Generally, the rate of inpatient smoking among schizophrenics is three to four times higher than the general smoking population. In one British study of 100 institutionalized schizophrenics cited by Lyon, 92% of the men and 82% of the women were smokers. Moreover, schizophrenics smoke more cigarettes per day than other smokers do, and they commonly smoke high-tar, unfiltered cigarettes — niche brands for heavy smokers used by only 1% of the total smoking population.

Australian research performed in 2001 found that because of high rates of smoking, “people with mental illness have 30% more heart disease and 30% more respiratory disorders,” according to Ann Crocker, now a professor of Clinical Psychiatry at McGill University.

Not only do an estimated 80% of schizophrenics smoke, compared to roughly 25% of the total adult population, psychiatric facilities report that depressives and those with anxiety disorders also smoke in great numbers.

Why?

The review of studies through 1999, undertaken by Lyon and published in Psychiatric Services, shows unequivocally that schizophrenic smokers are self-medicating to improve processing of auditory stimuli and to reduce many of the cognitive symptoms of the disease. “Neurobiological factors provide the strongest explanation for the link between smoking and schizophrenia,” Lyons writes, “because a direct neurochemical interaction can be demonstrated.”

Of particular interest is the interaction between nicotine and dopamine in the nucleus accumbens and prefrontal cortex.  Several of the symptoms of schizophrenia appear to be associated with dopamine release in these brain areas. A 2005 German study concluded that nicotine improved cognitive functions related to attention and memory. “There is substantial evidence that nicotine could be used by patients with schizophrenia as a ‘self-medication’ to improve deficits in attention, cognition, and information processing and to reduce side effects of antipsychotic medication,” the German researchers concluded.

In addition, the process known as “sensory gating,” which lowers response levels to repeated auditory stimuli, so that a schizophrenic’s response to a second stimulus is greater than a normal person’s, is also impacted by cigarettes.  Sensory gating may be involved in the auditory hallucinations common to schizophrenics. Receptors for nicotine are involved in sensory gating, and several studies have shown that sensory gating among schizophrenics is markedly improved after smoking.

There is an additional reason why smoking is an issue of importance for health professionals. According to Lyon, “Several studies have reported that smokers require higher levels of antipsychotics than nonsmokers. Smoking can lower the blood levels of some antipsychotics by as much as 50%…. For example, Ziedonis and associates found that the average antipsychotic dosage for smokers in their sample was 590 mg in chlorpromazine equivalents compared with 375 mg for nonsmokers.”

Smoking among inpatient psychiatric patients is not trivial. Neither is the decision to institute smoking bans in psychiatric hospitals, a move that is understandably unpopular with patients.

References

Lyon, E. (1999). A Review of the Effects of Nicotine on Schizophrenia and Antipsychotic Medications. Psychiatric Services, 50, 1346-1350.

Cattapan-Ludewig, K. (2005). Why do schizophrenic patients smoke? Nervenarzt, 76 (3), 287-294.

Mueser, K., Crocker, A., Frisman, L., Drake, R., Covell, N., & Essock, S. (2005). Conduct Disorder and Antisocial Personality Disorder in Persons With Severe Psychiatric and Substance Use Disorders Schizophrenia Bulletin, 32 (4), 626-636 DOI: 10.1093/schbul/sbj068

Adler, L., Hoffer, L. Wiser, A. (1993). Normalization of auditory physiology by cigarette smoking in schizophrenic patients. American Journal of Psychiatry, 150, 1856-1861.

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The current JAMA study concluded that cognitive behavioral therapy (CBT) –- one of the most studied and proven-effective interventions for the treatment of depression in adolescents -– is effective at reducing the risk of depression symptoms in adolescents with depressed parents. The study group consisted of 316 adolescents aged 13 to 17 years who had at least one parent or caregiver with a current or past diagnosis of a depressive disorder. All of the patients, themselves, also had a history of current or past subdiagnostic depressive symptoms.

The group was randomly assigned to either receive sessions of group CBT or continue their current treatment. The intervention group participated in 8 weekly CBT sessions, followed by 6 monthly sessions, that focused on learning new coping and cognitive restructuring techniques and problem-solving skills. The study leaders measured the rate of occurrence of depressive episodes that lasted at least 2 weeks. At the conclusion of the study and follow-up period, the overall incidence of depressive episodes in the intervention group was 21.4%, versus 32.7% in the control group. The intervention group also self-reported improvement in depressive symptoms more often than the control group.

However, factoring in parental mental health during the study confounds the results. The adolescents of non-depressed parents experienced significantly better results than the children of currently-depressed parents at the start of the study. For adolescents whose parents were not depressed at baseline, the incidence of depression in the intervention group was only 11.7%, compared to 40.5% in the control group. For adolescents whose parents were depressed at baseline, the incidence of depression was not significantly different in the intervention group versus the control group.

Many studies have shown CBT to be effective treatment for children and adolescents with depression, and a few have shown it to be effective prevention, also. Family-based therapies have, likewise, produced positive results in the prevention of depression in children with depressed parents. One study showed that simply increasing the child’s understanding of the parent’s mental illness and enhancing communication skills and encouraging parent-child dialogue about depression, children and adolescents experienced more resilience and a reduced risk of depressive symptoms. Studies like these highlight the value of parent and child therapies for depression treatment and prevention. In fact, effectively treating parents for depression first may reduce the need to treat children at all.

The symptoms associated with childhood and adolescent depression can be debilitating long into adulthood, and many young people with depression experience more serious affective disorders and psychopathology later in life. Additionally, many pharmacological treatment options available today pose unwelcome risks to children and adolescent patients. In this case, as with most health care interventions, prevention is better than a cure.

References

Beardslee, W., Gladstone, T., Wright, E., & Cooper, A. (2003). A Family-Based Approach to the Prevention of Depressive Symptoms in Children at Risk: Evidence of Parental and Child Change PEDIATRICS, 112 (2) DOI: 10.1542/peds.112.2.e119

Clarke, G. (2001). A Randomized Trial of a Group Cognitive Intervention for Preventing Depression in Adolescent Offspring of Depressed Parents Archives of General Psychiatry, 58 (12), 1127-1134 DOI: 10.1001/archpsyc.58.12.1127

David-Ferdon, C., & Kaslow, N. (2008). Evidence-Based Psychosocial Treatments for Child and Adolescent Depression Journal of Clinical Child & Adolescent Psychology, 37 (1), 62-104 DOI: 10.1080/15374410701817865

Garber, J., Clarke, G., Weersing, V., Beardslee, W., Brent, D., Gladstone, T., DeBar, L., Lynch, F., D’Angelo, E., Hollon, S., Shamseddeen, W., & Iyengar, S. (2009). Prevention of Depression in At-Risk Adolescents: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 301 (21), 2215-2224 DOI: 10.1001/jama.2009.788

Lakhan, S., & Hagger-Johnson, G. (2007). The impact of prescribed psychotropics on youth Clinical Practice and Epidemiology in Mental Health, 3 (1) DOI: 10.1186/1745-0179-3-21

WEERSING, V. (2006). Cognitive Behavioral Therapy for Depression in Youth Child and Adolescent Psychiatric Clinics of North America, 15 (4), 939-957 DOI: 10.1016/j.chc.2006.05.008

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Remember, we review the latest blogs related to drugs — medicinal, recreational, interactional, personal, professional, or any other aspect. If you were left out in this round, just leave a comment with your blog entry. You can check out the archives for every edition of this carnival.

For future editions, please remember to submit your blog entries using the online submission form. We will do our best to review and include your entry! Enjoy your readings…

Bioblog writes Bring on the free radicals!:

The use of antioxidants has been promoted for years to prevent disease and slow inevitable decline. The problem is, recent accumulating data suggests that vitamin E does not protect against disease and sometimes might even promote it. Once again, our overly simplistic assessment of a compound’s function in the human body has led us to believe we can easily alter that function to our benefit.

Surprising Science writes Drugs’ Odd Side Effects:

Can’t remember what you did yesterday? Are you taking Mirapex for restless-legs syndrome? Or maybe a statin, such a Lipitor? Both have had reports of short-term memory loss as a side effect. The good news, though, is that the problem seems to go away when people stop taking the drugs.

Darwin’s Finance writes Will Resveratrol Benefits Create the Biggest Blockbuster Drug Ever?:

Undoubtedly, you’ll be seeing ads for Resveratrol supplements all over the internet, but with the supplement industry needing no actual data to back up their claims in this regard, and the lack of a proven formulation to actually deliver the compound in the concentration needed to derive any benefit, it is my opinion that you’re throwing money down a rat hole.

My Meditation Garden writes Meditation for Dealing with the Recession:

In the great video [here], listen to Dr. Sarina Grosswald speak about studies made on children and adults suffering from ADHD and the beneficial impact that the regular practice of transcendental meditation has had on them. She speaks about school models, the negative impact of medication on the child suffering from ADHD, and all the side effects!

Branches Of Health writes Help Keep Small Farms Alive!!:

It was recently brought to my attention that there are a few bills going through congress right now that could affect the way local farmers make their living. HR 875 and HR 759 are being addressed as “food safety” bills that, intentionally or not, are targeted at industrial-sized farms, but do not exclude just growing vegetables in your backyard.

Wall & Main writes A glimpse into the future IV – Cancer Research:

An international team of scientists from the Moores Cancer Center at the University of California, San Diego, the University of North Carolina and several institutions in China have explained how a gene alteration can lead to the development of certain types of brain tumors -– low grade gliomas and secondary glioblastomas, and they have identified a compound -– alpha-KG -– that could staunch the cancer’s growth. The researchers have shown that when a mutated enzyme fails to do its job, the development of tumor-feeding blood vessels increases, allowing more nutrients and oxygen to fuel cancer growth.

Malignant Mesothelioma writes Research Suggests Vitamin D Plays a Large Role in Preventing and Fighting Lung Cancer:

An interesting fact found from the study suggests that cancer patients who had high intake of vitamin D doses from sunshine in summer months and who had Surgery during this time were more likely to live 5 years more than people who had surgery during winter months. Michael Thun, chief epidemiologist at the American Cancer Society quotes, “This is a very interesting study. It’s a new trend — looking at dietary factors as they relate to survival, not just the risk of getting a certain cancer.”

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The secret to a happy life has eluded mankind for generations. Ancient philosophers, progressive thinkers, and contemporary educators have all offered theories and opinions on what makes us happy. But no one has collected more objective evidence on the subject than researchers from the Harvard Medical School. The Harvard Study of Adult Development began in 1937, examining more than 200 healthy, well-adjusted Harvard sophomores. The study has become the preeminent example of a longitudinal study, following its subjects for more than 70 years. The group of men is not at all representative of the population as a whole, consisting entirely of well-educated, socioeconomically-favored males, but the homogenous group of subjects has still uncovered some surprises in the quest for happiness.

Over the years of the study, researchers have collected extensive information on the men’s physical, mental, and emotional health, and compared this to their accomplishments in their occupations, marriages, and hobbies, as well as their self-perceived level of satisfaction with life. Researchers have found that cholesterol levels in middle age had no correlation to overall health in old age. They concluded that regular exercise in college was positively correlated with mental health later in life. They discovered that religious involvement, in contrast to many previously reported studies, was not associated with physical, mental, or social well-being.

Successful aging and happiness later in life, the researchers have concluded, is predicted by many difference variables — some of which can be controlled, and some of which cannot: parental social class, family cohesion, major depression, ancestral longevity, childhood temperament, physical health at age 50, alcohol abuse, smoking, marital stability, exercise, body mass index, coping mechanisms, and education. Ultimately, there is no one secret to a happy, successful life. Men who seemed to have every advantage in life failed to succeed in careers and family life, and many have died prematurely or unexpectedly. Men, on the other hand, who seemed doomed for failure due to their circumstances rose to the challenge and eventually led exceptional lives.

It turns out that success and happiness might not be determined by what you know, but by who you know. The closest thing that researchers have been able to identify as a single secret to happiness is successful relationships. High levels of intelligence, social aptitude, physical strength, or mental health mean very little in the pursuit of happiness. Positive relationships — with parents, siblings, spouses, children, friends, neighbors, and colleagues — as early as childhood are the most important predictors of happiness and success as we age. Largely, loving relationships and an appreciation for beauty positively predict life satisfaction.

Of course, happiness and life satisfaction are individually defined, depending on culture, society, and personality. Self-expression and individualism play an important role in happiness in many cultures, while simple survival constitutes a successful life in others. But, however we define happiness, positive emotions are linked to resilience and a satisfaction for life. As much as scientists are called to delineate objective measures of subjective experiences, maybe we should heed Albert Camus’s warning:

You will never be happy if you continue to search for what happiness consists of.

References

Cohn, M., Fredrickson, B., Brown, S., Mikels, J., & Conway, A. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9 (3), 361-368 DOI: 10.1037/a0015952

ISAACOWITZ, D., VAILLANT, G., & SELIGMAN, M. (2003). STRENGTHS AND SATISFACTION ACROSS THE ADULT LIFESPAN The International Journal of Aging and Human Development, 57 (2), 181-201 DOI: 10.2190/61EJ-LDYR-Q55N-UT6E
Kuppens P, Realo A, Diener E. The role of positive and negative emotions in life satisfaction judgment across nations. J Pers Soc Psychol. Jul 2008;95(1):66-75. doi:10.1037/0022-3514.95.1.66

VAILLANT, G., TEMPLETON, J., ARDELT, M., & MEYER, S. (2008). The natural history of male mental health: Health and religious involvement Social Science & Medicine, 66 (2), 221-231 DOI: 10.1016/j.socscimed.2007.09.011

Vaillant, G., DiRago, A., & Mukamal, K. (2006). Natural History of Male Psychological Health, XV: Retirement Satisfaction American Journal of Psychiatry, 163 (4), 682-688 DOI: 10.1176/appi.ajp.163.4.682

Vaillant, G. (2001). Successful Aging American Journal of Psychiatry, 158 (987), 839-847 DOI: 10.1176/appi.ajp.158.987.839
Waldinger RJ, Vaillant GE, Orav EJ. Childhood sibling relationships as a predictor of major depression in adulthood: a 30-year prospective study. Am J Psychiatry. Jun 2007;164(6):949-954. doi:10.1176/appi.ajp.164.6.949

Shenk JW. What Makes Us Happy? The Atlantic; 2009.

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In the past few years, many health care agencies and organizations have promoted programs to reduce the use of unnecessary antibiotics. These programs have included everything from prescriber training to patient education to additional diagnostic testing, and only a few programs have seen moderate success in reducing the use of unnecessary antibiotics. A new study in the British Medical Journal (BMJ) evaluated yet another approach to promoting judicious antibiotic use and concluded that the most effective method of decreasing antibiotic use is a combination of diagnostic testing and enhanced physician-patient communication.

The BMJ study evaluated 413 patients with suspected LRTIs among 40 general practitioners in the Netherlands. Practitioners used a C-reactive protein (CRP) point of care test and enhanced communications techniques, alone and in combination. This assessment of a disease or diagnostic approach versus a patient-centered approach is similar to other studies conducted, and observed that antibiotics were prescribed significantly less often in the CRP test group versus the no test group (31% versus 53%). Similarly, antibiotics were prescribed significantly less often in the enhanced communication group (27%) compared with the group that practiced traditional communication techniques (54%). The practitioners who used a combination of CRP testing and enhanced communication skills prescribed antibiotics the least. These interventions did not affect patients’ recovery or satisfaction with care received.

The thoughtful and appropriate use of antibiotics is vital for reducing the global crisis of antibiotic resistance. Patient demands and lack of prescriber training and education contribute to the over-use and misuse of antibiotics for conditions for which they are ineffective. The current study is just one in a long line of similar appraisals that promote patient-centered approaches, including education and communication, as important factors in reducing unnecessary antibiotic use.

While nearly every health care professional acknowledges the general need to use antibiotics appropriately, most do not view it as a problem they can fix themselves and most have not altered their own prescribing habits, even in light of the increasing concern of antibiotic resistance. While the authors of the current study are doing their part to increase awareness of appropriate antibiotic use, it is a little disheartening that physicians need a randomized, controlled clinical trial and a peer-reviewed journal article to encourage them to communicate with their patients.

References

Briel M, Langewitz W, Tschudi P, Young J, Hugenschmidt C, Bucher HC. Communication training and antibiotic use in acute respiratory tract infections. A cluster randomised controlled trial in general practice. Swiss Med Wkly. Apr 15 2006;136(15-16):241-247.

Cals, J., Butler, C., Hopstaken, R., Hood, K., & Dinant, G. (2009). Effect of point of care testing for C reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial BMJ, 338 (may05 1) DOI: 10.1136/bmj.b1374

Cals JW, Hopstaken RM, Butler CC, Hood K, Severens JL, Dinant GJ. Improving management of patients with acute cough by C-reactive protein point of care testing and communication training (IMPAC3T): study protocol of a cluster randomised controlled trial. BMC Fam Pract. 2007;8:15. DOI: 10.1186/1471-2296-8-15

Francis NA, Hood K, Simpson S, Wood F, Nuttall J, Butler CC. The effect of using an interactive booklet on childhood respiratory tract infections in consultations: study protocol for a cluster randomised controlled trial in primary care. BMC Fam Pract. 2008;9:23. DOI: 10.1186/1471-2296-9-23

Spurling GK, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2007(3):CD004417. DOI: 10.1002/14651858.CD004417.pub3

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Gender reassignment was not something I had learned about in medical school. It was mentioned in passing, but there were no lectures about how to correctly dose estrogen for the male-to-female transsexual. I frankly had no idea what to do. I think my surprise and confusion were apparent, as the man blushed a little and suggested that I might want to refer him to a specialist.

Chastity Bono’s recent announcement that she will be transitioning from female to male reminded me anew what a deeply personal and difficult decision gender reassignment is. Medically, it’s complicated as well. Before even embarking on the anatomically-altering regimen, a great deal of therapy is recommended, as well as a “test run” living as the desired gender. Following that, hormones are begun. The regimen for a woman becoming a man is relatively straightforward: testosterone shots once every twelve weeks. Such a regimen produces increased facial hair, body mass index, a deeper voice, and enlargement of the clitoris, sometimes to the degree that intercourse is possible without surgery. It can have adverse effects on serum triglycerides and may cause acne.

A man wanting to become a woman faces a bit more complicated hormonal regimen, as not only does estrogen need to be added, but testosterone needs to be suppressed. Surgery to remove the testicles will obviate the latter, but is not a procedure that some are willing to undergo right away. This hormonal one-two punch will result in breast growth, increased subcutaneous fat, some decrease in upper body strength, and atrophy of both the testicles and prostate. Facial hair growth and voice depth will not change appreciably, however, and usually require additional procedures to mitigate.

The ultimate step in sexual reassignment is surgery. The most common type of surgery involves the removal of sex-specific organs; beyond that is genital reconstruction, which is significantly more complicated. After the entire process is completed, only 1 to 2 percent of postsurgical transsexuals experience regret.

As for my patient, I never saw him again after I referred him to another physician. Hopefully he is now a she, and is living a happy and fulfilling life.

References

Benjamin H. International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery Archives of Sexual Behavior, 32 (4), 299-315 DOI: 10.1023/A:1024086814364

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The study, funded by the National Institutes of Health, evaluated 149 children aged 5 to 17 years who had a diagnosis of autism spectrum disorders, Asperger disorder, or pervasive developmental disorder. The patients also had at least moderate severity ratings according to the Clinical Global Impressions, Severity of Illness Scale, as well as at least moderate compulsive behaviors according to the Children’s Yale-Brown Obsessive Compulsive Scale. The children were randomized to receive either citalopram (Celexa) or placebo by mouth daily for 12 weeks. During the trial period, physicians rated the children’s symptoms on a scale of 1 to 7, with 7 corresponding to more severe or worsening behaviors.

At the conclusion of the trial, nearly one-third (32.9%) of the patients receiving citalopram showed improvement in symptoms, but this was not significantly different from the 34.2% of patients who showed symptom improvement with placebo. Further, patients receiving citalopram were more likely to experience side effects, including nightmares, increased energy level, impulsiveness, decreased concentration, hyperactivity, diarrhea, insomnia, and dry skin than patients receiving placebo. Also, citalopram, as with all SSRIs, carries a warning regarding increased suicidal thoughts and behavior in children and adolescents, though no suicidal ideations were experienced in this study population. Overall, the authors of the current study conclude that citalpram cannot be endorsed as treatment for autism symptoms, since the risks outweigh the benefits.

Abnormal serotonin function is thought to contribute to some of the common symptoms of autism, namely repetitive behaviors such as spinning, twirling, and head-banging. Therefore, SSRIs were a natural choice for treatment of these behaviors. Today, the worldwide market for autism drug treatment is $2 billion and SSRIs account for 60% of that total. However, trials and data concerning the effectiveness of SSRIs in autism are mixed, at best. Some patients do experience symptom improvement, but there are several known risks of SSRI treatment that are particularly concerning in the autism population: suicide risk and increased agitation and aggression, primarily. Also, many of the clinical trials evaluated small populations, and many have used weak study designs, making the conclusions somewhat unreliable.

Treating autism — a condition with an unknown cause and wide-ranging symptoms — remains challenging. Symptom improvement during SSRI treatment may be due to the “placebo effect,” or the random fluctuation of autism symptoms over time. The actual outcomes are uncertain, but many clinicians are beginning to question the benefit of SSRIs versus the risks of treatment. At the very least, the door is still open to investigating the cause and possible treatment options for the ever-prevalent autism and related disorders.

References

Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. Selective serotonin reuptake inhibitors (SSRIs) for depressive disorders in children and adolescents. Cochrane Database Syst Rev. 2007(3):CD004851.

King, B., Hollander, E., Sikich, L., McCracken, J., Scahill, L., Bregman, J., Donnelly, C., Anagnostou, E., Dukes, K., Sullivan, L., Hirtz, D., Wagner, A., Ritz, L., & , . (2009). Lack of Efficacy of Citalopram in Children With Autism Spectrum Disorders and High Levels of Repetitive Behavior: Citalopram Ineffective in Children With Autism Archives of General Psychiatry, 66 (6), 583-590 DOI: 10.1001/archgenpsychiatry.2009.30

Kolevzon A, Mathewson KA, Hollander E. Selective serotonin reuptake inhibitors in autism: a review of efficacy and tolerability. J Clin Psychiatry. Mar 2006;67(3):407-414.

SOORYA, L., KIARASHI, J., & HOLLANDER, E. (2008). Psychopharmacologic Interventions for Repetitive Behaviors in Autism Spectrum Disorders Child and Adolescent Psychiatric Clinics of North America, 17 (4), 753-771 DOI: 10.1016/j.chc.2008.06.003

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Among the endogenous tasks performed by anandamide are pain control, memory blocking, appetite enhancement, the suckling reflex, lowering of blood pressure during shock, and the regulation of certain immune responses. These functions shed light on common hallmarks of cannabis withdrawal, such as anxiety, chills, sweats, flu-like physical symptoms, and decreased appetite. At Columbia University’s National Center on Addiction and Substance Abuse, where a great deal of National Institute for Drug Abuse (NIDA) funded research takes place, researchers have found that abrupt marijuana withdrawal leads to symptoms similar to depression and nicotine withdrawal.

What the NIDA has learned about cannabis addiction, according to the principal investigator of a recent NIDA study, was that “we had no difficulty recruiting dozens of people between the ages of 30 and 55 who have smoked marijuana at least 5,000 times. A simple ad in the paper generated hundreds of phone calls from such people.” (This would be roughly equivalent to 14 years of daily pot smoking.)

Here is a sampling of comments from dependent marijuana smokers, gathered from my blog, Addiction Inbox :

Comment 1

I’m 55 and I’ve been smoking pot off and on for the last 30 years… I had no idea of the withdrawal I would experience. Two days in, I thought for sure I had some dreaded disease. One minute I would be freezing, the next sweating. The loss of appetite doesn’t bother me because pot always helped me keep on an extra 5-10 lbs from the munchies and sweet tooth. Not sure how long it will take, but I do look forward to the day when this has all passed.

Comment 2

As far as symptoms, the worst for me so far has been insomnia, on day nine I was awake for 28 hours, a hallucinatory experience itself….The temperature regulation thing is very real, I’m freezing, I’m burning, I’m sweating. Starting to get hungry once a day.

Comment 3

The cravings have pretty much subsided but not completely. When I get bored is when it is the strongest. I have experienced the sweating, severe diarrhea, migraine headaches and sleeplessness…. I have hidden this addiction from family for so long and it’s nice to not have to worry if someone is going to stop by and smell it and catch me.

Comment 4

I have been smoking pot since I was 17, I am now 34, happily married with a child. I smoked at least once a day, up to 4 joints a day by myself. I stopped smoking a week ago but I am completely miserable…. I am always dreaming of using, I wake up in sweats and search the whole house for a roach sometimes when I am desperate but at the same time I feel proud that I have not called my dealer or visited my using friends, this time I might as well do it.

Comment 5

It’s been 2 weeks since I vaporized my last bowl, and since then I’ve gotten so desperate I’ve been smoking resin. Last night I used rubbing alcohol to get the resin out of my bong and smoked the resin after the alcohol evaporated. It tasted awful and barely got me high, but tonight I did it again, and I was so impatient that I put the resin-alcohol solution in the oven to help it evaporate! This is how desperate I’ve become – I’ve risked burning down my house in order to get marginally high.

Comment 6

After using heavily for the past 7 years, and basically all day every day for the last 6 months my side effects are major. i still cant sleep properly although at least now im getting 6 hours which isnt too bad. nausea every day. i have a bad stomach to begin with but i usually dont get sick every day. hot and cold sweats. im freezing right now but about half an hour ago i was boiling. i havent eaten properly since i stopped. the thing i dont like is that i feel spaced out constantly. i feel like im bent even when im not. and not bent in a calm relaxing way either.

Comment 7

I am a researcher at a university and have studied the effects of drugs, particularly alcohol, on the brain for the last decade or so. Like many of my friends and colleagues, I consider marijuana to be a relatively low-risk drug when used in moderation by responsible adults. However, I am now forced to admit that my view of the discontinuation syndrome was naïve and that I was completely unprepared for it myself:

Week 1: Despite missing my evening smoking session and feeling some mild irritability, I felt fine.

Week 2: Mild flu-like symptoms, which I assumed to be viral in nature though it did not exactly feel viral. No real desire to smoke marijuana. I assumed I was out of the woods and had gotten off easy.

Week 3: Sudden onset of incredibly intense and vivid dreams. Profuse sweating at night. Difficulty discerning dreaming from waking state. Lack of energy. Upset stomach. Absolutely no appetite. Unable to focus. Saw my primary care physician. All labs normal.

Week 4: This is where the real problems began for me. Sudden onset of intense, full body anxiety…. This led to complete insomnia for days. A very deep feeling of dread and a sense that I was going completely insane. Crying spells that came from nowhere….

Week 5: The intense anxiety slowly began to dissipate… was able to sleep for 4-6 hours a night, which is approaching normal for me. Appetite slowly came back but the thought of eating was unpleasant. Feeling of confidence began to return. Feelings of hopelessness and of going crazy began to diminish.

References

Budney, A. (2004). Review of the Validity and Significance of Cannabis Withdrawal Syndrome American Journal of Psychiatry, 161 (11), 1967-1977 DOI: 10.1176/appi.ajp.161.11.1967

Lichtman, A.H. and Martin, B.R. (2002) Marijuana withdrawal syndrome in the animal model. Journal of Clinical Pharmacology, 42, 20S-27S.

Vandrey, R., Budney, A., Kamon, J., & Stanger, C. (2005). Cannabis withdrawal in adolescent treatment seekers Drug and Alcohol Dependence, 78 (2), 205-210 DOI: 10.1016/j.drugalcdep.2004.11.001

WILSON, D., VARVEL, S., HARLOE, J., MARTIN, B., & LICHTMAN, A. (2006). SR 141716 (Rimonabant) precipitates withdrawal in marijuana-dependent mice Pharmacology Biochemistry and Behavior, 85 (1), 105-113 DOI: 10.1016/j.pbb.2006.07.018

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The authors claim that NSAIDs do not prevent the onset of dementia, but may simply delay it, leading to an increased appearance of dementia in older patients. The study participants included more than 3000 adults aged 65 years or older. Approximately 25% of the subjects were over 80 years old. At baseline, all participants showed normal cognitive function. Their cognitive function was evaluated every two years for 12 years using the Cognitive Abilities Screening Instrument. The researchers also collected data on each subject’s NSAID use, and divided the drug exposure into light or no use, moderate use, or heavy use categories.

During the study period, 476 patients developed dementia. (Of these, 356 patients were diagnosed with AD.) Heavy NSAID use was associated with a 66% increased risk for dementia, compared to the light or no NSAID use group. While this seems contradictory to many popular opinions, the authors claim that it may, in fact, reinforce other theories of dementia prevention with NSAID use. Most other studies have used younger populations to assess NSAID use and dementia onset, but the current study had a much older population. Therefore, the authors conclude that heavy NSAID use may not prevent –- but delay — dementia onset. And, in traditionally late-in-life disease onset such as dementia and AD, delay could masquerade as prevention. Other studies with younger populations may have inaccurately observed a delayed onset of dementia as complete prevention.

The exact mechanism of how NSAIDs influence dementia are not well understood, but may be due to the anti-inflammatory properties of the drugs. NSAIDs reduce inflammatory markers in the brain, and may also reduce the deposits of amyloid proteins in the brain. (These protein deposits are believed to play a role in the pathogenesis of dementia.)

Dementia is a prevalent health concern among elderly people around the world. AD is the leading cause of dementia, accounting for 50 to 70% of cases worldwide. Its precise cause is not known, but is likely a combination of diverse genetic and environmental factors. Unfortunately, treatment options for dementia remain unpredictable. The bottom line of all of these studies is that no one knows the real relationship between NSAIDs, aging, and dementia. If practitioners want to change their prescribing habits of NSAIDs in the elderly, well-designed clinical trials are needed to investigate true clinical indications for preventing or treating dementia. NSAID use in the elderly is highly prevalent for a host of conditions, and continued examination of the neuroprotective effects of NSAIDs will lead to a better understanding of the risks and benefits of NSAID use.

References

BREITNER, J. (2003). NSAIDs and Alzheimer’s disease: how far to generalise from trials? The Lancet Neurology, 2 (9), 527-527 DOI: 10.1016/S1474-4422(03)00498-8

Breitner, J., Haneuse, S., Walker, R., Dublin, S., Crane, P., Gray, S., & Larson, E. (2009). Risk of dementia and AD with prior exposure to NSAIDs in an elderly community-based cohort Neurology, 72 (22), 1899-1905 DOI: 10.1212/WNL.0b013e3181a18691

Cacabelos, R. (2008). Pharmacogenomics and therapeutic prospects in dementia European Archives of Psychiatry and Clinical Neuroscience, 258 (S1), 28-47 DOI: 10.1007/s00406-007-1006-x

Hayden, K., Zandi, P., Khachaturian, A., Szekely, C., Fotuhi, M., Norton, M., Tschanz, J., Pieper, C., Corcoran, C., Lyketsos, C., Breitner, J., Welsh-Bohmer, K., & , . (2007). Does NSAID use modify cognitive trajectories in the elderly?: The Cache County Study Neurology, 69 (3), 275-282 DOI: 10.1212/01.wnl.0000265223.25679.2a

. (2008). Cognitive Function Over Time in the Alzheimer’s Disease Anti-inflammatory Prevention Trial (ADAPT): Results of a Randomized, Controlled Trial of Naproxen and Celecoxib Archives of Neurology, 65 (7), 896-905 DOI: 10.1001/archneur.2008.65.7.nct70006

Szekely, C., Breitner, J., Fitzpatrick, A., Rea, T., Psaty, B., Kuller, L., & Zandi, P. (2008). NSAID use and dementia risk in the Cardiovascular Health Study*: Role of APOE and NSAID type Neurology, 70 (1), 17-24 DOI: 10.1212/01.wnl.0000284596.95156.48

Vlad, S., Miller, D., Kowall, N., & Felson, D. (2008). Protective effects of NSAIDs on the development of Alzheimer disease Neurology, 70 (19), 1672-1677 DOI: 10.1212/01.wnl.0000311269.57716.63

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Proprioception allows humans to control their limbs without directly looking at them. Take, for example, the complex task of driving. We are able to keep our eyes on the road and simultaneously adjust our arms and hands on the steering wheel, and apply the appropriate amount of pressure to the pedals to maintain speed. Talented drivers can also change the radio station, eat small meals, reach for something in the rear seat, or any host of other tasks while maintaining eye contact with the road ahead. If humans had to observe their limbs to successfully accomplish tasks, we would have to look down at our feet every time we wanted to change from gas to brake, or stare at our arms if we wanted to make a right turn. The distraction would make driving nearly impossible.

Human beings do not have a single organ for proprioception. Instead, the sense is processed by the entire nervous system as a whole. Inside every muscle and joint lie tiny meters called muscle spindles and Golgi tendons that constantly measure the amount of tension and degree of contraction. This information travels up a discreet highway in the spinal cord called the spinocerebellar tract, and makes its way to the cerebellum. The cerebellum accepts information from every muscle and joint in the body, and calculates where the limbs must be in space. The system is not perfect, but gives a rough estimate to allow for basic task completion. We can use our vision to confirm limb position for more technically demanding tasks.

Like most physiological processes, proprioception can be improved with challenging practice, and can also be impaired by disease or disuse. A concert pianist can play incredibly complex music with their eyes closed because they have trained the proprioceptive sense of their fingers to be precise enough for the task. If that same concert pianist tried to play a piece they have never seen before, they would have to look at their hands to master a complicated section.

By contrast, patients who suffer from stroke often have difficulty with balance and coordination during their recovery. Proprioception is also impaired by diseases or injuries affecting the musculoskeletal system, like an ankle sprain or diabetic neuropathy. Patients suffering from these types of conditions are predisposed to falls and repeat injuries, which compounds problems. For this reason, physical therapists can work with patients on proprioceptive training to help gain a stronger position sense.

Training usually consists of working on uneven or irregular surfaces, and balancing on affected joints with a blindfold to remove visual confirmation. Although these exercises are demanding, patients can usually see functional benefits within a few weeks. For any readers who have had previous impairments to their proprioception, comments below regarding any of these questions would be much appreciated:

How did you notice that your proprioception was impaired?

What kinds of therapies have you tried to improve your proprioception?

What impact has a lack of proprioception had on your daily life?

References

Victor, M, Ropper, A et al. Adams and Victor’s Principles of Neurology. Seventh Edition. McGraw-Hill Professional: 2000, Chapter 9. ISBN: 0070674973

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The BAIPA was initially understood to be antiabortion legislation, granting legal status to all live-born infants in the United States, regardless of whether birth was spontaneous, by Cesarean section, or induced by an elective abortion. Immediately after the passage of the BAIPA, the Neonatal Resuscitation Program Steering Committee issued an opinion that the law should not change neonatology practice with respect to the extremely premature infant. However, the DHS soon released enforcement guidelines that threatened investigations of violations of long-standing regulations — the Emergency Medical Treatment and Labor Act and the Child Abuse Prevention and Treatment Act — if any lay observer claimed that medical care was withheld from a newborn. The enforcement guidelines did not include a stipulation for a physician’s medical training and knowledge to prevail over the layperson’s observations. With the threat of hefty fines and litigation, many physicians and hospitals worry about the day when the BAIPA will actually be enforced.

The last several decades have seen vast improvements in technology and understanding of neonatal physiology, but surprisingly minor improvements in the actual survivability of extremely premature and low birth weight babies. Much debate still surrounds the gestational age and birth weight limits used to identify an infant’s ability to survive outside of the mother’s womb. In most cases, survival of infants born at less than 25 weeks gestation is unlikely. Most practitioners agree that aggressive measures of resuscitation for newborns born at less than 23 weeks gestation is futile and unwarranted. In such cases, neonatologists are more likely to provide comfort care to the infant and the family until the infant dies naturally.

The decision to resuscitate a newborn that is unlikely to survive is a complex one that should involve physicians, other health care professionals, and parents. However, these decisions must also be made quickly. In these cases, timely and appropriate decision-making can decide whether an infant dies, survives with impairment, or survives intact. The consequences of the decisions — positive or negative –- are almost immediate. Medical professionals bring their judgment and experience, as well as perceived obligations and legal mandates to the decision-making; parents bring cultural, personal, ideological, and religious beliefs to the decision-making. Who should be permitted to make the final judgment of what treatment is in the best interest of the child?

The American Academy of Pediatrics recommends that neonatologists perform complete prenatal consultations with parents in the likelihood of an extremely premature birth. Most physicians are comfortable discussing clinical issues with parents, but far fewer are comfortable discussing quality-of-life issues, expected long-term outcomes, or parental preferences. Physicians should provide parents with the medical information necessary for informed decision-making, and but should also foster parental involvement in the care of their child. A framework for newborn resuscitation may be necessary to clarify each practitioner’s role in the care of likely nonviable newborns, and to aid in decision-making, but the government should not be mandating medical procedures or making therapeutic decisions in a complex life or death decision of a child.

References

Campbell, D., & Fleischman, A. (2001). Limits of Viability: Dilemmas, Decisions, and Decision Makers American Journal of Perinatology, 18 (03), 117-128 DOI: 10.1055/s-2001-14530

HUSSAIN, N., & ROSENKRANTZ, T. (2003). Ethical considerations in the management of infants born at extremely low gestational age Seminars in Perinatology, 27 (6), 458-470 DOI: 10.1053/j.semperi.2003.10.005

Partridge, J., Sendowski, M., Drey, E., & Martinez, A. (2009). Resuscitation of Likely Nonviable Newborns: Would Neonatology Practices in California Change if the Born-Alive Infants Protection Act Were Enforced? PEDIATRICS, 123 (4), 1088-1094 DOI: 10.1542/peds.2008-0643

Sayeed, S. (2005). Baby Doe Redux? The Department of Health and Human Services and the Born-Alive Infants Protection Act of 2002: A Cautionary Note on Normative Neonatal Practice PEDIATRICS, 116 (4) DOI: 10.1542/peds.2005-1590

Lakshminrusimha S, Carrion V. Perinatal phsyiology and principles of neotal resuscitation. Clin Ped Emerg Med. 2008;9:131-139.

Bastek, T. (2005). Prenatal Consultation Practices at the Border of Viability: A Regional Survey PEDIATRICS, 116 (2), 407-413 DOI: 10.1542/peds.2004-1427

Partridge, J. (2005). International Comparison of Care for Very Low Birth Weight Infants: Parents’ Perceptions of Counseling and Decision-Making PEDIATRICS, 116 (2) DOI: 10.1542/peds.2004-2274

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Current thinking in the field of neuroplasticity holds that our brain development is wholly dependent upon the sum of our experiences. We all begin life as an infant with no particular skill sets or abilities to carry out tasks. As our brains develop we steadily gain more sophisticated control of our bodies, but only in respond to challenges. If a skill set is not required, then the brain has no need to invest any time or energy into developing a pathway for it. Only through steady experience and repetition does our brain lay the groundwork for semi-permanent change. As a result, when our experiences change, so do our brains.

Plasticity does not only apply to the brain, however. In the body, our ability to adapt to new situations is equally staggering. Evolution occurs on a micro scale with our everyday decisions, and our bodies have the capability to remake themselves to meet the demands placed upon them. If our desire is to have a runner’s body, then all we have to do is run. In response to the increased physical demands of that activity, our bodies respond over time by improving cardiovascular output, trimming excess body fat, increasing lean muscle mass, and improving glycogen stores to cope with the changes. Over a short period of time, the body can transform itself to serve its new purpose.

What lesson is to be learned from the study of plasticity? Human beings are very much in the driver’s seat when it comes to our long term physiological outlook. Even small changes in our lifestyle when applied consistently can fundamentally alter not only our way of thinking, but the actual biochemical composition of our bodies and brains. The first question to ask is, “Who do I want to be tomorrow?”

Recommended Viewing

Michael Merzenich on Exploring the re-wiring of the brain from TED.com.

References

MERZENICH, M., KAAS, J., WALL, J., NELSON, R., SUR, M., & FELLEMAN, D. (1983). Topographic reorganization of somatosensory cortical areas 3b and 1 in adult monkeys following restricted deafferentation Neuroscience, 8 (1), 33-55 DOI: 10.1016/0306-4522(83)90024-6

MERZENICH, M., KAAS, J., WALL, J., NELSON, R., SUR, M., & FELLEMAN, D. (1983). Topographic reorganization of somatosensory cortical areas 3b and 1 in adult monkeys following restricted deafferentation Neuroscience, 8 (1), 33-55 DOI: 10.1016/0306-4522(83)90024-6

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One of the newest areas of specialization in health care is hospice and palliative care. (The Centers for Medicare and Medicaid Services (CMS) just began recognizing hospice and palliative care early in 2009.) This new specialty focuses on treating not just physical symptoms, but psychological, social, and spiritual suffering that accompanies a terminal illness. Hospice and palliative care strive to optimize the quality of life for critically and terminally ill patients and their families when facing life-threatening illness or injury. Ideally, hospice and palliative care are provided by an interdisciplinary team, and emphasize communication, symptom management, and family support. In order to improve this new specialty, many hospitals, professional organizations, and palliative care advocacy groups are formulating objective measures of quality care. Also, many quality and benchmarking groups, such as the National Quality Forum and HealthGrades, are receiving increasing pressure from health care providers and payors to implement quality standards for hospice and palliative care. Still, quality of life near the end of life is not an easily measured or demonstrated outcome, making impartial and tangible conclusions difficult.

To standardize the quality of hospice and palliative care, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) proposed a palliative care certificate program for hospitals. The program was supposed to be in place in August of 2008, and was eagerly anticipated by practitioners and hospitals. However, due to the current economic environment, JCAHO has recently announced that the rollout of the certificate program is being put on hold, with no release date set for the future. This delay has frustrated many in the hospice and palliative care community who strive to provide high standards of care for patients and their families.

While quality care at the end of life is important, many proponents of spending cuts cite the Medicaid Hospice Benefit as a place to control spending and clean up the budget mess in many states. (Many hospice programs do make a sizable profit on stable, long-term patients.) However, cutting the entire benefit may not be a reasonable target. Many recent studies are reporting that paying for hospice benefits actually saves money in state-funded programs, as well as hospitals. To provide time and resources to sort out the truth, President Obama extended a 1-year moratorium on reductions in hospice reimbursement through the end of September 2009 as part of the economic stimulus package.

Spending money on hospice and palliative care may actually be part of the solution to the health care spending crisis. One study reported that coordinated palliative care led to a savings of $300 per patient per day receiving palliative care. For an average 400-bed hospital, this translates to a savings of $1.3 million annually. Actions as simple as physician-patient-family conversations in the last week of life as part of a comprehensive palliative care approach led to significantly lower costs (often thousands of dollars per week) in the final weeks of a patient’s life. The same patients, with decreased costs, showed improved quality of death versus those without physician discussions of end-of-life issues.

Recently, the legislators of Florida proposed cutting the state’s hospice benefit to reduce overall health care costs. The legislature concluded that the state would save $343 million. To fight back, Florida Hospices and Palliative Care conducted its own research and concluded that cutting the benefit would actually cost the state an additional $3.7 million. Similar results were found in a study conducted by Duke University that claimed the average hospice patient receiving palliative care actually saved health care payors $2300 compared to patients receiving traditional care.

With an aging population filled with chronic disease, hospice and palliative care will be a growing specialty in the decades to come. Similarly, cutting costs — in health care and other arenas –- will remain an important priority for America in the years to come. But, we must respect the need for quality care at the end of life. Health care is a lot more than lab tests, medicines, and people running around in white coats; health care, particularly near the end of life, is the attention paid to the whole patient and his or her family. If that attention to patients saves a few dollars, then maybe the health care system is on the right track, after all.

References

Morrison RS. Better care, better bottom line for hospitals. Medscape J Med. 2008;10(12):274.

Morrison, R., Penrod, J., Cassel, J., Caust-Ellenbogen, M., Litke, A., Spragens, L., Meier, D., & , . (2008). Cost Savings Associated With US Hospital Palliative Care Consultation Programs Archives of Internal Medicine, 168 (16), 1783-1790 DOI: 10.1001/archinte.168.16.1783

Mularski, R., Curtis, J., Billings, J., Burt, R., Byock, I., Fuhrman, C., Mosenthal, A., Medina, J., Ray, D., Rubenfeld, G., Schneiderman, L., Treece, P., Truog, R., & Levy, M. (2006). Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Foundation Critical Care Workgroup Critical Care Medicine, 34 (Suppl) DOI: 10.1097/01.CCM.0000242910.00801.53

Phelps, A., Maciejewski, P., Nilsson, M., Balboni, T., Wright, A., Paulk, M., Trice, E., Schrag, D., Peteet, J., Block, S., & Prigerson, H. (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA: The Journal of the American Medical Association, 301 (11), 1140-1147 DOI: 10.1001/jama.2009.341

Ray, D., Fuhrman, C., Stern, G., Geracci, J., Wasser, T., Arnold, D., Masiado, T., & Deitrick, L. (2006). Integrating palliative medicine and critical care in a community hospital Critical Care Medicine, 34 (Suppl) DOI: 10.1097/01.CCM.0000237046.62046.49

TAYLORJR, D., OSTERMANN, J., VANHOUTVEN, C., TULSKY, J., & STEINHAUSER, K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science & Medicine, 65 (7), 1466-1478 DOI: 10.1016/j.socscimed.2007.05.028

Zhang, B., Wright, A., Huskamp, H., Nilsson, M., Maciejewski, M., Earle, C., Block, S., Maciejewski, P., & Prigerson, H. (2009). Health Care Costs in the Last Week of Life: Associations With End-of-Life Conversations Archives of Internal Medicine, 169 (5), 480-488 DOI: 10.1001/archinternmed.2008.587

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What these researchers and others before them have done is taken a representative swath of humanity and labeled them as “healthy.” The JUPITER trial, for example, looked at using a statin for so-called “healthy” individuals and found that it reduced their risk of cardiovascular events. However, these people weren’t healthy. Average, yes; representative of the United States population, yes. Healthy, no. Seventy-five percent of the subjects in the JUPITER trial were overweight or obese and also had a blood test abnormality. Similarly, in the TIPs study the subjects did not have pre-existing cardiovascular disease but did have type 2 diabetes, increased waist-to-hip ratio, abnormal lipids, high blood pressure, or a history of recent smoking. In other words, not “healthy.” Notable, too, is the fact that each and every one of the things that renders these individuals unhealthy is almost entirely preventable with lifestyle modifications.

The fact that legitimate research is being conducted on this “polypill” is a sad commentary on the faith that the healthcare industry has in people to save themselves. Although the researchers in the TIPS trial point out that their medication is not intended to be a substitute for diet and exercise, as Dr. Clyde Yancy, medical director of the Baylor Heart Institute in Dallas, was quoted in Clinical Endocrinology News, “There is nothing more effective than modifying lifestyle, but people may tend to dismiss that concept if they believe a pill is lowering their risk of heart disease.”

In a few years, we’ll get the final results on the TIPS trial. I predict that it will show a benefit. I also predict that the drug will be heavily marketed to people who have had the power to lower their risk of cardiovascular disease in their own hands all along. It is up to us to decide if we want our health to be determined by our own efforts or those of the pharmaceutical industry.

References

Xavier, D., Pais, P., Sigamani, A., Pogue, J., Afzal, R., & Yusuf, S. (2008). The need to test the theories behind the Polypill: rationale behind the Indian Polycap Study Nature Clinical Practice Cardiovascular Medicine, 6 (2), 96-97 DOI: 10.1038/ncpcardio1438

Ridker, P., Danielson, E., Fonseca, F., Genest, J., Gotto, A., Kastelein, J., Koenig, W., Libby, P., Lorenzatti, A., MacFadyen, J., Nordestgaard, B., Shepherd, J., Willerson, J., Glynn, R., & , . (2008). Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein New England Journal of Medicine, 359 (21), 2195-2207 DOI: 10.1056/NEJMoa0807646

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As the medical profession evolved into a scientific discipline, the white coat began to represent the physician as a scientist. It also epitomized a feeling of cleanliness, and served as a barrier between the physician and his patient. As time passed, the white coat became so symbolic of physicians that medical students began taking part in “white coat ceremonies” to signify the beginning of a professional journey and undertaking of considerable responsibility. Many medical students see the white coat ceremony as the transition from nonphysician to physician and donning the coat helps to symbolize the commission they are accepting.

Still, the white coat – in all cleanliness and purity — is losing favor among some circles. Remarkably, white coats were actually banned in England in September of 2007 by the United Kingdom Department of Health. Physicians are now required to adhere to a “bare below the elbows” dress code. That is, short sleeves and no watches or jewelry when engaging in clinical activity. (Neckties are also banned.) The reason? Infection control. It was believed that white coats worn in clinical environments, and laundered infrequently, contribute to the spread of hospital-associated infections. Also, the dress code is believed to promote effective hand washing. On a smaller scale, some infectious disease departments in the United States, as well as some hospitals, have implemented, or are considering implementing, a similar policy.

While the dress code is well intentioned, it is not based on many facts. Many studies have shown that health care workers’ uniforms, as well as hospital curtains and linens, can be contaminated with pathogens from the clinical environment, but there is a lack of evidence that the colonization actually leads to the spread of disease. A recent poster presented at the annual meeting of the Society for Healthcare Epidemiology of America reported that bacteria common in hospital-acquired infections (methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, and pan-resistant Acinetobacter) could be isolated from lab coats, transferred to pig skin, and re-isolated from the skin. The isolates were obtained from the white coats at 1-minute, 5-minute, and 30-minutes intervals after contamination. While this investigation shows the biological plausibility of white coats transmitting infections, it is a long way from proving disease transmission.

So, should all physicians ditch the white coat? Not so fast, say the patients. In numerous studies, patients significantly favor physicians who dress professionally and wear white coats. Patients are also more likely to attribute competence to a physician who is professionally dressed. Many patients favor white coats owing to the ease of identification, as well as tradition. There are very few patients who believe white coats are an infection risk, though many do view them as intimidating.

Physicians who choose to wear white coats in daily practice do so for many reasons: tradition, peer pressure, identification, keeping underlying clothes clean, and pockets for carrying references and equipment. Also, many physicians still like the prestige that accompanies the white coat. However, with more and more health professionals working in clinical settings, everyone from pharmacists and nurse practitioners to phlebotomists and dietitians are dressing in white coats, making identification and stature harder to ascertain.

The English ban on white coats is not likely to cross its borders, so physicians in the United States can keep wearing the traditional cloak of hope and purity for now. Medical professionals would be better advised to focus on hand washing, high hospital bed occupancy, and the excessive use antibiotics to combat the spread of disease.

References

Douse, J. (2004). Should doctors wear white coats? Postgraduate Medical Journal, 80 (943), 284-286 DOI: 10.1136/pgmj.2003.017483

KAZORY, A. (2008). Physicians, Their Appearance, and the White Coat The American Journal of Medicine, 121 (9), 825-828 DOI: 10.1016/j.amjmed.2008.05.030

REHMAN, S., NIETERT, P., COPE, D., & KILPATRICK, A. (2005). What to wear today? Effect of doctor’s attire on the trust and confidence of patients The American Journal of Medicine, 118 (11), 1279-1286 DOI: 10.1016/j.amjmed.2005.04.026

Wilson, J., Loveday, H., Hoffman, P., & Pratt, R. (2007). Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England) Journal of Hospital Infection, 66 (4), 301-307 DOI: 10.1016/j.jhin.2007.03.026

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