability policy without any conditions attached that it will cost me more money for the insurance. The reason is because the extra costs helps partly cover the added potential cost that to the insurance company, which is taking a greater risk. Sure, I could demand the government pass a law preventing the insurance company from making such exclusions but if that happened, one needs to realize that the insurance company will likely go out of business one day and people will be left with government run healthcare (see statement three below). While some people think that this is good, it is important to remember that many doctors refuse to take patients with Medicare or Medicaid coverage because the reimbursement is so poor, the system is filled with beaurocracy, and they do not want to take the risk of making an innocent billing mistake yet find themselves charged with fraud. To be fair, many healthcare providers have also begun to refuse to take private insurance because of poor reimbursement, denials, and tedious paperwork, although this is less common. 

While it may feel like insurance companies have unchecked power, they actually do not. For example, many people do not realize that when they have a dispute with an insurance company and feel that they have been treated unfairly, they can call their state insurance agency, file a complaint, and unfair decisions and practices can be penalized and/or reversed. The state’s Attorney General’s Office also has the power to investigate insurance companies and apply sanctions against them. On the federal level, The Health and Human Services Department and the Justice Department are another check and balance on insurance companies that can and has been used many times in the past.

The second healthcare statement is the State of the Union speech was:

“Today, the discoveries taking place in our federally-financed labs and universities could lead to new treatments that kill cancer cells but leave healthy ones untouched.”

While this is a true statement, it leaves out that privately financed labs and universities also lead to new treatments to fighting cancer in this manner and in many other ways.

The third statement on healthcare in the State of the Union address last night was:

“That’s why our health care law relies on a reformed private market, not a Government program.”

This was the statement that I found to be most controversial. While it is true that there would be reforms in the private market with Obamacare, these reforms are not unrelated to a government healthcare program. Specifically, under Obamacare millions of citizens would be placed on government-run healthcare. To pay for the system, people who are not insured but refuse to take government-run healthcare will be fined, as will companies who do not provide the government-run healthcare option to their employees. While privately funded healthcare insurances are focused on making a profit (which some see as a bad thing), government run healthcare has no such constraints (although this can also be a bad thing). At a certain point, if a privately run healthcare system runs out of funds to support its beneficiaries, it will need close. For any insurance company to work properly there simply must be more funds coming in than going out. Private insurances cannot continue to function by simply requesting more money from Congress, much like government run healthcare can. This can be viewed as an unfair advantage that government run healthcare has over private insurances. As a result, many private healthcare companies can shut down, resulting in most people being forced to go on government run healthcare.

No matter where you stand on healthcare, expect to see this topic debated significantly during the next election.

Tuesday, January 24, 2012

Man Shoots 3 Inch Nail Into His Brain and Lives

This is something you will hopefully never see on the next episode of This Old House, but in Oak Lawn, Illinois, a man accidentally shot a 3.25-inch nail into his head and lived to tell about it. The interesting thing is that he did not even know he had done this and thought he had just cut himself with the nail gun.

The man went to the hospital to get checked out, received an x-ray, and doctors showed him the above picture. He thought they were joking. The reason he did not realize what he had done is because the brain does not have any pain receptors. Many people do not know this but it is true. The pain receptors in the head are in the skull. The man did not even go to the hospital that day. In fact, he continued to do some snow plowing that day. The next day he awoke, felt nauseous, and went to the hospital.

Fortunately doctors were able to remove the nail after a two hour procedure in which they drilled two burr holes in his skull, later replacing the skull pieces with titanium mesh. He apparently did not suffer any serious effects of the injury or the surgery. Injuries to the brain like this are referred to as penetrating brain injuries. The more common example is a gunshot wound to head, but bullets are more dangerous because they break into multiple pieces once they enter the brain and also fracture the skull significantly. A good example of this was the case of Gabrielle Giffords who is permanently brain damaged and recently had to resign from Congress after being shot in the head by Jared Loughner. Nails on the other hand, have a smaller sharp tip and usually a shorter trajectory than bullets, so one would not break apart when entering the brain. I am glad this man got through this ok. Moral of the story is that if you use a nail gun, keep it away from your head!

Reference: The Associated Press

Monday, January 23, 2012

Why Sports Leagues Need to Pay Attention to Malingering

One of the most fascinating areas in medicine and psychology is the study of symptom exaggeration and malingering. Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs (APA,1994).

FEATURED BOOK: Mild Traumatic Brain Injury and Malingering

In a prior blog entry, I discussed why physicians need to pay attention to malingering, but sports organizations need to pay attention to this as well. In sports, players are often routinely administered a battery of tests designed to measure thinking abilities (e.g., memory, thinking speed) before the seasons begins (known as baseline testing) to be used as a comparison point after an injury during season. The purpose is to use the follow-up testing to determine if the person is recovered after the injury, although there are numerous problems with this approach. One such problem is that some players intentionally perform poorly during the baseline testing so that future test results obtained after an injury will not look to be as low as they actually are.

Famous NFL quarterback, Peyton Manning admitted to doing this when he said: "They have these new (brain) tests we have to take. Before the season, you have to look at 20 pictures and turn the paper over and then try to draw those 20 pictures. And they do it with words, too. Twenty words, you flip it over, and try to write those 20 words. Then, after a concussion, you take the same test and if you do worse than you did on the first test, you can't play. So I just try to do badly on the first test."

Another area where faking is happening in sports is in college and professional football. The technique is used to slow down the other team’s momentum in the hopes of gaining an advantage that can be used to increase the chances of winning the game. Winning games in college and professional football increases the chances of fame, fortune, and other external incentives.

Here is an example from a New York Giants Game earlier this year.

And here is an example from a recent college football game.

Here are several other examples in college football.

And here is yet another example from the NBA playoffs of malingered head injury (watch how the player's head never hits the ground). He was fined $5,000 by the NBA for faking this injury, which an NBA official described as "...a gross over-embellishment and was inconsistent with the degree of contact received on the play."

But what I found most fascinating was a panel discussion about this on television in reaction to the Giant players faking injuries because it echoed the debates that often take place on this topic in the fields of medicine and psychology. That is, on one side you have people who are upset that this is taking place, believe that authorities should do something to stop it, and that there should be stiff penalties for faking. On the other hand, the player (akin to the malingering patient) acknowledges that faking takes place but tries to excuse it as a tactical maneuver (and not cheating), advises that one should do this in a way to avoid getting caught, and brazenly states that attempts to stop it will never work because he believes it cannot be proven. The debate also raised the topic of false positives (the problem of saying someone is faking when they are not) and other issues.
Fortunately, there are reliable and valid methods that health care professionals can use to assess malingering that greatly minimize false positives. Behavioral observations, including video evidence (e.g., surveillance), can also play an important role in assessing malingering and appears to be the main tool that NFL and college football leagues will have to assess the apparent faking demonstrated in the videos above. If these leagues begin to crack down on this issue, my prediction is that more sophisticated attempts at deception will emerge rather than some of the unsophisticated measures used above.

Disclosure: The author of this blog in the co-editor of the book, Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering.

Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, 4th ed. Washington, DC: American Psychiatric Association; 1994.

Friday, January 20, 2012

New York Neuropsychologists Leave State Psychological Association

Neuropsychologist members of the New York State Psychological Association (NYSPA) resigned from the organization en masse in December 2011 after years of conflict within NYSPA regarding the state’s ban on the use of neuropsychology technicians.

The resignations included current and past presidents of NYSPA’s Neuropsychology Division, which led to a vote to formally close the division and to place NYSPA in a position where it no longer represents the voice of neuropsychology in New York State. Many of the neuropsychologists who left are national leaders in the field leaving a gaping hole in the association.

For over 50 years, neuropsychologists in New York, as in the rest of the country, utilized trained technicians to assist with testing services performed under their direct supervision. The tests can be administered by technicians (also known as psychometrists) who work under the licensed psychologist and are trained to strictly adhere to manualized test administration procedures with clear and easy to follow instructions. The licensed psychologist always determines the treatment plan including all selection of tests, interpretation of results, report writing consultation with other professionals, and feedback regarding evaluation results. Thus, the technician’s job is purely mechanical, much like a technician who assists in running an X-ray machine. The radiologist does not actually run the x-ray machine but interprets the results.

Technician practice is critical in the access and delivery of health care. If medical doctors were required to collect all of the data necessary for diagnostic evaluations, our health care system would be overly burdened by cost and it would be impossible for patients to access quality care. Unfortunately, this is the current situation in New York State for psychologists trained to practice neuropsychology.

The practice of psychology pertaining to the use of technicians in New York changed in 2003 following passage of the state’s psychology scope of practice law. Despite a documented legislative intent stating that no such change would occur, an idiosyncratic and rigid interpretation of the law by the State Education Department’s (SED) led to a complete restriction on the use of technicians for psychologists throughout the state. Essentially, a parenthetical phrase was included in the scope of practice law stating the practice of psychology includes neuropsychological testing. This was then interpreted to mean that anyone besides a psychologist performing neuropsychological testing was practicing psychology without a license and that any psychologist facilitating this was aiding and abetting criminal behavior. In this way, the new interpretation essentially made it illegal for psychologists to use technicians to assist with testing services.

New York State licensed psychologists trained in the specialty of neuropsychology banded together following the 2003 interpretation with the goal of obtaining a reversal of the SED’s interpretation that would allow a return to the lawful use of neuropsychology technicians. Most initial efforts were made at fighting opposition within NYSPA, particularly from its School Psychology and Clinical Psychology divisions as well as the State Psychology Board, who generally supported the ban imposed by their department. These groups continued to oppose technician use despite being presented with statements from multiple state and national professional organizations, including Division 40 (Neuropsychology) of the American Psychological Association (APA), the National Academy of Neuropsychology, the American Academy of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and the APA Practice Directorate. These groups routinely noted that use of technicians is a standard practice in neuropsychology throughout the country with functions that are recognized and reimbursable under existing national billing codes such as 96119 (neuropsychological testing by a technician).

After years of continued discussion and conflict, neuropsychologists within NYSPA reached a tentative agreement with opposing psychologists and obtained support from the NYSPA Council of Representatives in 2007 to move ahead toward an administrative solution to further clarify SED’s interpretation so that it was more flexible with regard to technician use. In order to reach the 2007 accord with a NYSPA committee tasked to address the issue, neuropsychologists made a major concession towards school psychology that technicians would not be allowed to administer full intelligence tests and would not work in school systems. This concession was made even though technician use in assessment had never been problematic to school psychologists during the lengthy period prior to 2003 when it was legal.

In spite of the concessions by the NYSPA Neuropsychology Division, members of the School Psychology and Clinical Psychology divisions continued to lobby against NYSPA’s support and sought further restrictions for technicians, including attempts to prevent them from working with individuals less than 21 years of age and from administering most existing tests to individuals from any age group. These restrictions were sought by the opposing psychologists without any supporting evidence to back their claim technicians would be harmful to the public. The opposition continued despite clear documented evidence sent to SED (including documentation from an independently appointed advisor to SED to study the issue) that there was a restricted access to care in the state for receiving neuropsychological services. This led to long waiting lists that significantly affected the elderly (i.e., delaying a dementia or depression differential diagnosis which would lead to different treatments) and ethnic minorities, particularly those who spoke another language because there was no longer the ability to employ technicians who spoke the necessary languages to administer the tests.

The issue that eventually led to the recent mass resignations was that, after making concessions and reaching an initial agreement within NYSPA, the organization’s council of representatives returned to the issue four years later and voted against the use of technicians on administering even parts (subtests) of IQ tests, a critical element of almost all neuropsychological assessments. Neuropsychologists use these subtests due to their robust norms and to aid with the diagnostic process.

If neuropsychologists would have accepted the results of the vote, it would eliminate the way the vast number of neuropsychologists practice. This was considered totally unacceptable to neuropsychologists, who concluded that the organization was out of step with national practice standards and that neuropsychology could not have their interests represented by a group composed of so many disparate fractions who do not understand the intricacies of neuropsychological practice, some of whom were actively communicating with SED in an attempt to create further division, opposition, and prevention of a reasonable resolution. Although there were some members of NYSPA who were supportive, including the last three NYSPA presidents, the opposition by the School and Clinical Psychology Divisions led the day.  Mass resignations from NYSPA resulted and the Neuropsychology Division ceased to exist.

Neuropsychologists in New York are fortunate to have another organization to turn to after leaving NYSPA. In 2006, neuropsychologists in the state formed the New York State Association of Neuropsychology (NYSAN). This organization was initially formed on the recommendation of the APA Practice Directorate to establish a professional entity that could receive funding to hire a professional lobbyist to work at overturning the technician ban. Over the years, NYSAN has been supported generously by APA Neuropsychology Division and the other organizations mentioned above to continue its lobbying efforts. However, NYSAN has also branched into other areas of activity including development of an active Professional Affairs Committee (PAC), which has now become a major force within the state for representing neuropsychologists’ interests in negotiations with third party payers. Neuropsychologists in the state are urged to join NYSAN and help it develop as the only voice for neuropsychology in New York State and to continue its fight against opposing factions in Albany and within NYSPA. Neuropsychologists from across the country will surely be watching.

Disclaimer: Dr. Carone is a neuropsychologist who was President of NYSAN for 3.5 years.

Thursday, January 19, 2012

Does More Information Lead to Healthier Life Choices?

The following is a guest blog entry.

One thing we are not in want of these days is information. Through the internet you can find out just about anything about everything – so long as you know where to look. When it comes to public health awareness such technology couldn't be more priceless. The ability for individuals to research health and medical topics is groundbreaking in that while doctors and other medical professionals are as necessary as ever, they decreasingly need to be tasked with answering questions and can instead focus more on finding the most appropriate cure. Meanwhile, members of the public can spend less money on reassurances that they are in fact not dying of cancer, at least not anytime soon.

But when it comes to such knowledge playing a part in preventive measures and thus improving the quality of life for people, it does not seem as though access to health information makes much of a difference. Amidst the advent of the Internet, this country has only seen easily-preventable illnesses skyrocket and easily-treatable afflictions increasingly be left untreated due to rising costs. Take diabetes for example. Despite type 1 diabetes news and updates, as well as more than enough information covering type 2, the symptoms of the former are more commonly being ignored due to rising healthcare costs while the latter is occurring in record numbers because individuals do not see the writing on the wall about their own health. On the surface, online sources of information such as don't seem to work as ideally as they ought to be.

Yet ask medical experts and researchers what the problem is when it comes to American healthcare and they'll likely tell you that it's a lack of public awareness regarding health information. Such is the reason why the majority of 2010 healthcare reform law was written as to assign the government a stronger role in public health awareness. The theory goes that once people are able to have enhanced access to health and medical information, they'll be less likely to wait till their maladies become costly before getting help and much more likely to prevent such health problems altogether.

Medical professionals across the country are eager to see such long-awaited awareness efforts put into action on a governmental scale. But aren't we forgetting the fact that the overwhelming majority of Americans have had immediate home-based access to health knowledge for years? We've had the information right in front of us thanks to the web, yet we seem to carry on living the unhealthy lives that we do until the day comes when our bad habits transform into a $70,000 emergency surgery.

With that said, the entirety of health related information that can be found online is not exactly vetted by the medical community. For every WebMD there are millions of quack sites that hand out health information that is either outdated, out-of-sync with the majority medical opinion, or outright false. While finding the safe sources of health and medical information is quite easy, a decade of such fraudulent webpages finding their way to the top of search engine results has established a distrust of health-related information online by the majority of the public.

So are we simply waiting for trustworthy information to improve our health with? Or is it that no matter how much preventive awareness is thrown our way we'll still behave as though today's health choices are not going to affect tomorrow? Such are the questions medical professionals have been asking themselves for quite sometime, and it's unlikely we'll get the answer anytime soon.